Living with HIV, Dying of TB

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Living with HIV, Dying of TB Intensified TB case
finding among people living with HIV
Adapted from presentation by Colleen
Daniels TB/HIV Advocacy Stop TB Department, WHO
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Outline of presentation

• What is intensified case finding?
• Global implementation of TB case finding
• Challenges
• Conclusions

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Intensified Case Finding (ICF)

• Intensified TB case finding (ICF) is an activity,
  recommended by the World Health Organization
  (WHO), intended to detect possible TB cases as
  early as possible among people living with HIV
• Screening for symptoms and signs of TB
• TB treatment
• TB sputum smear
• - IPT
• ICF is the first step towards making a TB
  diagnosis.

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Intensified Case Finding (ICF)

• TB control programs generally rely on passive TB
  case finding
• People living with HIV are at much greater risk
  of getting TB and if not treated soon enough,
  dying from it
• often aggressive cases including hard-to-diagnose
  smear-negative or extrapulmonary disease.
• ICF consists of using a simple questionnaire
  looking for the signs and symptoms of TB.

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Percentage of PLHIV screened for TB in countries
with 80 of the global burden, 2006.
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Proportion of PLHIV screened and diagnosed with
TB in selected countries, 2006
29
8
20
31
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Country Screening Tools
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National screening strategy Kenya

• Symptoms and signs
• Adults (any of)
• 1. Cough (of any duration)?
• 2. Blood stained sputum?
• 3. Night sweats gt2 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 gt2 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?

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National screening strategy Malawi

• Any of the following
• Cough more than 3wks
• Weight loss
• Fever or night sweats
• Fatigue/tiredness
• Loss of appetite
• Lymph node enlargement

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Screening tools in countries

• 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

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Challenge implementation issues

• Standardised screening tool needed?
• 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?

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Review of some published evidence of TB screening
strategies
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Kimerling, et.al Cambodia,2002IJTLD 2002
6988994
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Day, et. al. South Africa, 2006IJTLD 2006
10523-529
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Demissie, et.al. EthiopiaWorld Lung Health
Conference 2007 Abstract S11
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Some Notes and Observations from available
evidence

• Sesitivity Ability of the test to accurately
  diagnose the presence of disease.
• Specificity Ability of the test to accurately
  identify all people without the condition
• These are both measures of accuracy of a
  screening tool to identify a person with TB, the
  higher the Sensitivity and Specificity the more
  accurate the tool.
• The accuracy of screening are generally
  inconsistent and dependent what types of
  screening questions are asked. Eg the more the
  symptoms the greater the chances of detecting
  anyone with TB, but also the greater the chances
  of wrongly suspecting that people have TB when
  they dont.
• Chronic cough more than 2 or 3 wks alone looks
  insensitive predictor of TB in PLHIV
• Role of CXR is not clear and inconsistent

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Living with HIV, Dying of TB Conclusions

• People with HIV have the right to ask for TB
  screening and diagnosis.
• Check your country's progress in implementing the
  12 collaborative activities and engage with the
  NTP and NAP to call for scale up (Global TB
  Report)

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Conclusions

• Mobilization by civil society urgently needed to
  scale up ICF.
• Community driven to create demand
• Educate increase literacy in communities and at
  health care facilities
• Work with joint TB/HIV national mechanisms to
  rapidly scale up
• Engage in processes such as Global Fund CCMs
• Demand creation
• Myth busting - ensure that arguments about
  challenges to implementation are not a barrier
  (HIV experience) - Just do it!

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Conclusions

• Massive research efforts to develop the best and
  feasible screening tool are urgently needed
• "TB dipstick test"- simple and rapid tool is
  crucial
• Call for investment and increase in laboratory
  capacity and call for adequate referral systems
• Recording and reporting

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