Tongue swab-based Targeted Universal Tuberculosis Testing in people living with HIV in KwaZulu-Natal, South Africa

Background: Targeted Universal Tuberculosis Testing (TUTT) may increase tuberculosis (TB) case detection by including people who are not actively seeking TB care but are at high risk of the disease.Non-invasive tongue swab (TS) testing may facilitate TUTT. We evaluated two TS testing protocols in people with HIV (PWH) tested irrespective of TB symptoms. Methods: Study staff collected Copan FLOQSwab and Medline foam swab specimens, alongside urine and sputa, from PWH, most of whom were presenting for antiretroviral therapy initiation at primary healthcare clinics in KwaZulu-Natal, South Africa. FLOQSwabs were tested by sequence-specific magnetic capture (SSMaC) with qPCR (FLOQSwab-SSMaC). Foam swabs were tested by centrifuge-sedimentation and high-volume qPCR (foam-sedimentation). Urine lipoarabinomannan was detected using LF-LAM. The extended microbiological reference standard (eMRS) comprised any positive result on Xpert Ultra and/or liquid culture of sputum. Results: We enrolled 251 participants (median age 34 years, 56% female, 67% with self-reported TB symptoms). Participants had a median CD4 count of 347 cells/µl, and 16% (40/251) had prior TB. FLOQSwab-SSMaC was 43% sensitive (13/30) and 100% specific (131/131) relative to eMRS. Foam-sedimentation was 47% (9/29) sensitive and 100% (176/176) specific. Sensitivity increased to 52% (FLOQSwab-SSMaC) and 50% (foam-sedimentation) when sputum Xpert Ultra Trace positive results were excluded from eMRS. TS was more sensitive than urine LAM, and both sample types were more sensitive when CD4 counts were below 200. Discussion: TS testing detected about half of PWH with TB and outperformed urine LAM within this population, including among PWH with low CD4 counts. Summary: TB testing approaches using tongue swabs (TS), combined with molecular methods, have the potential to identify people with TB in settings where sputum collection is not practical. People living with HIV are an at-risk group that could benefit from non-sputum based targeted TB testing programs.