Improving Detection and Prevention of Tuberculosis among Children Living with HIV through the integration of TB care within HIV care and treatment services in Uganda – (Pre and Post-implementation assessment of the CaP-TB project)

Introduction: Systematic integration of tuberculosis (TB) screening among children living with HIV (CLHIV) remains a crucial intervention for active TB case finding and prevention among children. Methods: The Catalyzing Pediatric TB Innovation Project (CaP-TB) implemented decentralized and integrated models of care during a 27-month period (July 2019 – September 2021) to improve the detection of active and latent TB among children aged 0-14 years living with HIV and receiving care. The project targeted 20 high TB burden HIV health facilities (primary 35%, Secondary 45% and tertiary 20%) of Southwestern Uganda. The study collected data before and during the project implementation period and conducted a pre and post quasi-experimental evaluation on outcomes change from pre- to post-intervention. Results: During the CaP-TB implementation period, 7,251 CLHIV (49.1% Male, 50.9% female; 0-<2yrs-0.5%, 2-<5yrs-6.7%, 5-<10yrs-27.5% and 10-<15yrs-65.3%) were screened for TB signs and symptoms at 20 HIV clinics. Significant improvements from pre- to post-intervention were noted in the following outcomes: Screening-percentage of CLHIV screened for TB per site increased from 3.6% to 38.1% (IRR: 9.7; p<0.001; 95% CI: 8.5-11.0). For children aged 0–<5 years, TB screening coverage increased more than five-fold (IRR: 5.2, 95% CI: 3.9–7.0), while among those aged 5–<15 years, it improved over ten-fold (IRR: 11.7, 95% CI: 10.2–13.6). In rural facilities, TB screening coverage increased nearly eight-fold (IRR: 7.9, 95% CI: 6.2–10.1), while in urban facilities, it improved more than eleven-fold (IRR: 11.6, 95% CI: 9.9–13.5). Presumption- percentage of presumptive TB positive cases per site increased from 3.0% to 5.8% (IRR: 1.7; p<0.001; 95% CI: 1.5-2.0), Among children aged 5–<15-year-olds, the percentage of presumptive TB positive cases per site more than doubled (IRR: 2.1, 95% CI: 1.8–2.4). In rural sites, the percentage of presumptive TB positive cases per site increased by 1.5 times sites (IRR: 1.5, 95% CI: 1.2–2.0) and doubled in urban sites (IRR: 2.0, 95% CI: 1.7–2.4). TB detection- Active TB case detection rate per site increased from 0.4% to 0.9% (IRR: 2.0; p<0.001; 95% CI: 1.4, 3.1). Among children aged 0–<5-year-olds, active TB case detection rate per site increased 1.4-fold (IRR: 1.4, 95% CI: 0.8–2.6) and a more than three-fold increase among 5–<15-year-olds (IRR: 3.3, 95% CI: 1.9–5.8). In rural facilities, active TB case detection rate per site increased 1.4-fold increase (IRR: 1.4, 95% CI: 0.7–3.1), while in urban facilities, it more than doubled (IRR: 2.5, 95% CI: 1.5–4.0). TPT initiation- percentage of new TPT initiations per site increased from 0.7% to 92.6% (IRR: 131; p<0.001, 95% CI: 95.8-177.8). Conclusion: Systematic integration of childhood TB screening in decentralized pediatric HIV clinics at multiple health facility levels significantly improves rates of active TB diagnosis and prevention therapy uptake among CLHIV in Uganda. Program implementers and managers therefore must prioritize systematic TB screening which offers opportunities to significantly enhance TB diagnosis, treatment, and prevention success among children 0 -14 years old.