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Kahn D, Pool KL, Phiri L, Chibwana F, Schwab K, Longwe L, Banda BA, Gama K, Chimombo M, Chipungu C, Grotts J, Schooley A, Hoffman RM. Diagnostic Utility and Impact on Clinical Decision Making of Focused Assessment With Sonography for HIV-Associated Tuberculosis in Malawi: A Prospective Cohort Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:28-37. [PMID: 32041772 PMCID: PMC7108937 DOI: 10.9745/ghsp-d-19-00251] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/10/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi. METHODS Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol. RESULTS A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P<.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%. CONCLUSION In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.
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Affiliation(s)
- Daniel Kahn
- Department of Internal Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Kara-Lee Pool
- Department of Radiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | - Kristin Schwab
- Department of Medicine, Division of Pulmonology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | | | - Jonathan Grotts
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Risa M Hoffman
- Department of Medicine, Division of Infectious Disease, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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