However, implementation of CXR needs resources to meet operational costs related to electricity, X-ray films, CXR maintenance, and good real-estate facilities that are frequently not available in most RLS. National TB guidelines for most RLS have included use of CXR as part of diagnostic algorithms to complement clinical diagnosis for TB especially for patients with negative sputum smear and/or Xpert MTB/RIF. The WHO still considers CXR an important piece in TB diagnosis particularly as an adjuvant test in smear-negative TB diagnostic algorithms. This highlights the need for adjuvant tests and empiric decision-making for smear-negative HIV-positive individuals in particular. Additionally, although the sensitivity of Xpert MTB/RIF assay for pulmonary TB detection was found to be approximately 98% for sputum smear-positive individuals, the sensitivity is much lower at 67–75% for sputum smear-negative HIV-positive individuals. However, implementation of Xpert MTB/RIF is costly for most low-income countries and requires sophisticated infrastructure that may not be readily accessible in most resource-limited settings. The Xpert MTB/RIF and Ultra assays on the GeneXpert platform (Cepheid, Sunnyvale, CA) have shown the potential to provide rapid, sensitive diagnosis and have been rolled out in several countries in SSA. One of the strategies to improve identification of these missing cases is improved diagnosis including application of new TB diagnostic tools that have been found to have improved performance. In order to achieve the World Health Organization (WHO) goal of ending the TB epidemic by 2035, we need to identify missing TB cases, link them and retain them in appropriate care. Low accuracy of sputum smear microscopy has resulted into high frequency of smear-negative TB and increased reliance on empiric decision-making to initiate TB treatment in HIV co-infected patients. In many RLS, sputum smear microscopy is still the most widely used up-front diagnostic method at most low-level health centers, and yet it only detects about half of TB cases especially in immunocompromised patients. Delayed and missed TB diagnosis in HIV-positive individuals is largely responsible for the high mortality reported in many RLS endemic for TB/HIV in sub-Saharan Africa (SSA). Of the estimated new TB cases in Uganda, only 65% were notified to the national TB program in 2018. In the same year, 34,000 of the new cases were HIV and TB co-infected with an estimated 11,000 HIV-infected individuals having died from TB, making Uganda one of the most affected countries worldwide for TB/HIV co-infection. In 2018, Uganda had an estimated TB incidence of 86,000 cases with 24% deaths. A recent study showed that in resource-limited settings (RLS), TB accounted for approximately 40% of facility-based HIV/AIDS-related adult deaths, and that in almost half of these, TB was undiagnosed at the time of death. These unreported and hence untreated cases are a reservoir of infection with on-going transmission and contribute significantly to the persistently high TB prevalence and mortality particularly among HIV co-infected individuals. Globally, in 2018, a total of 10 million cases of TB were estimated, of which only 6.4 million (64%) were diagnosed and notified to national programs, the remaining 36% of the estimated TB cases were left unreported. Key global priorities for TB care and control emphasize improving earlier case detection and linkage to care. Tuberculosis (TB) remains a significant public health problem globally and is the main cause of death among persons living with HIV. The Creative Commons Public Domain Dedication waiver ( ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.
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