1. 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

2. Outline of presentation What is intensified case finding? Global implementation of TB case finding Challenges Conclusions

3. 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.

4. 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.

5. Percentage of PLHIV screened for TB in countries with 80% of the global burden, 2006.

6. Proportion of PLHIV screened and diagnosed with TB in selected countries, 2006 29% 8%20% 31%

7. Country Screening Tools

8. National screening strategy: Kenya Symptoms and signs Adults (any of) 1. Cough (of any duration)? 2. Blood stained sputum? 3. Night sweats >2 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 >2 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?

9. 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

10. 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

11. 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?

12. Review of some published evidence of TB screening strategies

13. Kimerling, et.al – Cambodia,2002 IJTLD 2002; 6:988–994 Population441 HIV+ in home-based care Gold stn.Single sputum culture # with TB41 (9%) with culture-confirmed TB CoughCough >3 weeks 65% sensitive, 33% specific AlgorithmAny 1 of: - cough>3 wks - hemoptysis - weight loss - fever - night sweats - weakness No information on role of CXR Sensitivity= 95% Specificity= 10%

14. Day, et. al. – South Africa, 2006 IJTLD 2006: 10:523-529 Population899 HIV-infected miners being evaluated for IPT Gold Stn.Culture positive or clinical improvement # with TB44 (5%) patients met definition for TB, 35 culture + CoughCough >3 weeks 14% sensitive, 88% specific Algorithm Any 1 of - night sweats - new or worsening cough - weight loss >5% - abnormal CXR. Combination of - night sweats - cough - reported weight loss CXR increased the sensitivity of the screening Sensitivity= 91% Specificity= 59% Sensitivity= 59% Specificity= 76%

15. Demissie, et.al. – Ethiopia World Lung Health Conference 2007 Abstract S11 SettingAddis Ababa, Ethiopia – community hospital Study pop.438 newly diagnosed HIV+ Gold Stn.Concentrated sputum smear and culture # with TB32 (7%) with culture-confirmed TB CoughCough> 2 wks is 44% sensitive, 76% specific AlgorithmCough or fever – 75% sensitivity, 57% specificity CXR improved sensitivity to 91% (at a cost of specificity)

16. 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 don’t. Chronic cough more than 2 or 3 wks alone looks insensitive predictor of TB in PLHIV Role of CXR is not clear and inconsistent

17. 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)

18. 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!

19. 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