1. Diagnosis of AFB Smear- Negative Pulmonary TB in HIV- Infected Persons Richard OBrien Foundation for Innovative New Diagnostics (FIND)

2. Diagnosis of Smear- PTB in HIV- Infected Persons – Background (1) HIV infection associated with large increases in smear-negative (SN) PTB SN PTB in HIV+ persons has much higher mortality than smear+ PTB Current WHO diagnostic algorithm for SN PTB inadequate for HIV+ persons –Lengthy process –Antibiotic trial lacks sensitivity and specificity, especially in HIV+ persons

3. Diagnosis of SN PTB in HIV+ Persons Background (2) Raised as urgent issue by TB/HIV WG Expert group convened by WHO (Sept 05) Recommendations and new algorithms posted on STB website for comments (Nov 05) Expert group revised guidelines and algorithms (March 06) Presentation to STAG (June 06)

4. Diagnosis of SN PTB in HIV+ Persons New Diagnostic Algorithm (1) Applies to high HIV settings (>1% in general population, >5% in TB cases) Initial HIV DTC at first visit, together with at least 2 sputa for AFB smears –One positive smear sufficient for diagnosis of smear+ PTB in HIV+ persons –Two negative AFB smears sufficient for diagnosis of SN PTB in HIV+ persons (plus compatible CXR and decision to treat with full course of anti-TB therapy) Different algorithms for ambulatory and seriously ill patients (with danger signs)

5. Diagnosis of SN PTB in HIV+ Persons New Diagnostic Algorithm (2) Chest radiograph (CXR) required earlier in diagnostic process Cultures should be done when available Reduced number of visits to complete diagnostic process Single course of antibiotic –Non-response not required for diagnosis

6. Diagnosis of Extrapulmonary TB (EPTB) in HIV+ Persons New guidelines developed for EPTB Initial HIV DTC –Lymphatic: needle aspiration –Pleural: aspiration, CXR –Disseminated: CXR, blood cultures –TB meningitis: LP

7. Diagnosis of SN PTB and EPTB in HIV+ Persons: Implications Policy implementation in NTPs Expanded HIV DTC needed Facilities and training for CXR Upgraded and expanded TB laboratory services (culture capability) Training and services for EPTB diagnosis Systematic evaluation of new algorithms needed to assess feasibility, cost, and impact

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