Low implementation of Xpert MTB/RIF among HIV/TB co-infected adults in the International epidemiologic Databases to Evaluate AIDS (IeDEA) program.
OBJECTIVE
Xpert MTB/RIF is recommended by the World Health Organization (WHO) as the initial tuberculosis (TB) diagnostic test in individuals suspected of HIV-associated TB. We sought to evaluate field implementation of Xpert among a cohort of HIV/TB co-infected individuals, including availability, utilization and outcomes.


METHODS
Observational cohort study (patient-level data) and cross-sectional study (site-level Xpert availability data).


METHODS
Data were collected at 30 participating International epidemiologic Databases to Evaluate AIDS (IeDEA) sites in 18 countries from January 2012-January 2016. All patients were HIV-infected and diagnosed with TB, either bacteriologically or clinically, and followed until a determination of TB treatment outcome. We used multivariable modified Poisson regression to estimate adjusted relative risk (RR) and 95% confidence intervals for unfavorable TB treatment outcomes.


RESULTS
Most sites (63%) had access to Xpert, either in the clinic (13%), in the same facility (20%) or offsite (30%). Among 2722 HIV/TB patients included, median age was 35.4 years and 41% were female; BMI and CD4 count were low. Overall, most patients (76%) received at least one TB test; 45% were positive. Only 4% of all patients were tested using Xpert: 64% were Xpert-positive, 13% showed rifampicin (RIF) resistance and 30% were extrapulmonary (EPTB) or both pulmonary-EPTB. Treatment outcomes were mostly favorable (77%) and we found little association between Xpert use and an unfavorable TB treatment outcome (RR 1.25, 95%CI: 0.83, 1.90).


CONCLUSIONS
In this cohort, Xpert utilization was low even though the majority of sites had access to the test. Our findings show the need for expanded implementation and further research exploring barriers to use in low-resource settings.
Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America.|Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.|Vanderbilt Tuberculosis Center, Nashville, Tennessee, United States of American.
Kate
http://orcid.org/0000-0002-0190-7398
K
Clouse
Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America.|Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.
Meridith
M
Blevins
Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America.|Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.
Mary Lou
ML
Lindegren
College of Public Health, The Ohio State University, Columbus, Ohio, United States of America.
Marcel
M
Yotebieng
National Hospital of Tropical Diseases, Hanoi, Vietnam.
Dung Thi
DT
Nguyen
Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.
Alfred
A
Omondi
National Institute for Medical Research (NIMR), Mwanza, Tanzania.
Denna
D
Michael
Faculté des Sciences de la Santé, Université d'Abomey-Calavi, Cotonou, Bénin.
Djimon Marcel
DM
Zannou
Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru.
Gabriela
G
Carriquiry
Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.|Vanderbilt Tuberculosis Center, Nashville, Tennessee, United States of American.
April
A
Pettit
D000163:Acquired Immunodeficiency Syndrome / Q000150:complications / Q000453:epidemiology; D000328:Adult; D015331:Cohort Studies; D060085:Coinfection / Q000175:diagnosis / Q000453:epidemiology; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D015497:HIV-1; D006801:Humans; D038622:Internationality; D008297:Male; D018088:Tuberculosis, Multidrug-Resistant / Q000150:complications* / Q000175:diagnosis* / Q000453:epidemiology