The World Health Organization estimates nearly 500,000 cases of tuberculosis (TB) among people living with HIV (PLHIV) go unreported each year. Among PLHIV, four-symptom TB screening (cough, fever, weight loss, and night sweats) is recommended at every clinical encounter, followed by sputum testing with Xpert MTB/RIF for positive screens. We assessed TB screening programs in countries supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).
We analyzed TB screening and diagnostic testing data collected at PEPFAR-supported sites during October 2017–March 2019. Countries reporting TB screening data with ≥90% completeness were included. Using pooled and country-specific data, we determined the proportion of patients screened for TB symptoms and those who screened positive among PLHIV newly initiating ART vs those already receiving ART at the time of screening. We also determined the proportion of patients with a positive TB screen who had TB diagnostic testing, including Xpert MTB/RIF.
Of 30 countries reporting TB screening data, we included 20. Of the 8,337,799 PLHIV already receiving ART, 7,273,266 (87%) were screened at least once for TB symptoms in the most recent biannual reporting period. In the same period, the pooled rate of positive TB symptom screens was 2.6% (7.0% among ART-naïve PLHIV vs 2.3% among those already receiving ART). Median country-specific rates of positive TB screening results were 2.5% (interquartile range [IQR], 1.7%–5.8%) overall (ART-naïve PLHIV, 7.4% [IQR: 5.8%–13.8%]; PLHIV already receiving ART, 2.1% [IQR, 1.5%–5.3%]). Since 2017, the rate of positive TB screens globally has increased from 3.9% to 6.9% among ART-naïve PLHIV and has decreased to 2.8% from 3.4% among those already receiving ART. Among all PLHIV with a positive TB screen result, 85% had sputa sent for diagnostic testing (58% for Xpert MTB/RIF testing); trends in specimen testing decreased over the analysis period.
The proportion of ART-naïve PLHIV with a positive TB screen result is increasing but remains lower than expected for high-burden settings. We identified gaps in TB diagnostic services: roughly 1 in 6 PLHIV with TB symptoms does not receive diagnostic testing. Our findings suggest that improved TB screening and GeneXpert-based TB testing will be crucial in improving progress.