Tuberculosis in people newly diagnosed with HIV at a large HIV care and treatment center in Northwest Cameroon: Burden, comparative screening and diagnostic yields, and patient outcomes

BACKGROUND: Diagnosis of tuberculosis in people living with HIV is challenging due to non-specific clinical presentations and inadequately sensitive diagnostic tests. The WHO recommends screening using a clinical algorithm followed by rapid diagnosis using the Xpert MTB/RIF assay, and more information is needed to evaluate these recommendations in different settings. METHODS: From August 2012 to September 2013, consecutive adults newly diagnosed with HIV in Bamenda, Cameroon, were screened for TB regardless of symptoms by smear microscopy and culture; the Xpert MTB/RIF assay was performed retrospectively. Time to treatment and patient outcomes were obtained from routine registers. RESULTS: Among 1,149 people enrolled, 940 (82%) produced sputum for lab testing; of these, 68% were women, the median age was 35 years (IQR, 28–42 years), the median CD4 count was 291cells/μL (IQR, 116–496 cells/μL), and 86% had one or more of current cough, fever, night sweats, or weight loss. In total, 131 people (14%, 95% CI, 12–16%) had sputum culture-positive TB. The WHO symptom screening algorithm had a sensitivity of 92% (95%CI, 86–96%) and specificity of 15% (95%CI, 12–17%) in this population. Compared to TB culture, the sensitivity of direct smear microscopy was 25% (95% CI, 18–34%), and the sensitivity of Xpert was 68% (95% CI, 58–76); the sensitivity of both was higher for people reporting more symptoms. Only one of 69 people with smear-negative/culture-positive TB was started on TB treatment prior to culture positivity. Of 71 people with bacteriologically-confirmed TB and known outcome after 6 months, 13 (17%) had died, including 11 people with smear-negative TB and 6 people with both smear and Xpert-negative TB. CONCLUSIONS: Use of the most sensitive rapid diagnostic test available is critical in people newly diagnosed with HIV in this setting to maximize the detection of bacteriologically-confirmed TB. However, this intervention is not sufficient alone and should be combined with more comprehensive clinical diagnosis of TB to improve outcomes.