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Recommendations on specific tools to be used for screening people living with HIV are described in detail in Section 3. Persons living with HIV who have a positive or abnormal screening test should go on to have primary diagnostic tests to confirm or rule out TB disease including an mWRD and lateral flow urine lipoarabinomannan assay (LF-LAM), if eligible (8).
People living with HIV are approximately 19 times more likely to develop TB disease than those without HIV; in 2019, an estimated 44% of people living with HIV who also had TB disease did not reach care, and 30% of all HIV-related deaths were due to TB (1). Thus, ensuring early detection and treatment for TB among all people living with HIV is crucial for reducing morbidity and mortality in this group.
Populations with structural risk factors for TB are those that are at increased risks of TB and of poor health outcomes from TB due to structural determinants in their environment, defined as the conditions that generate or reinforce social stratification (e.g. socioeconomic inequalities, population growth, urbanization), and therefore give rise to an unequal distribution of key social determinants of TB epidemiology, such as poor housing, poverty and malnutrition, which in turn influence exposure to risk, vulnerability and ability to recover after developing the disease (16,17).
The magnitude and balance of desirable and undesirable effects vary according the epidemiological conditions (the prevalence of TB and of risk factors) and the intensity of the screening intervention being implemented (the coverage of the population and the sensitivity of the screening test and algorithm). There is currently no evidence that population-wide screening using less sensitive screening algorithms that begin with symptom screening are effective at reducing the population prevalence or transmission of TB.
Standard monitoring and evaluation procedures may be complemented by operational research aimed at improving the performance of screening in the local setting as well as research aimed at improving the global evidence base for screening. Topics that may be explored include:
Contact screening should always be done when a person with TB has any of the following characteristics: bacteriologically confirmed pulmonary TB, proven or presumed multidrug-resistant TB or extensively drug-resistant TB, is a person living with HIV or is a child younger than 5 years. Among contacts of patients with bacteriologically confirmed TB, the weighted pooled prevalence of TB was 3.4% (95% CI: 2.9–3.8). Among contacts of patients with multidrug-resistant or extensively drug-resistant TB the weighted pooled prevalence of TB was 3.7% (95% CI: 2.4–5.3).
Further evidence is needed about the performance of CAD software stratified according to the characteristics of the individual being evaluated (e.g. by smear status, HIV status, age cohort, history of TB, smoking status, sex) to allow for better setting-specific and patient-specific calibration of CAD programmes.
More research on users’ perspectives is needed about CAD technologies in TB screening and triage, including their perceived acceptability to patients, providers and other stakeholders.
The GDG considered data on using mWRDs for screening children and adolescent outpatients accessing health care. They felt that the data, which included 2 studies with 787 participants and had results demonstrating substantial heterogeneity, represented insufficient evidence to establish an accurate and reliable estimate of the diagnostic accuracy of mWRDs, and, thus, the GDG decided not to issue a recommendation for or against their use as a screening tool for children and adolescents.
TB screening tools are designed to distinguish people with a higher probability of having TB disease from those with a low probability and can be assumed to be free of TB disease. They are not intended to provide a definitive diagnosis. In general, they need to be able to be implemented easily and relay results rapidly in order to be informative in a screening context. Screening tests need to be followed by a diagnostic test, offered as part of a comprehensive clinical evaluation, to confirm or rule out TB disease in individuals who screen positive.
Well-designed clinical trials are needed to strengthen the evidence about the accuracy, effectiveness (including the impact on patient-important outcomes such as mortality), feasibility and cost implications of using the W4SS, CRP, CXR and mWRD to screen for TB across all HIV subpopulations in settings with low, medium and high burdens of HIV and TB with and without high ART coverage.