“ICF is the gatekeeper for everything else [IPT and IC],” said Dr Wafaa El-Sadr, of ICAP and Columbia University, “what happens next is the problem.” See HATIP 104 & 105). In addition, Dr El-Sadr said, ICF that leads to early diagnosis (and treatment) of TB could help reduce immune response inflammatory syndrome and improve outcomes on ART.
“We have clear reasons to intensify case finding,” agreed Ezio Santos-Filho, member of the Stop TB Coordinating Board and an HIV/TB treatment advocate. “It should be common sense — but it’s not.” The Brazilian activist speaks from experience: he has had TB twice.
Even though ICF is policy in most countries, so far that policy has not been translated into operational guidelines or standard operating procedures. Screening tools have not been standardised and screening is not occurring in all the appropriate settings — wherever people with HIV congregate or come into contact with health services.
According to meeting participants, programmes want more clarity on the best symptom complex to include on a TB screening tool that could be easily administered by trained lay healthcare staff.
One persistent question in some countries is whether chest x-rays should be required to exclude TB — in fact, in some Asian countries, clinicians rely upon them exclusively — although studies suggest that they miss a lot of TB cases. Studies where they have been added to symptom screens have yielded mixed results, some suggesting that they do not greatly improve sensitivity for TB, others suggesting that they do.
But chest-x-rays are rarely possible in most settings.“I find it hard to imagine a chest x-ray as a screening tool —it’s overwhelming if not impossible requiring it in most settings where we work because of the huge numbers of patients involved and because of the lack of availability of chest x-ray even for diagnostic purposes; as well as the need for repeated screening in individuals in HIV care and treatment,” said Dr El-Sadr.
Family contacts also need to be screened since TB can spread in the home. “TB is a family disease,” said Dr El-Sadr. “If you have one person in a household with TB, you’ll have others with TB infection.” However, screening in children is particularly difficult and existing history/symptom scoring systems perform poorly, especially in children who are malnourished or living with HIV. More research is desperately needed to improve TB diagnosis in children.
Another issue is that many programmes have resisted updating their standard TB screening tools that rely on questions about chronic cough (for 3 or more weeks) despite the fact it has been shown to be poorly sensitive as the single gatekeeper symptom for TB in people with HIV.
More sensitive screens that capture up to 90% of the patients with TB would be preferred, but they will dramatically increase the demand on laboratory services to diagnose TB. And, unless diagnostic services are co-located, or specimen transport systems are arranged, patient must be referred to another facility — which isn’t always effective.
“Referral systems are mostly on paper,” said Mr Santos-Filho. “When people have a positive screen, what do we do? If they are referred somewhere else for diagnosis, are they properly encouraged? Do they have the means? People do not have money to go the TB clinic that may be far away. For instance, in Mexico City, the brand new HIV centre doesn’t do microscopy so people have to travel two hours by bus or do a culture.”
And yet there are models where ICF has been scaled up successfully, such as in India’s voluntary testing and counselling clinics, which Dr Puneet Dewan described to the Three I’s participants (a similar presentation was covered in HATIP 105). In addition, Dr Dewan described a more recent collaboration between the national TB programme and Avahan — a Gates Foundation-supported network of NGOs, in which STI clinic staff, outreach staff and peer educators have been trained to perform routine symptom screening.
One of the meeting participants, Dr Kudur Prakash, Deputy Director of the SANKALP Project in Bangalore, works with this network, and said that the outreach workers bring patients into clinics for TB screening, and then there will either be an accompanied referral to the nearest microscopy centre, or the sputum can be collected in the clinic and transported to the lab.
“There’s beginning to be an effort to try to reach beyond the walls of the facilities to reach people at home,” said Dr El-Sadr. “There’s a lot of potential to use the systems for support, care and treatment for HIV for case finding in households — there are lots of motorcycles and bicycles out there, peer workers going out to the homes, outreach workers trying to ensure that people are brought back in for services. It is potentially possible to layer case-finding within the community using this incredible workforce.”