review · World Journal of Virology
A systematic review of nineteen studies across Africa evaluated the uptake and outcomes of tuberculosis screening in over sixteen thousand individuals living with advanced HIV disease. Despite World Health Organization guidelines recommending tests such as urine lateral flow lipoarabinomannan, approximately four in ten eligible patients were not screened, resulting in an overall screening uptake rate of roughly sixty-five percent. Among those evaluated, nearly thirty percent were diagnosed with tuberculosis, and over three-quarters of diagnosed patients initiated treatment. However, mortality remained high at nearly twenty percent. Substantial disparities were observed across patient groups: children experienced significantly lower screening uptake than adults, reaching only twenty-eight percent compared to sixty-six percent in adults. Similarly, screening uptake was lower in multi-site studies than in single-site settings, highlighting persistent operational gaps in routine tuberculosis diagnosis for highly vulnerable groups.
Tuberculosis is a major cause of death among people living with advanced HIV disease. Urine-based screening tests are recommended because standard sputum tests often fail in these patients. Demonstrating that over a third of eligible patients, and an even higher proportion of children, miss out on testing helps healthcare programmes target implementation gaps and ensure timely, life-saving treatment.
This work evaluates real-world clinical implementation rather than developing a new product, showing that existing diagnostics such as lateral flow urine lipoarabinomannan tests are underutilised. The findings can guide public health agencies, diagnostic manufacturers, and healthcare providers to design better delivery models and paediatric diagnostic tools, addressing operational barriers in near-market deployment across African healthcare facilities.
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BACKGROUND Due to low bacteria count and high likelihood of having extrapulmonary tuberculosis (TB) among patients with advanced human immunodeficiency virus (HIV) disease, the World Health Organization (WHO) recommended the use of urine lateral flow urine lipoarabinomannan (LF-LAM) or sputum-Xpert to screen for TB. AIM To estimate pooled prevalence of TB screening uptake, TB diagnosis, TB treatment initiation and mortality among patients with advanced HIV disease in Africa. METHODS PubMed, Cochrane Library and EMBASE were searched for articles published between January 2011 and December 2024. TB screening uptake was defined as percentage of patients with advanced HIV disease (CD4 ≤ 200 cells/mm3 or WHO stage III/IV) who tested for TB. Using random effects models, we computed the pooled estimate of TB screening uptake, TB prevalence, TB treatment initiation and mortality and their corresponding 95%CIs. Stratified analysis to compare uptake of TB testing and TB prevalence between children vs adults and multisite vs single site studies was performed. RESULTS A total of nineteen studies with 16065 people with advanced HIV disease were analyzed. The pooled prevalence of TB screening uptake was 64.6% (95%CI: 49.2–80.1). The pooled prevalence of TB was 29.4% (95%CI: 22.0–36.8), and TB treatment initiation was 77.9% (95%CI: 63.9–91.8), and mortality was 19.5% (95%CI: 8.9–30.0). The pooled prevalence of TB testing uptake was significantly lower among children compared to adults (28.2% vs 66.4%, P = 0.003) and lower for multi-sites compared to single site studies (58.8% vs 82.9%, P = 0.002). The pooled prevalence of TB was significantly lower among children compared to adults (24.2% vs 27.6%, P = 0.012) and higher among studies that involved multi vs single sites (30.0% vs 21.9%, P = 0.001). CONCLUSION Four in ten people with advanced HIV disease were not screened for TB as recommended by the WHO, indicating significant gaps in identifying patients with TB. Excluding patients with evidence of TB is critical to avoid exposing them to subtherapeutic levels of anti TB treatment.
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DOI: 10.5501/wjv.v14.i3.107214
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