Abstract
BACKGROUND: Intensified tuberculosis (TB) case finding is recommended for people living with HIV (PLHIV) at every clinical encounter using the World Health Organization (WHO) screening tool (W4SS), comprising any of current cough, fever, night sweats or weight loss. We determined the frequency of W4SS symptoms at repeat visits among individuals without TB attending for HIV care in Gauteng province, South Africa. METHODS: In a cohort study, we enrolled PLHIV (adults) attending clinics for routine HIV care. At enrolment, patients were screened using W4SS, and categorised into high (cough, body mass index (BMI) ≤ 18.5, CD4 < 100 cells/mm(3), fever ≥ 3 weeks, and unintentional weight loss ≥ 10%), medium (1 ≥ W4SS symptoms but not fulfilling criteria for high priority) or low priority (no W4SS symptoms) for TB testing with Xpert MTB/RIF; and anyone diagnosed with TB was excluded. This analysis was restricted to individuals with no TB diagnosis by month three. RESULTS: We enrolled 3,738 patients in the parent study. Of this, 88.5% (3,309/3,738) completed month three follow up visits, of whom 71.0% (2,349/3,309) were female, median CD4 count 427 [interquartile range (IQR) 275-607] cells/mm(3), 71.8% (2,377/3,309) on antiretroviral therapy (ART) with median duration 4 [IQR 2-7] years). At enrolment, 29.9% (991/3,309) were positive on W4SS, among whom 62.7% (621/991) were pre-ART. The proportion of patients who reported any of the four symptoms on W4SS was 15.1% (331/2,191) at month one, 13.5% (276/2,052) at month two, and 8.9% (294/3,309) at month three. Cough was the symptom most frequently reported at all time points, followed by weight loss and then night sweats. CONCLUSION: W4SS symptoms remained relatively common at repeat visits among people without TB in HIV care. Repeat testing of symptomatic patients with Xpert MTB/RIF would have substantial resource implications. Sensitive and specific TB screening tools which are not dependent on symptoms are needed.