Intensive Tuberculosis Screening for HIV-Infected Patients Starting Antiretroviral Therapy in Durban, South Africa
Intensive Tuberculosis Screening for HIV-Infected Patients Starting Antiretroviral Therapy in Durban, South Africa
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DOI：
10.1086/656282
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发表时间：
2010-10-01
影响因子：
11.8
通讯作者：
Freedberg, Kenneth A.
中科院分区：
文献类型：
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作者：
Bassett, Ingrid V.;Wang, Bingxia;Freedberg, Kenneth A.
背景。世界卫生组织 (WHO) 建议将咳嗽作为人类免疫缺陷病毒 (HIV) 感染患者结核病筛查的触发因素，并以抗酸杆菌 (AFB) 涂片作为初步诊断测试。我们的目标是评估在南非德班开始抗逆转录病毒治疗 (ART) 的 HIV 感染患者中进行更强化的结核病筛查的效果和成本。方法。我们前瞻性地招募了 2007 年 5 月至 2008 年 5 月期间接受 ART 培训的成年人，无论其结核病体征/症状如何。症状筛查后，患者咳痰进行 AFB 涂片、结核聚合酶链反应 (PCR) 和分枝杆菌培养。将不同症状和测试单独和组合的敏感性和特异性与6周结核培养结果的参考标准进行比较。项目成本包括人员、材料和文化。结果。 1035 名受试者中，487 名（59%）为女性； CD4 细胞计数中位数为 100 个细胞/μL。共有 210 名受试者 (20%) 正在接受结核病治疗并被排除。其余 825 名受试者中，158 名（19%）痰培养呈阳性，其中 14 名（9%）AFB 涂片呈阳性，82 名（52%）报告有咳嗽。咳嗽、其他症状、AFB 涂片和胸片的组合具有 93% 的敏感性（95% 置信区间，88%-97%）和 15% 的特异性（95% 置信区间，13%-18%）。每增加一个结核病病例，包括培养在内的强化筛查的增量成本为 360 美元。结论。在南非德班，近 20% 开始接受 ART 的患者患有未确诊的培养阳性肺结核。尽管有世界卫生组织的建议，但咳嗽和 AFB 涂片对于筛查来说都不够敏感。在艾滋病毒和结核病高发地区，无论症状如何，都应在开始 ART 之前进行结核病痰培养。
Background. The World Health Organization (WHO) recommends cough as the trigger for tuberculosis screening in human immunodeficiency virus (HIV)-infected patients, with acid-fast bacillus (AFB) smear as the initial diagnostic test. Our objective was to assess the yield and cost of a more intensive tuberculosis screening in HIV-infected patients starting antiretroviral therapy (ART) in Durban, South Africa.Methods. We prospectively enrolled adults, regardless of tuberculosis signs/symptoms, who were undergoing ART training from May 2007 to May 2008. After the symptom screen, patients expectorated sputum for AFB smear, tuberculosis polymerase chain reaction (PCR), and mycobacterial culture. Sensitivity and specificity of different symptoms and tests, alone and in combination, were compared with the reference standard of 6-week tuberculosis culture results. Program costs included personnel, materials, and cultures.Results. Of 1035 subjects, 487 (59%) were female; median CD4 cell count was 100 cells/mu L. A total of 210 subjects (20%) were receiving tuberculosis treatment and were excluded. Of the remaining 825 subjects, 158 (19%) had positive sputum cultures, of whom 14 (9%) had a positive AFB smear and 82 (52%) reported cough. The combination of cough, other symptoms, AFB smear, and chest radiograph had 93% sensitivity (95% confidence interval, 88%-97%) and 15% specificity (95% confidence interval, 13%-18%). The incremental cost of intensive screening including culture was $360 per additional tuberculosis case identified.Conclusions. Nearly 20% of patients starting ART in Durban, South Africa, had undiagnosed, culture-positive pulmonary tuberculosis. Despite WHO recommendations, neither cough nor AFB smear were adequately sensitive for screening. Tuberculosis sputum cultures should be performed before ART initiation, regardless of symptoms, in areas with a high prevalence of HIV and tuberculosis.