Research in context
Evidence before this study
Tuberculosis preventive treatment is an essential intervention recommended by WHO for people living with HIV. WHO recommends a four-symptom screen rule for adults and adolescents with HIV to exclude active tuberculosis before provision of preventive treatment. This recommendation was based on a systematic review and individual patient data meta-analysis of more than 8000 mostly antiretroviral therapy (ART)-naive people with HIV done in 2011. The rule was instrumental for global scale-up of tuberculosis preventive treatment among people living with HIV. However, there was concern among tuberculosis and HIV experts that the four-symptom rule might not reliably exclude active tuberculosis among people receiving ART. We did a search of PubMed, Embase, and the Cochrane Library for studies published from Jan 1, 2011, to March 12, 2018, with the search terms “HIV” and “TB” and “screening” or “algorithm”. Our findings indicated that a systematic review of the four-symptom rule had not been done.
Added value of this study
To our knowledge, this is the first systematic review and meta-analysis to investigate the sensitivity and specificity of the WHO four-symptom screening rule for the exclusion of active tuberculosis stratified by ART status. We showed that the sensitivity of the rule is lower among people with HIV on ART compared with those who are not receiving ART, but sensitivity is increased by adding abnormal chest radiographic findings.
Implications of all the available evidence
Following the findings of this review, we suggest that chest radiography could be added to the WHO four-symptom screening rule in people living with HIV on ART to improve its performance in excluding active tuberculosis before provision of tuberculosis preventive treatment.