title: Tuberculosis in Pediatric Antiretroviral Therapy Programs in Low- and Middle-Income Countries: Diagnosis and Screening Practices.
abstract: BACKGROUND
  The global burden of childhood tuberculosis (TB) is estimated to be 0.5 million new cases per year. Human immunodeficiency virus (HIV)-infected children are at high risk for TB. Diagnosis of TB in HIV-infected children remains a major challenge.
  
  
  METHODS
  We describe TB diagnosis and screening practices of pediatric antiretroviral treatment (ART) programs in Africa, Asia, the Caribbean, and Central and South America. We used web-based questionnaires to collect data on ART programs and patients seen from March to July 2012. Forty-three ART programs treating children in 23 countries participated in the study.
  
  
  RESULTS
  Sputum microscopy and chest Radiograph were available at all programs, mycobacterial culture in 40 (93%) sites, gastric aspiration in 27 (63%), induced sputum in 23 (54%), and Xpert MTB/RIF in 16 (37%) sites. Screening practices to exclude active TB before starting ART included contact history in 41 sites (84%), symptom screening in 38 (88%), and chest Radiograph in 34 sites (79%). The use of diagnostic tools was examined among 146 children diagnosed with TB during the study period. Chest Radiograph was used in 125 (86%) children, sputum microscopy in 76 (52%), induced sputum microscopy in 38 (26%), gastric aspirate microscopy in 35 (24%), culture in 25 (17%), and Xpert MTB/RIF in 11 (8%) children.
  
  
  CONCLUSIONS
  Induced sputum and Xpert MTB/RIF were infrequently available to diagnose childhood TB, and screening was largely based on symptom identification. There is an urgent need to improve the capacity of ART programs in low- and middle-income countries to exclude and diagnose TB in HIV-infected children.
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland.
authors.forename: Marie
authors.initials: M
authors.lastname: Ballif
authors.affiliation: University of Ghana Medical School, Korle Bu, Accra.
authors.forename: Lorna
authors.initials: L
authors.lastname: Renner
authors.affiliation: Women's Equity in Access to Care & Treatment, Kigali, Rwanda.
authors.forename: Jean
authors.initials: J
authors.lastname: Claude Dusingize
authors.affiliation: Inserm, U897, Epidémiologie-Biostatistiques ISPED, University of Bordeaux, France.
authors.forename: Valeriane
authors.initials: V
authors.lastname: Leroy
authors.affiliation: Department of Child Health and Pediatrics, Moi University School of Medicine, Kenya.
authors.forename: Samuel
authors.initials: S
authors.lastname: Ayaya
authors.affiliation: Indiana University School of Medicine.
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
authors.affiliation: University of Chile School of Medicine, Santiago.
authors.forename: Claudia P
authors.initials: CP
authors.lastname: Cortes
authors.affiliation: Vanderbilt University School of Medicine, Nashville, Tennessee.
authors.forename: Catherine C
authors.initials: CC
authors.lastname: McGowan
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland.
authors.forename: Claire
authors.initials: C
authors.lastname: Graber
authors.affiliation: Tuberculosis Initiative, Texas Children's Hospital, and Baylor College of Medicine, Houston.
authors.forename: Anna M
authors.initials: AM
authors.lastname: Mandalakas
authors.affiliation: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
authors.forename: Lynne M
authors.initials: LM
authors.lastname: Mofenson
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland.
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.affiliation: Sanglah Hospital, Udayana University, Bali, Indonesia.
authors.forename: Ketut Dewi
authors.initials: KD
authors.lastname: Kumara Wati
authors.affiliation: Penang Hospital, Malaysia.
authors.forename: Revathy
authors.initials: R
authors.lastname: Nallusamy
authors.affiliation: Rahima Moosa Mother and Child Hospital, Department of Pediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Gary
authors.initials: G
authors.lastname: Reubenson
authors.affiliation: Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa.
authors.forename: Mary-Ann
authors.initials: MA
authors.lastname: Davies
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland Swiss Tropical and Public Health Institute, Basel, Switzerland University of Basel, Switzerland.
authors.forename: Lukas
authors.initials: L
authors.lastname: Fenner
mesh_terms: D017954:Africa South of the Sahara; D000569:Americas; D019380:Anti-HIV Agents / Q000191:economics* / Q000627:therapeutic use*; D001208:Asia; D002648:Child; D002675:Child, Preschool; D003906:Developing Countries; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy / Q000191:economics; D006801:Humans; D007223:Infant; D008853:Microscopy / Q000191:economics / Q000379:methods; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D011203:Poverty; D013902:Radiography, Thoracic / Q000191:economics / Q000379:methods; D013183:Sputum / Q000382:microbiology; D014376:Tuberculosis / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000191:economics*
chemical_list: D019380:Anti-HIV Agents
keywords: HIV; low-income countries; pediatric; survey; tuberculosis.