Late Breaking Abstract - The tuberculosis diagnostic evaluation cascade of care at microscopy centers linked to Xpert MTB/RIF hubs in Uganda

Background: Many high-burden countries are scaling-up Xpert MTB/RIF using a hub-and-spoke model. We evaluated steps in the cascade of care for patients undergoing TB evaluation at microscopy centers linked to Xpert testing sites in Uganda. Methods: We conducted a prospective cohort study of all adults with presumed pulmonary TB at 23 health centers linked to 20 Xpert sites. Health center staff used a smartphone to photograph TB registers and upload photos to REDCap. We assessed the proportion of patients initiating testing, completing testing, and treated for confirmed TB within 14 days. Results: Between Nov. 2016-May 2017, 1455 patients were referred for sputum-based TB testing. 1157 (80%) initiated testing, of whom 687 (59%) completed recommended testing. 134/411 HIV-positive (33%) and 553/746 (74%) HIV-negative/unknown patients completed recommended testing. Overall, only 209/1157 (18%) patients had Xpert testing. 130 (73%) MTB patients started treatment within 14 days of referral for testing, including 117/150 (78%) smear-positive and 13/28 (46%) Xpert-positive patients (none RIF-resistant). Conclusions: Xpert uptake was low, and >50% of Xpert-positive patients did not initiate treatment. Addressing patient socio-economic barriers, improved sputum transport/results reporting and/or rapid onsite molecular testing should be considered to close gaps in the TB diagnostic evaluation cascade of care.