TB is the main cause of hospitalization and mortality among people living with HIV. The assessment of the performance of an mWRD used as a combined TB screening and diagnostic strategy for medical ward patients with HIV included 4 studies in Ghana, Myanmar and South Africa with a total of 639 participants (see Web Annex B, Table 15, and Web Annex C, Table 8). The prevalence of TB in the included studies was 23.8%, ranging from 7% to 26%. The mWRD test assessed in the IPD was primarily the Xpert MTB/RIF assay.
Using the W4SS alone had 96% sensitivity and 11% specificity in the IPD meta-analysis of medical ward inpatients living with HIV, 94% of whom were positive on the W4SS. Thus, the difference in accuracy was minimal between the full screening and diagnostic strategy of using W4SS followed by mWRD and using mWRD alone. Therefore, the value of the W4SS was judged to have limited utility in screening for TB in this population prior to an mWRD test, and the GDG recommended that medical inpatients should be screened and tested with an mWRD, irrespective of symptoms, to inform a decision about whether to treat for TB. A 10% threshold TB prevalence among hospital inpatients living with HIV is recommended, taking into account the TB prevalence among the participants studied and striking a balance between ensuring rapid diagnosis in this critically ill population and the need to avoid overtreatment. In lower prevalence settings, a screening and diagnostic strategy with mWRD alone would give rise to higher numbers of false positives, with overtreatment and the related social and economic consequences, including potential delay in starting ART. This recommendation may not be applicable to settings with a lower pretest probability of TB.