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Diagnosis of AFB Smear-Negative Pulmonary TB in HIV-Infected Persons

Diagnosis of AFB Smear-Negative Pulmonary TB in HIV-Infected Persons. Richard O’Brien Foundation for Innovative New Diagnostics (FIND). Diagnosis of Smear- PTB in HIV-Infected Persons – Background (1). HIV infection associated with large increases in smear-negative (SN) PTB

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Diagnosis of AFB Smear-Negative Pulmonary TB in HIV-Infected Persons

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  1. Diagnosis of AFB Smear-Negative Pulmonary TB in HIV-Infected Persons Richard O’Brien Foundation for Innovative New Diagnostics (FIND)

  2. Diagnosis of Smear- PTB in HIV-Infected Persons – Background (1) • HIV infection associated with large increases in smear-negative (SN) PTB • SN PTB in HIV+ persons has much higher mortality than smear+ PTB • Current WHO diagnostic algorithm for SN PTB inadequate for HIV+ persons • Lengthy process • Antibiotic trial lacks sensitivity and specificity, especially in HIV+ persons

  3. Diagnosis of SN PTB in HIV+ PersonsBackground (2) • Raised as urgent issue by TB/HIV WG • Expert group convened by WHO (Sept 05) • Recommendations and new algorithms posted on STB website for comments (Nov 05) • Expert group revised guidelines and algorithms (March 06) • Presentation to STAG (June 06)

  4. Diagnosis of SN PTB in HIV+ PersonsNew Diagnostic Algorithm (1) • Applies to high HIV settings (>1% in general population, >5% in TB cases) • Initial HIV DTC at first visit, together with at least 2 sputa for AFB smears • One positive smear sufficient for diagnosis of smear+ PTB in HIV+ persons • Two negative AFB smears sufficient for diagnosis of SN PTB in HIV+ persons (plus compatible CXR and decision to treat with full course of anti-TB therapy) • Different algorithms for ambulatory and seriously ill patients (with danger signs)

  5. Diagnosis of SN PTB in HIV+ PersonsNew Diagnostic Algorithm (2) • Chest radiograph (CXR) required earlier in diagnostic process • Cultures should be done when available • Reduced number of visits to complete diagnostic process • Single course of antibiotic • Non-response not required for diagnosis

  6. Diagnosis of Extrapulmonary TB (EPTB) in HIV+ Persons • New guidelines developed for EPTB • Initial HIV DTC • Lymphatic: needle aspiration • Pleural: aspiration, CXR • Disseminated: CXR, blood cultures • TB meningitis: LP

  7. Diagnosis of SN PTB and EPTB in HIV+ Persons: Implications • Policy implementation in NTPs • Expanded HIV DTC needed • Facilities and training for CXR • Upgraded and expanded TB laboratory services (culture capability) • Training and services for EPTB diagnosis • Systematic evaluation of new algorithms needed to assess feasibility, cost, and impact

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