Authors: A. von Braun(1), C. Sekaggya(1), L. Henning(2), R. Nakijoba(1), I. Ariko(1), J. Mayito(1), D. Nalwanga(1), S. Okware(1), B. Castelnuovo(1), J. Fehr (2), A. Kambugu(1)
1) Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
2) Division of Infectious Diseases and Infection Control, University Hospital Zurich, University of Zurich, Switzerland
Key words: tuberculosis, HIV, screening, follow-up
Aims: In this study, we aimed to assess the clinical outcome of patients classified as having “no pulmonary TB” (PTB) after screening according to the WHO algorithm at the TB-HIV integrated clinic of the Infectious Diseases Institute (IDI) in Kampala, Uganda.
Methods: Patients presenting at IDI with cough for more than two weeks are referred to the TB-HIV integrated clinic and screened for PTB according to the WHO algorithm. We retrospectively analysed data on all patients screened for PTB between April 29 and July 9 2013 in which screening results were negative. Information was collected from the screening log, the clinic files and the electronic medical records from the time of screening up to October 2014. Patients not seen at the IDI at least every 3 months since the initial screening visit were additionally contacted by telephone for information on their outcome.
Results: During the analysed period 73 HIV-infected adults were screened for PTB (Figure). Of these, 41 (56%) patients with negative results for microscopy (33/41; 80.5%) and/or GeneXpert MTB/RIF (11/41; 26.8%) were classified as “no PTB” on the basis of clinical and radiological findings. Female patients accounted for 68.3% (28/41) and the median age was 36 years (range: 20-65, IQR). Median CD4 cell count of all subjects was 312/ul (IQR: 224-435), and 48.8% (20/41) were on antiretroviral treatment (ART) at the time of TB screening. All patients with negative screening results were treated with antibiotics for presumed lower respiratory tract infection. The majority of these patients (29/41; 70.1%) experienced complete resolution of symptoms. Due to lack of clinical improvement on antibiotic treatment 6/41 (14.6%) were re-assessed and diagnosed with TB within 3 months, which puts the rate of delayed TB cases after initial screening at 15.8% (6/38). Our analysis further revealed that 14.6% (6/41) were lost to follow-up after screening; 2 patients (33 %) were not reachable by phone while the remaining 4 (66%) were reported to have died by family members.
Conclusions: Our findings emphasize the importance of active tracking and equally close monitoring of HIV-infected patients independently of TB screening results. The integrated TB-HIV clinic at the IDI therefore plans to adapt internal standard operating procedures accordingly. Patients screened for TB will be followed up two weekly for three months and actively tracked through phone calls and home visits if they do not return for appointments.