# Operational indicators for pulmonary tuberculosis diagnosis in people living with HIV before and after Xpert MTB/RIF implementation in the state of São Paulo, Brazil

## TL;DR

This study shows that using the Xpert test in HIV-positive patients in Brazil reduced unconfirmed tuberculosis cases, especially in areas with higher test coverage.

## Contribution

The study demonstrates the real-world impact of Xpert test implementation on reducing non-confirmed TB in HIV-positive individuals.

## Key findings

- Xpert test implementation led to a significant decrease in non-confirmed pulmonary TB rates in PLHIV.
- Higher Xpert coverage in cities like Ribeirão Preto correlated with greater reductions in non-confirmed TB.
- Low Xpert coverage areas showed slower and smaller decreases in non-confirmed TB rates.

## Abstract

Tuberculosis (TB) in people living with HIV (PLHIV) is usually paucibacillary and the smear microscopy has limitations and may lead to high proportions of non-confirmed pulmonary tuberculosis (NC-PTB). Despite culture being the reference method, it usually takes 6 to 8 weeks to produce the results. This study aimed to analyze the effect of a rapid molecular test (Xpert) in the confirmatory rate of PTB among PLHIV, from 2010 to 2020, in São Paulo state, Brazil. This is an ecological study with time series analysis of the trend and the NC-PTB rates before and after Xpert implementation in 21 municipalities. The use of Xpert started and gradually increased after 2014, while the rate of NC-PTB in PLHIV decreased over this time, being more significant between late 2015 and mid-2017. The city of Ribeirão Preto stands out for having the highest percentage (75.0%) of Xpert testing among PLHIV and for showing two reductions in the NC-PTB rate. The cities with low Xpert coverage had a slower and smaller decrease in the NC-PTB rate. Despite being available since 2014, a significant proportion of PLHIV suspected of PTB in the state of São Paulo did not have an Xpert ordered by the doctors. The implementation of Xpert reduced the NC-PTB rates with growing effect as the coverage increased in the municipality.