Tuberculosis Case Finding in HIV-Infected Pregnant Women in Kenya Reveals Poor Performance of Symptom Screening and Rapid Diagnostic Tests

• Type of Material: Article
• Authors: Sylvia M. LaCourse, University of Washington; Lisa Cranmer, Emory University; Daniel Matemo, Kenyatta Natl Hosp; John Kinuthia, Kenyatta Natl Hosp; Barbra A. Richardson, University of Washington; Grace John-Stewart, University of Washington; David J. Horne, University of Washington
• Language: English
• Date: 2016-02-01
• Publisher: Lippincott, Williams & Wilkins
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
• Final Published Version (URL): http://dx.doi.org/10.1097/QAI.0000000000000826
• Title of Journal or Parent Work: Journal of Acquired Immune Deficiency Syndromes
• ISSN: 1525-4135
• Volume: 71
• Issue: 2
• Start Page: 219
• End Page: 227
• Grant/Funding Information: SOURCE OF FUNDING: This work was supported by the National Institute of Allergy and Infectious Diseases and the National Institute of Child Health and Human Development at the National Institutes of Health [grant number K23 AI 85036-01 to DJH, K24 HD054314-06 to GJS, K12 HD000850 to LMC, T32 AI07140 to SML], the National Center for Research Resources at the National Institutes of Health [grant number UL1TR000423] and the Firland Foundation.
• Keywords: Xpert; RISK; CHILD HEALTH; PREVENTION; tuberculosis; PULMONARY TUBERCULOSIS; POSTPARTUM WOMEN; ACTIVE TUBERCULOSIS; ACCURACY; Infectious Diseases; pregnancy; urine TB LAM; HIV; Immunology; ANTIRETROVIRAL THERAPY; SOUTH-AFRICA; Life Sciences & Biomedicine; INDIVIDUALS; Science & Technology; screening
• Research Categories: Health Sciences, Epidemiology

Abstract

Background: Tuberculosis (TB) during pregnancy in HIV-infected women is associated with poor maternal and infant outcomes. There are limited data on TB prevalence, optimal TB screening, and performance of rapid diagnostics in pregnant HIV-infected women. Methods: We conducted a cross-sectional study among HIV-infected pregnant women seeking antenatal care in western Kenya. After a standardized questionnaire, sputum smear microscopy for acid-fast bacilli, mycobacterial liquid culture, GeneXpert MTB/RIF (Xpert), urine lipoarabinomannan, and tuberculin skin testing were performed. We determined prevalence and correlates of culture-confirmed pulmonary TB, and compared diagnostic performance of World Health Organization (WHO) symptom screening and rapid diagnostic tests to sputum culture. Results: Between July 2013 and July 2014, we enrolled 306 women. Among 288 women with a valid sputum culture result, 54% were on antiretroviral treatment, median CD4 cell count was 437 cell per cubic millimeter (IQR 342-565), and prevalence of culture-confirmed pulmonary TB was 2.4% (confidence interval: 1.0% to 4.9%). Cough >2 weeks (P 0.04) and positive tuberculin skin testing (≥5 mm, P 0.03) were associated with pulmonary TB. Women with TB were 23-fold (95% confidence interval: 4.4 to 116.6) more likely to report a household member with TB symptoms (P 0.002). WHO symptom screen (43%), acid-fast bacilli smear (0%), Xpert (43%), and lipoarabinomannan (0%) had low sensitivity but high specificity (81%, 99%, 99%, and 95%, respectively) for pulmonary TB. Conclusions: HIV-infected pregnant women had appreciable prevalence of pulmonary TB despite modest immunosuppression. Current TB screening and diagnostic tools perform poorly in pregnant HIV-infected women. Adapted TB screening tools that include household member TB symptoms may be useful in this population.