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. 2021 Aug;24(8):e25775.
doi: 10.1002/jia2.25775.

Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique

Santiago Izco  1   2 , Adrià Murias-Closas  1 , Alexander M Jordan  3 , Gregory Greene  3 , Nteruma Catorze  2 , Helio Chiconela  4 , Juan Ignacio Garcia  1   2   5 , Alejandro Blanco-Arevalo  6 , Anna Febrer  1 , Aina Casellas  1 , Belén Saavedra  1   2 , Tom Chiller  3 , Tacilta Nhampossa  2 , Alberto Garcia-Basteiro  1   2 , Emilio Letang  1   7
Affiliations

Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique

Santiago Izco et al. J Int AIDS Soc. 2021 Aug.

Abstract

Introduction: AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population.

Methods: All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months.

Results: A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts.

Conclusions: A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.

Keywords: AHD; ART initiation; CrAg; TB contact-tracing; TB-LAM; sub-Saharan Africa.

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Figures

Figure 1
Figure 1
Flow chart of interventions. Blue boxes, Xpatial‐TB interventions. Green boxes, study‐intervention. Yellow boxes, routine provision of care in district ART units (government health centers). ALT, alanine‐amino‐transferase; ART, antiretroviral therapy; FBC, full blood count; FU, follow‐up; HCT, HIV counselling and testing; LTFU, lost to follow‐up; M6, month six; OI, opportunistic Infections; POC, point of care; TB‐ACF, tuberculosis active case finding.
Figure 2
Figure 2
Time to ART‐initiation. Daily cumulative proportion of participants (ART‐naïve and ART interrupters) starting or resuming ART as part of the intervention (‘treated’). Left, TB‐free participants; Right, TB cases including TB‐index and TB‐contacts with TB. Four additional TB‐cases started ART 148, 148, 246 and 247 days after enrolment respectively.
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