PLoS ONE (Jan 2017)

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

  • Yasmeen Hanifa,
  • Katherine L Fielding,
  • Violet N Chihota,
  • Lungiswa Adonis,
  • Salome Charalambous,
  • Nicola Foster,
  • Alan Karstaedt,
  • Kerrigan McCarthy,
  • Mark P Nicol,
  • Nontobeko T Ndlovu,
  • Edina Sinanovic,
  • Faieza Sahid,
  • Wendy Stevens,
  • Anna Vassall,
  • Gavin J Churchyard,
  • Alison D Grant

DOI
https://doi.org/10.1371/journal.pone.0181519
Journal volume & issue
Vol. 12, no. 8
p. e0181519

Abstract

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The 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.To develop a diagnostic prediction model for TB, for symptomatic adults attending for routine HIV care, to prioritise TB investigation.Cohort study exploring a TB testing algorithm.HIV clinics, South Africa.Representative 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.TB, 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.Overall, 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 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.Our clinical score may help prioritise TB investigation among symptomatic individuals.