title: Performance of Clinical Screening Algorithms for Tuberculosis Intensified Case Finding among People Living with HIV in Western Kenya.
abstract: OBJECTIVE
  To assess the performance of symptom-based screening for tuberculosis (TB), alone and with chest radiography among people living with HIV (PLHIV), including pregnant women, in Western Kenya.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  PLHIV from 15 randomly-selected HIV clinics were screened with three clinical algorithms [World Health Organization (WHO), Ministry of Health (MOH), and "Improving Diagnosis of TB in HIV-infected persons" (ID-TB/HIV) study], underwent chest radiography (unless pregnant), and provided two or more sputum specimens for smear microscopy, liquid culture, and Xpert MTB/RIF. Performance of clinical screening was compared to laboratory results, controlling for the complex design of the survey.
  
  
  RESULTS
  Overall, 738 (85.6%) of 862 PLHIV enrolled were included in the analysis. Estimated TB prevalence was 11.2% (95% CI, 9.9-12.7). Sensitivity of the three screening algorithms was similar [WHO, 74.1% (95% CI, 64.1-82.2); MOH, 77.5% (95% CI, 68.6-84.5); and ID-TB/HIV, 72.5% (95% CI, 60.9-81.7)]. Sensitivity of the WHO algorithm was significantly lower among HIV-infected pregnant women [28.2% (95% CI, 14.9-46.7)] compared to non-pregnant women [78.3% (95% CI, 67.3-86.4)] and men [77.2% (95% CI, 68.3-84.2)]. Chest radiography increased WHO algorithm sensitivity and negative predictive value to 90.9% (95% CI, 86.4-93.9) and 96.1% (95% CI, 94.4-97.3), respectively, among asymptomatic men and non-pregnant women.
  
  
  CONCLUSIONS
  Clinical screening missed approximately 25% of laboratory-confirmed TB cases among all PLHIV and more than 70% among HIV-infected pregnant women. National HIV programs should evaluate the feasibility of laboratory-based screening for TB, such as a single Xpert MTB/RIF test for all PLHIV, especially pregnant women, at enrollment in HIV services.
authors.affiliation: Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America.
authors.forename: Surbhi
authors.identifier: http://orcid.org/0000-0003-2143-672X
authors.initials: S
authors.lastname: Modi
authors.affiliation: Division of Tuberculosis Elimination, CDC, Atlanta, Georgia, United States of America.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Cavanaugh
authors.affiliation: Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America.
authors.forename: Ray W
authors.initials: RW
authors.lastname: Shiraishi
authors.affiliation: Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Alexander
authors.affiliation: Division of Tuberculosis Elimination, CDC, Atlanta, Georgia, United States of America.
authors.forename: Kimberly D
authors.initials: KD
authors.lastname: McCarthy
authors.affiliation: Kenya Medical Research Institute (KEMRI) Center for Global Health Research, Kisumu, Kenya.|KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya.
authors.forename: Barbara
authors.initials: B
authors.lastname: Burmen
authors.affiliation: CDC, Kisumu, Kenya.
authors.forename: Hellen
authors.initials: H
authors.lastname: Muttai
authors.affiliation: Division of Tuberculosis Elimination, CDC, Atlanta, Georgia, United States of America.
authors.forename: Chad M
authors.initials: CM
authors.lastname: Heilig
authors.affiliation: Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America.
authors.forename: Allyn K
authors.initials: AK
authors.lastname: Nakashima
authors.affiliation: Division of Tuberculosis Elimination, CDC, Atlanta, Georgia, United States of America.|CDC, Kisumu, Kenya.
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Cain
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000453:epidemiology; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008400:Mass Chest X-Ray; D008875:Middle Aged; D011247:Pregnancy; D011446:Prospective Studies; D014376:Tuberculosis / Q000150:complications* / Q000175:diagnosis* / Q000453:epidemiology; D055815:Young Adult