A Clinical Scoring Algorithm for Determination of the Risk of Tuberculosis in HIV-Infected Adults: A Cohort Study Performed at Ethiopian Health Centers

Balcha, Taye Tolera; Skogmar, Sten; Sturegård, Erik; Schӧn, Thomas; Winqvist, Niclas; Reepalu, Anton; Jemal, Zelalem Habtamu; Tibesso, Gudeta; Björk, Jonas; Björkman, Per

doi:10.1093/ofid/ofu095

Cited by 33 publications

(42 citation statements)

References 32 publications

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“…Ninety-five percent (95.67%) of the visitors recorded in the study cohort had TB screening. Routine TB screening is in line with the WHO recommendations (18), and such high TB screening scores among PLHIV has also been reported in other studies (12,(19)(20)(21). TB screening is known to be good to rule out TB disease in PLHIV with a negative predictive value of 97.7% (22).…”

Section: Discussionsupporting

confidence: 71%

Performance of and Factors Associated With Tuberculosis Screening and Diagnosis Among People Living With HIV: Analysis of 2012–2016 Routine HIV Data in Tanzania

Maokola

Ngowi

Lawson

et al. 2020

Front. Public Health

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Section: Discussionsupporting

confidence: 71%

Performance of and Factors Associated With Tuberculosis Screening and Diagnosis Among People Living With HIV: Analysis of 2012–2016 Routine HIV Data in Tanzania

Maokola

Ngowi

Lawson

et al. 2020

Front. Public Health

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“…Our clinical scoring system compares favourably, in terms of simplicity and ability to identify patients with lowest prevalence of TB, with that derived by Balcha et al, also as a second step after WHO symptom screen, for ART naïve patients attending for HIV care in Ethiopia. [ 8 ] In this smaller and as yet unvalidated (internally or externally) study, amongst 569 WHO tool positive patients, a more complex score which included Karnofsky status, MUAC, peripheral lymphadenopathy and anaemia, using a cut off of ≥2 was able to avoid investigation of 45% (255/569) of whom 8% (20/255) had culture confirmed TB. Rudolf et al derived TBscore II from a population in Bissau who were seeking care for symptoms suggestive of TB, of whom only 164 were HIV-positive.…”

Section: Discussionmentioning

confidence: 99%

“…These models are increasingly abundant in the literature, with variable quality of construction as well as reporting, as highlighted by the recent TRIPOD statement which presents a recommended reporting framework. [ 6 , 7 ] Clinical scoring algorithms have been developed for PLHIV with symptoms suggestive of TB to prioritise investigation for those with greatest probability of having TB prior to antiretroviral therapy (ART) initiation, [ 8 ] and improve case finding, [ 9 ] but these algorithms have not been validated or applied to patients on ART.…”

Section: Introductionmentioning

confidence: 99%

A clinical scoring system to prioritise investigation for tuberculosis among adults attending HIV clinics in South Africa

et al. 2017

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BackgroundThe World Health Organization (WHO) recommendation for regular tuberculosis (TB) screening of HIV-positive individuals with Xpert MTB/RIF as the first diagnostic test has major resource implications.ObjectiveTo develop a diagnostic prediction model for TB, for symptomatic adults attending for routine HIV care, to prioritise TB investigation.DesignCohort study exploring a TB testing algorithm.SettingHIV clinics, South Africa.ParticipantsRepresentative sample of adult HIV clinic attendees; data from participants reporting ≥1 symptom on the WHO screening tool were split 50:50 to derive, then internally validate, a prediction model.OutcomeTB, defined as “confirmed” if Xpert MTB/RIF, line probe assay or M. tuberculosis culture were positive; and “clinical” if TB treatment started without microbiological confirmation, within six months of enrolment.ResultsOverall, 79/2602 (3.0%) participants on ART fulfilled TB case definitions, compared to 65/906 (7.2%) pre-ART. Among 1133/3508 (32.3%) participants screening positive on the WHO tool, 1048 met inclusion criteria for this analysis: 52/515 (10.1%) in the derivation and 58/533 (10.9%) in the validation dataset had TB. Our final model comprised ART status (on ART > 3 months vs. pre-ART or ART < 3 months); body mass index (continuous); CD4 (continuous); number of WHO symptoms (1 vs. >1 symptom). We converted this to a clinical score, using clinically-relevant CD4 and BMI categories. A cut-off score of ≥3 identified those with TB with sensitivity and specificity of 91.8% and 34.3% respectively. If investigation was prioritised for individuals with score of ≥3, 68% (717/1048) symptomatic individuals would be tested, among whom the prevalence of TB would be 14.1% (101/717); 32% (331/1048) of tests would be avoided, but 3% (9/331) with TB would be missed amongst those not tested.ConclusionOur clinical score may help prioritise TB investigation among symptomatic individuals.

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“…This approach is also used in HIV care, especially for estimation of the risk of tuberculosis co-infection [12,13]. Some groups have also attempted to develop algorithms for determination of VF [14–17], but to our knowledge these algorithms are hitherto not in general use nor recommended in ART guidelines.…”

Section: Introductionmentioning

confidence: 99%

Development of an algorithm for determination of the likelihood of virological failure in HIV-positive adults receiving antiretroviral therapy in decentralized care

Reepalu

Balcha

Skogmar

et al. 2017

Global Health Action

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Background: Early identification of virological failure (VF) limits occurrence and spread of drug-resistant viruses in patients receiving antiretroviral treatment (ART). Viral load (VL) monitoring is therefore recommended, but capacities to comply with this are insufficient in many low-income countries. Clinical algorithms might identify persons at higher likelihood of VF to allocate VL resources. Objectives: We aimed to construct a VF algorithm (the Viral Load Testing Criteria; VLTC) and compare its performance to the 2013 WHO treatment failure criteria. Methods: Subjects with VL results available 1 year after ART start (n = 494) were identified from a cohort of ART-naïve adults (n = 812), prospectively recruited and followed 2011–2015 at Ethiopian health centres. VF was defined as VL≥1000 copies/mL. Variables recorded at the time of sampling, with potential association with VF, were used to construct the algorithm based on multivariate logistic regression. Results: Fifty-seven individuals (12%) had VF, which was independently associated with CD4 count <350 cells/mm3, previous ART interruption, and short mid-upper arm circumference (<24cm and <23cm, for men and women, respectively). These variables were included in the VLTC. In derivation, the VLTC identified 52/57 with VF; sensitivity 91%, specificity 43%, positive predictive value (PPV) 17%, negative predictive value (NPV) 97%. In comparison, the WHO criteria identified 38/57 with VF (sensitivity 67%, specificity 74%, PPV 25%, NPV 94%). Conclusions: The VLTC identified subjects at greater likelihood of VF, with higher sensitivity and NPV than the WHO criteria. If external validation confirms this performance, these criteria could be used to allocate limited VL resources. Due to its limited specificity, it cannot be used to determine treatment failure in the absence of a confirmatory viral load.

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A Clinical Scoring Algorithm for Determination of the Risk of Tuberculosis in HIV-Infected Adults: A Cohort Study Performed at Ethiopian Health Centers

Cited by 33 publications

References 32 publications

Performance of and Factors Associated With Tuberculosis Screening and Diagnosis Among People Living With HIV: Analysis of 2012–2016 Routine HIV Data in Tanzania

Performance of and Factors Associated With Tuberculosis Screening and Diagnosis Among People Living With HIV: Analysis of 2012–2016 Routine HIV Data in Tanzania

A clinical scoring system to prioritise investigation for tuberculosis among adults attending HIV clinics in South Africa

Development of an algorithm for determination of the likelihood of virological failure in HIV-positive adults receiving antiretroviral therapy in decentralized care

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