Diagnosis of smear-negative pulmonary tuberculosis in people with HIV infection or AIDS in resource-constrained settings: informing urgent policy changes

• Published in: The Lancet (British edition) Vol. 369; no. 9578; pp. 2042 - 2049
• Main Authors: Getahun, Haileyesus, Dr, Harrington, Mark, MA, O'Brien, Rick, MD, Nunn, Paul, FRCP
• Format: Journal Article
• Language: English
• Published: London Elsevier Ltd 16.06.2007; Lancet; Elsevier Limited
• Subjects: Acquired immune deficiency syndrome; Africa - epidemiology; AIDS; AIDS-Related Opportunistic Infections - diagnosis; AIDS-Related Opportunistic Infections - epidemiology; AIDS-Related Opportunistic Infections - mortality; Algorithms; Antibiotics; Bacterial diseases; Bacterial diseases of the respiratory system; Biological and medical sciences; Diagnosis; Diagnostic software; Diagnostic systems; Epidemics; Female; Fluorescence; Fluorescence microscopy; General aspects; Health facilities; Health Policy; Health services; HIV; Human bacterial diseases; Human immunodeficiency virus; Human resources; Humans; Infections; Infectious diseases; Internal Medicine; Liquefaction; Male; Medical diagnosis; Medical sciences; Microscopy; Mortality; Peer review; Public health; Quality assurance; Radiography; Smear; Sputum; System effectiveness; Systematic review; Technological change; Tuberculosis; Tuberculosis and atypical mycobacterial infections; Tuberculosis, Pulmonary - diagnosis; Tuberculosis, Pulmonary - epidemiology; Tuberculosis, Pulmonary - mortality; Africa; Uganda; Zambia; Malawi; Ethiopia; Immunopathology; Lung disease; Respiratory disease; Pulmonary tuberculosis; Resource; AIDS; Health service; Mycobacterial infection; Change; Immune deficiency; Infection; Medicine; Health policy; Viral disease; Bacteriosis; Smear; Diagnosis; Public health
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(07)60284-0

Summary The HIV epidemic has led to large increases in the frequency of smear-negative pulmonary tuberculosis, which has poor treatment outcomes and excessive early mortality compared with smear-positive disease. We used a combination of systematic review, document analysis, and global expert opinion to review the extent of this problem. We also looked at policies of national tuberculosis control programmes for the diagnosis of smear-negative pulmonary tuberculosis to assess their coverage, identify the diagnostic difficulties, and find ways to improve the diagnosis of this type of tuberculosis, with a focus on resource-constrained settings with high HIV infection rates. We propose that the internationally recommended algorithm for the diagnosis of smear-negative pulmonary tuberculosis should be revised to include HIV status, severity of AIDS and tuberculosis, and early use of chest radiography in the decision tree. Increased use of promising methods of diagnosis such as sputum liquefaction and concentration and increased availability of fluorescence microscopy should be explored and encouraged. Culturing of sputum in resource-constrained settings with high HIV infection rates should also be encouraged, existing facilities should be made full use of and upgraded, and effective quality-assurance systems should be used. Innovative ways to address human resources issues involved in addressing the diagnostic difficulties are also needed. The development of rapid, simple, and accurate tuberculosis diagnostic tools with applicability at point of care and remote location is essential. To achieve these goals, greater political commitment, scientific interest, and investment are needed.