title: Implementation and Operational Research: Use of Symptom Screening and Sputum Microscopy Testing for Active Tuberculosis Case Detection Among HIV-Infected Patients in Real-World Clinical Practice in Uganda.
abstract: The uptake of intensified active TB case-finding among HIV-infected patients using symptom screening is not well understood. We evaluated the rate and completeness of each interim step in the TB pulmonary "diagnostic cascade" to understand real-world barriers to active TB case detection.
  
  
  
  We conducted a cohort analysis of new, antiretroviral therapy-naive, HIV-infected patients who attended a large HIV clinic in Mbarara, Uganda (March 1, 2012-September 30, 2013). We used medical records to extract date of completion of each step in the diagnostic cascade: symptom screen, order, collection, processing, and result. Factors associated with lack of sputum order were evaluated using multivariate Poisson regression and chart review of 50 screen-positive patients.
  
  
  
  Of 2613 patients, 2439 (93%) were screened for TB and 682 (28%) screened positive. Only 90 (13.2%) had a sputum order. Of this group, 83% completed the diagnostic cascade, 13% were diagnosed with TB, and 50% had a sputum result within 1 day of their visit. Sputum ordering was associated with WHO stage 3 or 4 HIV disease and greater number of symptoms. The main identifiable reasons for lack of sputum order in chart review were treatment of presumed malaria (51%) or bacterial infection (43%).
  
  
  
  The majority of newly enrolled HIV-infected patients who screened positive for suspected TB did not have a sputum order, and those who did were more likely to have more symptoms and advanced HIV disease. Further evaluation of provider behavior in the management of screen-positive patients could improve active TB case detection rates.
authors.affiliation: *Division of HIV, ID, and Global Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA;†Mbarara University of Science and Technology, Mbarara, Uganda; and‡Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA.
authors.forename: Monika
authors.initials: M
authors.lastname: Roy
authors.forename: Winnie
authors.initials: W
authors.lastname: Muyindike
authors.forename: Tara
authors.initials: T
authors.lastname: Vijayan
authors.forename: Michael
authors.initials: M
authors.lastname: Kanyesigye
authors.forename: Mwebesa
authors.initials: M
authors.lastname: Bwana
authors.forename: Megan
authors.initials: M
authors.lastname: Wenger
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Martin
authors.forename: Elvin
authors.initials: E
authors.lastname: Geng
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D060085:Coinfection / Q000453:epidemiology* / Q000382:microbiology; D015658:HIV Infections / Q000453:epidemiology* / Q000382:microbiology; D006801:Humans; D008403:Mass Screening; D008853:Microscopy; D009874:Operations Research; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D015995:Prevalence; D013183:Sputum / Q000382:microbiology*; D014376:Tuberculosis / Q000175:diagnosis* / Q000453:epidemiology* / Q000382:microbiology; D014454:Uganda / Q000453:epidemiology