Uptake and disparities in tuberculosis screening using urine-lipoarabinomannan among patients with advanced human immunodeficiency virus-disease in Africa: A systematic review.

Abstract

Background: Due to low bacteria count and high likelihood of having extrapulmonary tuberculosis (TB) among patients with advanced human immunodeficiency virus (HIV) disease, the World Health Organization (WHO) recommended the use of urine lateral flow urine lipoarabinomannan (LF-LAM) or sputum-Xpert to screen for TB.

Aim: To estimate pooled prevalence of TB screening uptake, TB diagnosis, TB treatment initiation and mortality among patients with advanced HIV disease in Africa.

Methods: PubMed, Cochrane Library and EMBASE were searched for articles published between January 2011 and December 2024. TB screening uptake was defined as percentage of patients with advanced HIV disease (CD4 ≤ 200 cells/mm³ or WHO stage III/IV) who tested for TB. Using random effects models, we computed the pooled estimate of TB screening uptake, TB prevalence, TB treatment initiation and mortality and their corresponding 95%CIs. Stratified analysis to compare uptake of TB testing and TB prevalence between children vs adults and multisite vs single site studies was performed.

Results: A total of nineteen studies with 16065 people with advanced HIV disease were analyzed. The pooled prevalence of TB screening uptake was 64.6% (95%CI: 49.2-80.1). The pooled prevalence of TB was 29.4% (95%CI: 22.0-36.8), and TB treatment initiation was 77.9% (95%CI: 63.9-91.8), and mortality was 19.5% (95%CI: 8.9-30.0). The pooled prevalence of TB testing uptake was significantly lower among children compared to adults (28.2% vs 66.4%, P = 0.003) and lower for multi-sites compared to single site studies (58.8% vs 82.9%, P = 0.002). The pooled prevalence of TB was significantly lower among children compared to adults (24.2% vs 27.6%, P = 0.012) and higher among studies that involved multi vs single sites (30.0% vs 21.9%, P = 0.001).

Conclusion: Four in ten people with advanced HIV disease were not screened for TB as recommended by the WHO, indicating significant gaps in identifying patients with TB. Excluding patients with evidence of TB is critical to avoid exposing them to subtherapeutic levels of anti TB treatment.