Haileyesus Getahun Stop TB Department WHO

1. 13th TB/HIV Core Group Meeting, April 17-18, 2008, New York, USA Intensified TB case finding among people living with HIV: what are the challenges of current strategies? Haileyesus Getahun Stop TB Department WHO

2. Outline of presentation • Global implementation of TB case finding • Examples of country screening strategies • Review of evidence on screening strategies • Challenges • Conclusions

3. Countries with policy on intensified TB case finding among PLHIV, 2006 (N=109) Key No policy on ICF With policy on ICF The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2006. All rights reserved

4. Key No reported activity Countries reporting ICF The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2006. All rights reserved Countries reported TB screening among PLHIV, 2006 (N= 44) • 0.96% of PLHIV are screened for TB globally • South Africa and Russia report 68% of the screened PLHIV * Brazil did not report for 2006

5. Percentage of PLHIV screened for TB in countries with 80% of the global burden, 2006.

6. Proportion of PLHIV screened and diagnosed with TB in selected countries, 2006 29% 20% 31% 8% 72%

7. Examples of TB screening tool from countries

8. National screening strategy: Rwanda 3-6 months

9. Symptoms and signs Adults (any of) 1. Cough (of any duration)? 2. Blood stained sputum? 3. Night sweats >2 weeks 4. Fever ? 5. Weight loss? 6. Chest pain? 7. Breathlessness? 8. Fatigue? 9. History of previous TB treatment? 10. History of close contact with a person confirmed to have TB? 11. Swellings in the neck, armpits or elsewhere? 12: Diarrhea for more than two weeks? Symptom and signs Children (any of) 1. Cough: (of any duration)? 2. Blood stained sputum? 3. Night sweats >2 weeks 4. Fever? Of any duration? 5. Weight loss? 6. Chest pain? 7. Fast Breathing? 8. Fatigue? 9. History of previous TB treatment? 10. History of close contact with a person confirmed to have TB? 11. Swellings in the neck, armpits or elsewhere? 12: Diarrhea for more than 2 weeks? 13. Failure to thrive? National screening strategy: Kenya

10. If any of the symptoms: Cough of 2wks and/or household contact with TB patient Hemoptysis Fever Excessive fatigue/night sweats/loss of apetite Pleuritic chest pain (increasing on cough/deep breathing) Swelling in the neck, arm pit, groin, abdomen, joints etc National screening strategy: India

11. Do you have the following? (one or more) Cough for 2 or more wks? Hemoptysis? Fever for 2 or more wks? Noticeable wt loss for new patients or a 3kg loss in a month? Excessive sweating at night for 2 or more wks? National screening strategy: Tanzania Every month

12. Any of the following Cough more than 3wks Weight loss Fever or night sweats Fatigue/tiredness Loss of appetite Lymph node enlargement National screening strategy: Malawi

13. Observations from country practice • Screening tools vary from country to country • More and more non-specific constitutional symptoms and signs included in tools • Children are not addressed • Presence of nationally recommended screening tool does not always guarantee implementation

14. Review of the published evidence of TB screening strategies

15. Sensitivity= 95% Specificity= 10% Kimerling, et.al – Cambodia,2002IJTLD 2002; 6:988–994

16. Mohammed, et.al. – South Africa, 2004IJTLD 2004: 8:792-795 Sensitivity= 100% Specificity= 88%

17. Sensitivity= 91% Specificity= 59% Sensitivity= 59% Specificity= 76% Day, et. al. – South Africa, 2006IJTLD 2006: 10:523-529

18. Chheng, et.al. – Cambodia,2008IJTLD 2008: 12: S54-S62 Sensitivity= 100% Specificity= 19% Sensitivity= 100% Specificity= 20%

19. Demissie, et.al. – EthiopiaWorld Lung Health Conference 2007 Abstract S11

20. Cain, et.al.Thailand, Cambodia, 2008World Lung Health Conference 2007 Abstract S11 Sensitivity= 91% Specificity= 33%

21. Recalculation on the published algorithms using Thailand and Cambodia data (Courteousy of Cain & Varma, 2008) * In Blue are original figures

22. Recalculation of published algorithmsusing Thailand and Cambodia data (Courteousy of Cain & Varma,2008)

23. Observations from available evidence • Findings are generally inconsistent • Chronic cough more than 2 or 3 wks alone looks insensitive predictor of TB in PLHIV • Role of CXR is not clear and inconsistent

24. Challenges: "Sub-clinical" TB in PLHIV • Lucas et al. AIDS 1991 (Cote D’Ivoire) • Mtei et al. Clin Infect Dis 2004 (Tanzania) • Day et al. Int J Tuberc Lung Dis 2006 (S. Africa) • Wood et al. AJRCCM 2007 (S. Africa) • Corbett et al. PLoS Med 2007 (Zimbabwe)

25. Challenge: implementation issues Standardised screening tool needed but is there enough evidence to develop an optimal one? Screening tool that can rule out active TB disease is needed and how best to link it with IPT? Who administers the standard tool and where? How often should it be administered? Monitoring and evaluation- how should it be recorded and reported?

26. Conclusions • TB screening among PLHIV is poorly implemented and requires urgent action • Standardised screening tool is needed but there is no complete evidence to develop one • Massive research efforts to develop the best and feasible screening tool are urgently needed • Interim tool through meta-analysis of existing data need to be explored through collaboration • "TB dipstick test"- simple and rapid tool is crucial