title: Missed Opportunities for TB Investigation in Primary Care Clinics in South Africa: Experience from the XTEND Trial.
abstract: METHODS
  40 primary health clinics (PHCs) in four provinces in South Africa, June 2012 -February 2013.
  
  
  OBJECTIVE
  To determine whether health care worker (HCW) practice in investigating people with TB symptoms was altered when the initial test for TB was changed from smear microscopy to Xpert MTB/RIF.
  
  
  METHODS
  Cross-sectional substudy at clinics participating in a pragmatic cluster randomised trial, Xpert for TB: Evaluating a New Diagnostic "XTEND", which evaluated the effect of Xpert MTB/RIF implementation in South Africa.
  
  
  METHODS
  Consecutive adults exiting PHCs reporting at least one TB symptom (defined as any of cough, weight loss, night sweats and fever) were enrolled. The main outcome was the proportion who self-reported having sputum requested by HCW during the clinic encounter just completed.
  
  
  RESULTS
  3604 adults exiting PHCs (1676 in Xpert arm, 1928 in microscopy arm) were enrolled (median age 38 years, 71.4% female, 38.8% reported being HIV-positive, 70% reported cough). For 1267 participants (35.2%) the main reason for attending the clinic was TB symptom(s). Overall 2130/3604 (59.1%) said they reported their symptom(s) to HCW. 22.7% (818/3604) reported having been asked to give sputum for TB investigation. Though participants in the Xpert vs. microscopy arm were more likely to have sputum requested by HCW, this was not significantly different: overall (26.0% [436/1676] vs 19.8% [382/1928]; adjusted prevalence ratio [aPR] 1.31, [95% CI 0.78-2.20]) and when restricted to those presenting at clinics due to symptoms (49.1% [260/530] vs 29.9% [220/737]; aPR 1.38 [0.89-2.13]) and those reporting being HIV-positive (29.4% [190/647] vs 20.8% [156/749]; aPR 1.38[0.88-2.16]). Those attending clinic due to TB symptoms, were more likely to have sputum requested if they had increasing number of symptoms; longer duration of cough, unintentional weight loss and night sweats and if they reported symptoms to HCW.
  
  
  CONCLUSIONS
  A large proportion of people exiting PHCs reporting TB symptoms did not get tested. Implementation of Xpert MTB/RIF did not substantially change the probability of testing for TB. Better systems are needed to ensure that opportunities to identify active TB among PHC attendees are not missed.
authors.affiliation: The Aurum Institute, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Violet N
authors.initials: VN
authors.lastname: Chihota
authors.affiliation: The Aurum Institute, Johannesburg, South Africa.
authors.forename: Sibuse
authors.initials: S
authors.lastname: Ginindza
authors.affiliation: The Aurum Institute, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Kerrigan
authors.initials: K
authors.lastname: McCarthy
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Alison D
authors.initials: AD
authors.lastname: Grant
authors.affiliation: The Aurum Institute, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Gavin
authors.initials: G
authors.lastname: Churchyard
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Katherine
authors.initials: K
authors.lastname: Fielding
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000458:organization & administration / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005260:Female; D006301:Health Services Needs and Demand / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D011320:Primary Health Care / Q000458:organization & administration / Q000706:statistics & numerical data*; D013019:South Africa / Q000453:epidemiology; D013183:Sputum / Q000382:microbiology; D014376:Tuberculosis / Q000175:diagnosis* / Q000453:epidemiology*