Completion of the tuberculosis care cascade in a community‐based HIV linkage‐to‐care study in South Africa and Uganda

Abstract

IntroductionTuberculosis (TB) is the leading cause of HIV‐associated mortality in Africa. As HIV testing, linkage to care and antiretroviral treatment initiation intensify to meet UNAIDS targets, it is not known what effect these efforts will have on TB detection and prevention. We aimed to characterize the TB care cascade of screening, diagnostic testing, treatment and provision of isoniazid preventive therapy (IPT) in a study of community‐based HIV screening and linkage to care and determine whether symptom screening results affected progress along the cascade.MethodsBetween June 2013 and March 2015, HIV‐infected adults enrolled in the Linkages study, a multi‐site, community‐based, randomized HIV screening and linkage‐to‐care study in South Africa and Uganda. All participants were screened for TB symptoms at entry after testing positive for HIV and referred to local clinics for care. During the 9 month follow‐up, participants were periodically surveyed about clinic linkage and initiation of HIV care as well as subsequent TB testing, treatment, or IPT. We compared outcomes between persons with and without a positive symptom screen at baseline using descriptive statistics and Poisson regression to calculate relative risks of outcomes along the care cascade.Results and discussionOf the 1,325 HIV‐infected adults enrolled, 26% reported at least one TB symptom at the time of HIV diagnosis. Loss of appetite and fever were the most commonly reported symptoms on a TB symptom screen. Despite 92% HIV linkage success, corresponding TB linkage was incomplete. Baseline TB symptoms were associated with an increased risk of a TB diagnosis (relative risk 3.23, 95% CI 1.51 to 6.91), but only 34% of symptomatic persons had sputum TB testing. Fifty‐five percent of participants diagnosed with TB started TB treatment. In South Africa, only 18% of asymptomatic participants initiated IPT after linkage to HIV care, and presence of symptoms was not associated with IPT initiation (relative risk 0.86 95% CI 0.6 to 1.23).Conclusions HIV linkage to care interventions provide an opportunity to improve completion of the TB care cascade, but will require additional support to realize full benefits.

Home-based tuberculosis contact investigation in Uganda: a household randomised trial

“…Finally, because intervention households were distributed among 17 CHWs, some CHWs only rarely collected sputum, limiting the opportunities to gain proficiency. Low success rates of sputum collection have been observed in other similar settings [9], including among PLWHs [24]. Future studies should evaluate strategies to promote health worker confidence and competence in sputum collection, including delivery of instructional videos via phones or tablet computers [25].…”

Diagnostic practices and estimated burden of tuberculosis among children admitted to 13 government hospitals in Kenya: An analysis of two years’ routine clinical data

“…Guidelines suggest clinicians should follow a series of steps spanning assessment, diagnosis and treatment, which can be represented in a care cascade. Cascades have been extensively used in HIV studies to describe quality of care [17–21], and are now increasingly used in TB care [22–25]. We identified one study using the cascade concept in paediatric TB [26] and another in adolescent TB [27] but none specifically looking at paediatric in-patient care.…”

Cascade Variabilities in TB Case Finding among People Living with HIV and the Use of IPT: Assessment in Three Levels of Care in Cross River State, Nigeria

“…In this study, a lot more PLHIVs (210%) were sent to the TB diagnostic unit for definitive TB diagnosis than the number that received clinical screening. This is contrary to documentations in pilot programs in Sub-Saharan Africa where the true cascade is followed through, many of them showing far less presumptive TB patients reaching the diagnostic point than the number originally screened positive for TB [10]. Der et al (2020) showed in a similar cascade analysis in rural and urban Ghana that most of the losses are due to the long travel distance between the service delivery points [11].…”