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Chaisson LH, Semitala FC, Mwebe S, Katende J, Asege L, Nakaye M, Andama AO, Atuhumuza E, Kamya M, Cattamanchi A, Yoon C. Transaminitis prevalence among HIV-infected adults eligible for tuberculosis preventive therapy. AIDS 2022; 36:1591-1595. [PMID: 35730395 PMCID: PMC9391292 DOI: 10.1097/qad.0000000000003299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the prevalence of severe transaminitis precluding tuberculosis (TB) preventive therapy (TPT) initiation for people with HIV (PWH) in a high TB/HIV burden setting. DESIGN/METHODS We conducted a secondary analysis of data from a prospective cohort study of PWH with pre-antiretroviral therapy (ART) CD4 + counts 350 cells/μl or less undergoing systematic TB screening from two HIV clinics in Uganda. For this analysis, we excluded patients with culture-confirmed TB and patients without aspartate transaminase (AST) or alanine transaminase (ALT) levels measured within three months of enrollment. We compared the proportion of patients with any transaminitis (AST or ALT greater than one times the upper limit of normal ULN) and severe transaminitis (AST or ALT >3 times ULN) for patients screening negative for TB by symptoms and for those screening negative by C-reactive protein (CRP). We also assessed the proportion of patients with transaminitis by self-reported alcohol consumption. RESULTS Among 313 participants [158 (50%) women, median age 34 years (IQR 27-40)], 75 (24%) had any transaminitis and six (2%) had severe transaminitis. Of 32 of 313 (10%) who screened negative for TB by symptoms, none had severe transaminitis. In contrast, six-times more PWH screened negative for TB by CRP (194 of 313; 62%), of whom only four (2.1%) had severe transaminitis. Differences in the proportion with any and severe transaminitis according to alcohol consumption were not statistically significant. CONCLUSION Prevalence of severe transaminitis was low among PWH without culture-confirmed TB in this setting, and is therefore, unlikely to be a major barrier to scaling-up TPT.
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Affiliation(s)
- Lelia H Chaisson
- Division of Infectious Diseases, Department of Medicine
- Center for Global Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Fred C Semitala
- College of Health Sciences, Makerere University
- Infectious Diseases Research Collaboration
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Jane Katende
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Lucy Asege
- Infectious Diseases Research Collaboration
| | | | - Alfred O Andama
- College of Health Sciences, Makerere University
- Infectious Diseases Research Collaboration
| | | | - Moses Kamya
- College of Health Sciences, Makerere University
- Infectious Diseases Research Collaboration
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital
- Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, USA
| | - Christina Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital
- Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, USA
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Yoon C, Semitala FC, Asege L, Katende J, Mwebe S, Andama AO, Atuhumuza E, Nakaye M, Armstrong DT, Dowdy DW, McCulloch CE, Kamya M, Cattamanchi A. Yield and Efficiency of Novel Intensified Tuberculosis Case-Finding Algorithms for People Living with HIV. Am J Respir Crit Care Med 2020; 199:643-650. [PMID: 30192649 DOI: 10.1164/rccm.201803-0490oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE The recommended tuberculosis (TB) intensified case finding (ICF) algorithm for people living with HIV (symptom-based screening followed by Xpert MTB/RIF [Xpert] testing) is insufficiently sensitive and results in unnecessary Xpert testing. OBJECTIVES To evaluate whether novel ICF algorithms combining C-reactive protein (CRP)-based screening with urine Determine TB-LAM (TB-LAM), sputum Xpert, and/or sputum culture could improve ICF yield and efficiency. METHODS We compared the yield and efficiency of novel ICF algorithms inclusive of point-of-care CRP-based TB screening and confirmatory testing with urine TB-LAM (if CD4 count ≤100 cells/μl), sputum Xpert, and/or a single sputum culture among consecutive people living with HIV with CD4 counts less than or equal to 350 cells/μl initiating antiretroviral therapy in Uganda. MEASUREMENTS AND MAIN RESULTS Of 1,245 people living with HIV, 203 (16%) had culture-confirmed TB including 101 (49%) patients with CD4 counts less than or equal to 100 cells/μl. Compared with the current ICF algorithm, point-of-care CRP-based TB screening followed by Xpert testing had similar yield (56% [95% confidence interval, 49-63] vs. 59% [95% confidence interval, 51-65]) but consumed less than half as many Xpert assays per TB case detected (9 vs. 4). Addition of TB-LAM did not significantly increase diagnostic yield relative to the current ICF algorithm but provided same-day diagnosis for 26% of TB patients with advanced HIV. Addition of a single culture to TB-LAM and Xpert substantially improved ICF yield, identifying 78% of all TB cases. CONCLUSIONS Point-of-care CRP-based screening can improve ICF efficiency among people living with HIV. Addition of TB-LAM and a single culture to Xpert confirmatory testing could enable HIV programs to increase the speed of TB diagnosis and ICF yield.
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Affiliation(s)
- Christina Yoon
- 1 Division of Pulmonary & Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, and
| | - Fred C Semitala
- 2 Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,3 Makerere University Joint AIDS Program, Kampala, Uganda
| | - Lucy Asege
- 4 Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | - Jane Katende
- 3 Makerere University Joint AIDS Program, Kampala, Uganda
| | - Sandra Mwebe
- 4 Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | - Alfred O Andama
- 2 Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,4 Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | - Elly Atuhumuza
- 4 Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | - Martha Nakaye
- 4 Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | | | - David W Dowdy
- 6 Division of Infectious Disease Epidemiology, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and
| | - Charles E McCulloch
- 7 Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Moses Kamya
- 2 Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.,3 Makerere University Joint AIDS Program, Kampala, Uganda.,4 Makerere University-University of California, San Francisco Research Collaboration, Kampala, Uganda
| | - Adithya Cattamanchi
- 1 Division of Pulmonary & Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, and.,8 Curry International Tuberculosis Center, University of California, San Francisco, Oakland, California
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Yoon C, Semitala FC, Atuhumuza E, Katende J, Mwebe S, Asege L, Armstrong DT, Andama AO, Dowdy DW, Davis JL, Huang L, Kamya M, Cattamanchi A. Point-of-care C-reactive protein-based tuberculosis screening for people living with HIV: a diagnostic accuracy study. Lancet Infect Dis 2017; 17:1285-1292. [PMID: 28847636 PMCID: PMC5705273 DOI: 10.1016/s1473-3099(17)30488-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/30/2017] [Accepted: 07/18/2017] [Indexed: 01/18/2023]
Abstract
Background Symptom-based screening for tuberculosis (TB) is recommended for all people living with HIV (PLHIV) resulting in unnecessary Xpert MTB/RIF testing for the vast majority of individuals living in TB endemic areas and thus, poor implementation of intensified case finding (ICF) and TB preventive therapy. Novel approaches to TB screening are therefore critical in achieving global targets for TB elimination. Methods In a prospective study of PLHIV with CD4+ T-cell count ≤350 cells/uL initiating antiretroviral therapy (ART) from two HIV/AIDS clinics in Uganda, we evaluated the performance of C-reactive protein (CRP) measured using a rapid and inexpensive point-of-care (POC) assay as a screening tool for active pulmonary TB. Findings Of 1177 HIV-infected adults (median CD4+ T-cell count 168 cells/µL) enrolled, 163 (14%) had culture-confirmed TB. POC CRP had 89% (145/163) sensitivity and 72% (731/1014) specificity for culture-confirmed TB. Compared to the WHO symptom screen, POC CRP had lower sensitivity (difference −7% [95% CI: −12 to −2], p=0.002) but substantially higher specificity (difference +58% [95% CI: +61 to +55], p<0.0001). When Xpert MTB/RIF results were used as the reference standard, sensitivity of POC CRP and the WHO symptom screen were similar (94% [79/84] vs. 99% [83/84]; difference −5% [95% CI: −12 to +2], p=0.10). Interpretation The performance characteristics of CRP support its use as a TB screening test for PLHIV with CD4+ T-cell count ≤350 cells/µL initiating ART. HIV/AIDS programs should consider POC CRP-based TB screening to improve the efficiency of ICF and increase uptake of TB preventive therapy. FUNDING National Institutes of Health; Presidential Emergency Plan for AIDS Relief; University of California, San Francisco, Nina Ireland Program for Lung Health
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Affiliation(s)
- Christina Yoon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
| | - Fred C Semitala
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Makerere University Joint AIDS Program, Kampala, Uganda
| | - Elly Atuhumuza
- Makerere University-University of California, San Francisco Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | - Jane Katende
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Sandra Mwebe
- Makerere University-University of California, San Francisco Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | - Lucy Asege
- Makerere University-University of California, San Francisco Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | | | - Alfred O Andama
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Makerere University-University of California, San Francisco Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | - David W Dowdy
- Department of Epidemiology, Division of Infectious Disease Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - J Luke Davis
- School of Medicine, Department of Medicine, Pulmonary, Critical Care, and Sleep Medicine Section, Yale University, New Haven, CT, USA; Department of Epidemiology of Microbial Diseases, Yale University, School of Public Health, New Haven, CT, USA
| | - Laurence Huang
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Department of Medicine, HIV/AIDS, Infectious Diseases and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Makerere University-University of California, San Francisco Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | - Moses Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Makerere University Joint AIDS Program, Kampala, Uganda
| | - Adithya Cattamanchi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Curry International Tuberculosis Center, University of California, San Francisco, Oakland, CA, USA
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Rajasingham R, Rhein J, Klammer K, Musubire A, Nabeta H, Akampurira A, Mossel EC, Williams DA, Boxrud DJ, Crabtree MB, Miller BR, Rolfes MA, Tengsupakul S, Andama AO, Meya DB, Boulware DR. Epidemiology of meningitis in an HIV-infected Ugandan cohort. Am J Trop Med Hyg 2014; 92:274-9. [PMID: 25385864 DOI: 10.4269/ajtmh.14-0452] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
There is limited understanding of the epidemiology of meningitis among human immunodeficiency virus (HIV)-infected populations in sub-Saharan Africa. We conducted a prospective cohort study of HIV-infected adults with suspected meningitis in Uganda, to comprehensively evaluate the etiologies of meningitis. Intensive cerebrospiral fluid (CSF) testing was performed to evaluate for bacterial, viral, fungal, and mycobacterial etiologies, including neurosyphilis,16s ribosomal DNA (rDNA) polymerase chain reaction (PCR) for bacteria, Plex-ID broad viral assay, quantitative-PCR for HSV-1/2, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and Toxoplasma gondii; reverse transcription-PCR (RT-PCR) for Enteroviruses and arboviruses, and Xpert MTB/RIF assay. Cryptococcal meningitis accounted for 60% (188 of 314) of all causes of meningitis. Of 117 samples sent for viral PCR, 36% were EBV positive. Among cryptococcal antigen negative patients, the yield of Xpert MTB/RIF assay was 22% (8 of 36). After exclusion of cryptococcosis and bacterial meningitis, 61% (43 of 71) with an abnormal CSF profile had no definitive diagnosis. Exploration of new TB diagnostics and diagnostic algorithms for evaluation of meningitis in resource-limited settings remains needed, and implementation of cryptococcal diagnostics is critical.
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Affiliation(s)
- Radha Rajasingham
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joshua Rhein
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kate Klammer
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Abdu Musubire
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Henry Nabeta
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew Akampurira
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Eric C Mossel
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Darlisha A Williams
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Dave J Boxrud
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mary B Crabtree
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Barry R Miller
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Melissa A Rolfes
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Supatida Tengsupakul
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Alfred O Andama
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B Meya
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David R Boulware
- University of Minnesota, Minneapolis, Minnesota; Infectious Disease Institute, Makerere University, Kampala, Uganda; Minnesota Department of Health, St. Paul, Minnesota; Centers for Disease Control and Prevention, Fort Collins, Colorado; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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