Implementation Guidelines For Lateral Flow Urine Lipoarabinomannan

Implementation Guidelines for
Lateral Flow Urine Lipoarabinomannan

Assay (Lf-lam) In The Detection of Active
Tuberculosis in People Living With HIV
ADDIS ABABA, ETHIOPIA

August, 2021
Implementation Guidelines for Lateral
Flow Urine Lipoarabinomannan Assay
(LF-LAM) in the Detection of Active
Tuberculosis in People Living With HIV
ADDIS ABABA, ETHIOPIA
August, 2021
Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
LF-LAM Implementation Guideline Development Group.II
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1. Epidemiology and situation analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2. WHO policy recommendation for the use of LF-LAM. . . . . . . . . . . 3
1.3. Scope of the implementation guideline. . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4. Objectives of the implementation guidelines. . . . . . . . . . . . . . . . . . . . 7
2. Strategic approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1. Eligible PLHIV for LF_LAM Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1.1. In outpatient settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1.2. In inpatient settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2. National TB Diagnostic Algorithm for PLHIV Incorporating Urine

LAM test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.1. Algorithm for LF-LAM testing to aid in the diagnosis of TB among

PLHIV in outpatient settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.2. Algorithm for LF-LAM testing to aid in the diagnosis of TB among

PLHIV in inpatient settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.3. Laboratory order and result interpretation. . . . . . . . . . . . . . . . . . . . . . 13
2.3.1. Urine LAM test workflow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.3.2. Result interpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4. Case definition, classification,treatment follow up, case registration and

relevant indicators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.4.1. Case definition: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.4.2. Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.4.3. Treatment follow up of Patients diagnosed using Urine LF-LAM test

algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.4.4. Indicators and definitions for PLHIV evaluated with Urine LAM test
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.5. Patient Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3. Laboratory testing of LF-LAM for PLHIV. . . . . . . . . . . 18

3.1. The LF-LAM Assay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.2. Laboratory infrastructure and Supplies needed for testing. . . . . . . . . 21
3.3. Sample collection, testing and interpretation for LF-LAM. . . . . . . . 21
3.4. Biosafety requirements and waste disposal. . . . . . . . . . . . . . . . . . . . . . 25
4. Human Resource Development. . . . . . . . . . . . . . . . . . . . . 26

4.1. Technical Training on LF-LAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.2. Sensitization Workshop on LF-LAM. . . . . . . . . . . . . . . . . . . . . . . . . . 26
5. Supply chain management for LF-LAM. . . . . . . . . . . . . . 27

6. Quality Assurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
6.1. Internal quality control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
6.2. External quality control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
6.2.1.On-site supervisory and evaluaton visits. . . . . . . . . . . . . . . . . . . . . . . 30
6.2.2. Proficiency testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
6.3. Quality indicators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
7. Monitoring and Evaluation (M&E) Plan for LF-LAM

Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
8. Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . 33
9. LF-LAM Implementation steps . . . . . . . . . . . . . . . . . . . . 35
10. References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
ANNEXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Annex 1: Algorithm for LF-LAM testing to aid in the diagnosis of TB
among PLHIV in outpatient settings. . . . . . . . . . . . . . . . . . . . . . . . . . 40
Annex 2: Algorithm for LF-LAM testing to aid in the diagnosis of TB among

PLHIV in inpatient settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Annex 3: ART Register . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Annex 4: Unit TB Register . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Annex 5: HIV/ART Follow Up Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Annex 6: HIV Care /Follow up form 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Annex 7: TB Laboratory reqeust and report form. . . . . . . . . . . . . . . . . . . . 50
Annex 8: Job aid forLF-LAM testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Annex 9: Standard operating procedure for performing the Alere determine

TB LAM Ag lateral flow assay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Annex 10: Internal Quality Control (IQC) log sheet for LF-LAM test. . 58
Annex 11: Laboratory Register for Smear Microscopy, LF-LAM and

GeneXpert MTB/RIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Annex 12: LF-LAM monthly reporting form. . . . . . . . . . . . . . . . . . . . . . . 60

Foreword
TB/ HIV coinfection continues to be a challenge in the fight against TB and HIV. Ac-
cording the 2020 global TB report Ethiopia is among the 15 high TB/HIV burdened
countries. This indiacates it is still very important to implement collaborative TB/HIV
activities and management of comorbidities as an essential strategies to curl the impact of
these two epidemics. Of these strategies rapid detection of TB among people living with
HIV is very cruitial.
In the last two decades and more several strategies have been implemented to fight TB/
HIVcoinfection in Ethiopia .This measure have supported the country to reduce mortality
of people living with HIV due to TB and other opportunistic infections. Of the imple-
mented strategies one was increaseing access for early diagnosis of TB and drug resistance
through expansion of sputum based rapid molecular tests and diagnostic facilities. How-
ever, there are still gaps in the early diagnosis of TB in PLHIV due to inability of such
patients to expectorate sputum ,the frequency of extra-pulmonary TB and paucibacillary
pulmonary TB.
Through the global guidances for early detection of TB among people living with HIV
it very essential to implement WHO-recommened, rapid, point of care tests like urine
based lateral flow lippoarabinamanan (LF-LAM) . In line with the 2019 World Health
Organisation policy recommendations this implementation guideline aims to provide
guidance on how to use urine LF-LAM to facilitate early diagnosis and treatment of TB
in HIV positive patients and concurrently reduce mortality due to TB.This guideline en-
compasess the algorithms, strategies and laboratory diagnosis of TB in HIV patients using
urine LF-LAM.
Furthermore, the Ethiopian Public Health Institute wants to expresses its organizational
commitment for fight against TB and HIV. Moreover, I would also like to acknowledges
all partners and experts that contributed in the development of this urine LF-LAM im-
plementation guideline.
I Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

(LF-LAM) in the Detection of Active Tuberculosis in People Living With HIV
LF-LAM Implementation Guideline
Development Group
Name Position information Institutions
Executive summary
Dr. Tsigerada Kifle Director General EPHI
Dr. Geatchew Tollera Deputy Director General EPHI
Saro Abdella TB/ HIV disease research directorate EPHI
director
Misiker Amare EPHI-NTRL Head EPHI,NTRL
Mirte Getachew HIV program coordinator MOH
Taye Letta TBL program coordinator MOH
Epidemiology and Situation analysis
Mengistu Tadesse Senior TB Advisor EPHI,NTRL
Habteyes Hailu Epidemiologist EPHI,NTRL
Clinical use and application
Beniam Feleke(MD) TB/HIV expert CDC Ethiopia
FanaTefera(MD) HIV care & treatment program CDC Ethiopia
expert
Miftah Kemal(MD) Central HIV Care and Treatment CU_ICAP
Adviser
Mesfin Bekele TB/HIV Expert NTP/MOH
Berhanemeskal Asse- Principal TB,TBHIV USAID
fa(MD) Advisor,MSH Eliminate TB
Andargachew Kumsa Senior TB expert USAID
(MD)
Zerihun Hika (MD) MOH -HIV program MOH
Genet Getachew MOH -HIV program MOH
Tilaye Gudina MOH -TB program MOH
Laboratory use and application
Getachew Aga TB Lab STA MOH
Biniyam Dagne TB lab expert EPHI-NTRL
KumeraTerfa NLCBD, EPHI TB Focal EPHI
Solomon Assefa NLCBD, EPHI TB Focal EPHI
Feven Girmachew NlCBD, EPHI Service expansion TL EPHI
Million Hailu Laboratory support Director CU_ICAP
Dessie Adugna Laboratory support Associate Director CU_ICAP
Endale Mengesha USAID Eliminate TB Project Advisor USAID
Eliminate TB
Waganeh Sinishaw TB lab expert EPHI-NTRL
Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

II
Acknowledgements
The Ethiopian Public Health Institute would like to acknowledges, the contribution of all
stakeholders and experts; that participated in the development of this urine lateral flow
lippoarabinomanna implementation guideline. Especially Ministry of Health, CDC Ethi-
opia, ICAP Ethiopia, USAID Eliminate-TB.
Disclamer
This guideline is printed and distributed under outhrization and control of EPHI and
minstry of Health ,any organization need permission and approval from the above listed
institiotions for re printing and edition of the guidline.
III Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

Executive Summary
The World Health Organization’s (WHO’s) strategy for tuberculosis (TB) prevention,
care and control from 2015 to 2035 - which is better known as the End TB Strategy -
prioritizes the early diagnosis of TB. This prioritization is particularly due to smear-neg-
ative TB cases, which are often associated with HIV co-infection and young age. Of the
10 million new cases of TB occurred across the world in 2019, an estimated 0.82 million
(9%) incidence cases occurred among peopleliving with HIV (PLHIV). The WHO Afri-
can region accounts for 72% of the estimated number of HIV-positive incident TB cases.
Ethiopia is one of the 30 countries with high TB and TB/HIV countries with an esti-
mated TB incidence cases of 140 per 100,000 population, and 5.3% TB/HIV co-infection
prevalence in 2019.
Lack of an effective diagnostic test for smear-negative TB cases is a major contributor to

the death of HIV positive people in countries with high burden of TB/HIV co-infection.
To alleviate the problems related to diagnose smear-negative TB cases in the PLHIV,
several tests have been designed and evaluated at the global level. Of these, tests based on
the detection of mycobacterial lipoarabinomannan (LAM) antigen in urine have emerged
as potential point-of-care test for TB. The currently available urine LAM assays have sub-
optimal sensitivity hence are suitable for a specific group of TB patients such as PLHIV.
Unlike traditional diagnostic methods such as smear microscopy and culture, urine LAM
assays demonstrate improved sensitivity for the diagnosis of TB among individuals co-in-
fected with HIV. The estimated sensitivity is even greater in patients with lower CD4 cell
counts.
This implementation guideline is developed based on evidence obtained from national and
international studies and WHO policy recommendation for the use of urine LAM for the
diagnosis of TB in PLHIV in Ethiopia. It comprises the eligibility of PLHIV for the LF-
LAM test, national TB diagnostic algorithm for PLHIV that incorporate LF-LAM test,
and laboratory results order interpretation. It also consists case definition and registration,
patient classification and relevant indicators for urine LAM test. In addition, this guide-
line in detail explains patient management, test principle and procedure, required labora-
tory infrastructure and supply issues, sample collection, quality control issues, biosafety
requirements and waste disposal system. Further, it comprises monitoring and evaluation
plan with its important indicators.

IV
Abbreviations
AFB Acid Fast Bacilli
AHD Advanced HIV Disease
AlereLAM Alere DetermineTM TB LAM Ag assay
ART Anti-Retroviral Therapy
CD4 Cluster of Differentiation
CSF Cerebro Spinal Fluid
CXR Chest X-ray
DR-TB Drug Resistant TB
DST Drug Susceptibility Testing
EFDA Ethiopian Food and Drug Administration
EMRs Electronic Medical Records
EPHI Ethiopian Public Health Institute
EPHI NTRL Ethiopian Public Health Institute National Tuberculosis Ref-
erence Laboratory
EPSA Ethiopian Pharmaceutical Supply Agency
EPTB External pulmonary Tuberculosis
EQA External quality Assessment
GLI Global Laboratory Initiative
HAPCO HIV/AIDS Prevention and Control Office
HCWs Health Care Workers
HF Health Facility
HIV Human Immunodeficiency Virus
IPLS Integrated Pharmaceutical Logistics System
IQC Internal Quality Control
LAM Lipoarabinomannan protein
LAMP Loop Mediated Isothermal Amplification
LF-LAM Lateral Flow Lipoarabinomannan assay
mWRD WHO recommended rapid diagnostic
MDR-TB Multidrug Resistant Tuberculosis
M&E Monitoring and Evaluation
V Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

MOH Ministry of Health
MTB Mycobacterium Tuberculosis
NTP National Tuberculosis Program
NTRL National Tuberculosis Reference Laboratory
PT Panel testing
PCR Polymerase Chain Reaction
PLHIV People Living with Human Immunodeficiency Virus
RHB Regional Health Bureau
RRL Regional Reference Laboratory
SOPs Standard Operating Procedures
TB Tuberculosis
TB/HIV GL Tuberculosis/Human Immunodeficiency Virus Guideline
TAT Turn Around Time
TB LAM Ag Tuberculosis Lipoarabinomannan Antigen
TB LAMP Tuberculosis Loop Mediated Isothermal Amplification
WHO World Health Organization
Xpert® MTB/ GeneXpert Mycobacterium Tuberculosis/Rifampicin
RIF

VI
1. Introduction
1.1. Epidemiology and situation analysis
Tuberculosis (TB) causes ill-health and death to millions every year across the world. An
estimation indicated that more than 2 billion people are infected with Mycobacterium tu-
berculosis complex (MTB) worldwide, and 5–10% of infected individuals have a lifetime
risk of progressing from TB infection to TB disease (1). A recent global TB report esti-
mated 10 million new TB cases developed in 2019; of these, 815,000 (0.85%) were among
HIV positive people (1). The World Health Organization (WHO) recent estimation in-
dicates the risk of developing active TB disease is 18 times higher in people living with
HIV (PLHIV) with 10% risk of developing TB each year than those without HIV (1).
Among 10 million new TB cases developed in 2019 across the world 8.2% were in PLHIV
(1) 2020), and WHO African region bears the highest burden of TB/HIV co-infection
(1). Of the total of 456,426 cases of TB detected in PLHIV, 208,000 were died globally
in 2019 (1). Ethiopia is among the 30 countries with high TB, TB/HIV and MDR-TB
burden with an estimated incidence rate of 140 per 100,000 population (1). A recently
reported systematic review study indicated that the prevalence of TB/HIV co-infection in
Ethiopia is 22% (2). However, WHO estimation indicated that 5.3% of TB cases notified
in PLHIV in Ethiopia in 2019 (1). Moreover, a national level data report indicated that
the prevalence of TB in PLHIV is 7.3% (3).
Although there is a significant improvement in diagnosis and treatment of TB, there is still
a limitation in early detection and treatment of all forms of TB cases among HIV positive
individuals. A systematic review study that estimated the prevalence of TB through pool-
ing the results of studies reported on postmortem showed 46% of TB cases remain undi-
agnosed (4), which made TB the most important opportunistic infection among PLHIV
(4). Moreover, of the total of 815,000 estimated HIV associated TB cases worldwide in
2019, only 56% were notified (1). This indicates that TB diagnosis is still a challenge in
PLHIV and it is rarely bacteriologically confirmed (5,6).
The conventional sputum microscopy is the cheapest and fastest method that is used to
diagnose TB since 1882. However, the sensitivity of sputum smear microscopy for the
diagnosis of TB is low in HIV infected individuals due to poor quality sputum production
and low bacillary concentration (7). Particularly in severely immunocompromised HIV
infected individuals, the sensitivity of sputum smear microscopy is significantly reduced
(8). Other challenges that make TB diagnosis difficult include non-specific clinical pre-
sentation of TB that is attributable to high prevalence of extra-pulmonary and disseminat-
1 Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

ed forms of TB in individuals with advanced HIV clinical stage disease (8).
Nowadays, rapid and more accurate molecular technologies have been developed and
available to diagnose HIV related TB (9). Polymerase chain reaction (PCR), real-time
PCR, and loop-mediated isothermal amplification (LAMP) are the molecular techniques
that are commercially available for the diagnosis of TB(10,11). Xpert® MTB/RIF and
Xpert® MTB/RIF Ultra (Cepheid, Sunnyvale, CA, United States) assays are rapid mo-
lecular technologies that are recommended by WHO as initial diagnostic tests for TB in
adults, adolescent and children(10,11). TB-LAMP and TruenatTM (Molbio Diagnostics,
Goa, India) are also other molecular technologies that are recommended by WHO for the
diagnosis of TB(10). However, the diagnostic performance of these technologies have not
been fully evaluated for the diagnosis of TB in PLHIV(10).
Although rapid and accurate molecular assays have significantly reduced the gap in TB
case detection among PLHIV, their accessibility continued to be a challenge, due to the
infrastructure required and the cost of procurement and maintenance. Thus, access to rap-
id and accurate diagnostic tests significantly restricted in resource limited settings where
the burden of TB/HIV co-infection is high(10). Moreover, interruption of electricity and
inadequate laboratory infrastructure and inefficient sample referral mechanisms are the
challenges that limit the accessibility of rapid and accurate molecular diagnostic tests (12–
14). Beside the challenges listed above, lack of quality sputum production and the pauci-
bacillary nature of TB in HIV positive individuals are additional problems that make the
use of sputum-based testing more difficult.
To minimize the challenges that are associated to sputum based diagnostic tests, urine
based rapid TB diagnostic tests are recommended to detect TB in PLHIV in advanced
disease condition (15–18). Alere lipoarabinomannan (LAM) assay is one of the urine
based rapid diagnostic tests for TB detection in PLHIV (15). Evidence suggests the im-
portance of LAM in the detection of TB at high TB/HIV burden settings (15,17,19,20).
It is recommended for use as a simple point-of-care test to assist TB diagnosis in HIV
positive adult hospital in-patients with signs and symptoms of TB and with CD4 cell
counts ≤ 100 cells/mm3 or in HIV positive people who are seriously ill regardless of their
CD4 count or who have an unknown CD4 count (21). This recommendation is also ap-
plied to HIV positive adults who are outpatients and have signs and symptoms of TB and
who have CD4 cell count ≤100 cells/mm3 or who are seriously ill, regardless of their CD4
count (21). Based on the generalization of the data from adults, this recommendation is
also used in children living with HIV who have signs and symptoms of TB (21). However,
there is evidence limitation on the specificity of LAM test in children.
2
LAM test could decrease mortality through quicker diagnosis and early treatment com-
mencement among PLHIV and severely sick (15–17,22,23).
1.2. WHO policy recommendation for the use of LF-LAM
For out patient setting use of LF-LAM
WHO suggests(21) using LF-LAM to assistin the diagnosis of active TB in HIV-positive

adults, adolescents and children:
• With signs and symptoms of all forms TB or seriously ill.

• Irrespective of signs and symptoms of TB and with a CD4 cell count of less than 100
cells/mm3
WHO recommendation against(21) using LF-LAM toassist in the diagnosis of active

TB in HIV-positive adults, adolescents and children:
For outpatient settings not to use LF-LAM
• without assessing TB symptoms not recommended .

• For PLHIV Without TB symptoms and unknown CD4 cell count not recommended.
• For PLHIV without TB symptoms and CD4 cell count greater than or equal to 200
cells/ mm3 not recommended.
• PLHIV Without TB symptoms and with a CD4 cell count of 100–200 cells/ mm3 is
not recommended (27, 28, 29).
Note: Strong recommendation for bullet 1&2, conditional recommendation for 3rd
bullet due to very low certainty in the evidence about test accuracy.
Key WHO Remark:
• All patients with signs and symptoms of pulmonary TB who are capable of producing
sputum should have at least one sputum specimen submitted for mWRD test. This
also includes children and adolescents living with HIV who are able to provide a spu-
tum sample.
• LF-LAM should be used as an add-on to clinical judgment in combination with other
tests.
• LF-LAM It should not be used as a replacement or triage test.
• No recommendation for other LF -LAM Test Kit other than Alere LAM until Qual-
ity evidence is obtained.
For inpatient settings
WHO strongly recommends(21)using LF-LAM to assistin the diagnosis of active TB in

HIV-positive adults, adolescents and children:
• Patient with signs and symptoms of TB (pulmonary and/or extra pulmonary).

• For persons with advanced HIV diseaseandCD4 cell count of less than 200 cells/
mm3 or WHO clinical stage 3 or 4 event at presentation or children with HIV who
are aged under 5 years at presentation,or PLHIVwho are seriously ill based on four
danger signs: respiratory rate of more than 30/minute, temperature of more than 39 °C,
heart rate of more than 120/minute and unable to walk unaided.
• Irrespective of signs and symptoms of TB and with a CD4 cell less than 200 cells/
mm3(27, 28, 29).
Note: Strong recommendation; moderate certainty in the evidence about the intervention
effects.
Ethiopian contextual update and recommendation to use AlereLAM.
The National Guidelines for Clinical and Programmatic management of TB,DR TB and
Leprosy guideline recommends (24)the use of LF-LAM in the following Key areas.
General Recommendation ForDiagnosis of TB among HIV positives in all settings
• Lateral flow lipoarabinomannan assay (LF-LAM) test is recommended to as-

sist the Diagnosis of TB among selected groups of HIV-infected presumed TB
patients ,in conjunction with Molecular WRDs (Xpert MTB/RIF test, Xpert
Ultra, Trunat and TB-LAMP) among PLHIV with advanced HIV disease stat.
• For seriously ill patient with negative Xpert MTB/RIF and/or sputum smear
results on full course anti-TB treatment using only suggestive findings on ra-
diography. In such circumstances, the clinical response of the patient has to be
monitored and if possible repeat the Xpert tests. UrineLF-LAM test is recom-
mended whenever available.
For outpatient settings:
• WHO suggests using LF-LAM to assist in the diagnosis of active TB in HIV

positive adults, adolescents and children who: have signs and symptoms of TB (pul-
monary or extrapulmonary); are seriously ill; or have a CD4 cell count of less than
100 cells/mm3 irrespective of signs and symptoms of TB.

4
Not Recommended to use LF-LAM test in following condition
• Outpatient settings, it is not recommended to use LF-LAM to assist in the diag-

nosis of active TB in HIV-positive adults, adolescents and children without TB
symptoms and with an unknown CD4 cell count, or with a CD4 cell count greater
than 100 cells/mm3.
• LF-LAM should be used as an add-on to clinical judgment in combination with

other tests. It should not be used as a replacement or triage test.
• For hospitalized PLHIV without signs or symptoms of TB and whose CD4 is 200
cells/mm3 or above (or is unknown), do not conduct an LF-LAM test.
Remark
• For initial diagnostic test, all patients with signs and symptoms of pulmonary TB
who are capable of producing sputum should have at least one sputum specimen
submitted for a molecular WRD assay. This also includes children and adolescents
living with HIV who are able to provide a sputum sample. LF-LAM results (test
time< 15 minutes) are likely to be available before molecular WRD test results;
hence, treatment decisions should be based on the LF-LAM result while awaiting
the results of other diagnostic tests (27, 28, 29).
For in patient settings LF-LAM recommended under the following conditions:
1. After evaluating hospitalized PLHIV for TB, assess the presence of danger signs for
being seriously ill. In PLHIV who are not seriously ill, consider measuring CD4 cell
counts, to assess eligibility for testing with the LF-LAM assay.
A. For hospitalized HIV-positive adults, adolescents and children with signs or

symptoms suggestive of all forms of TB or with a chest X-ray suggestive of TB,
or hospitalized patients who have advanced HIV disease (AHD), or seriously
ill or have CD4 counts of less than 200/mm3 , regardless of TB signs and symp-
toms is eligible for testing with the LF-LAM assay.
B. For PLHIV who is “Seriously ill” is defined as presenting with any one of the
following danger signs: Respiratory rate >30 per minute, Temperature >39 °C,
Heart rate >120 beats per minute or unable to walk unaided.
C. For adults, adolescents and children aged more than 5 years, AHD is defined as
CD4 cell count <200 cells/mm3or WHO clinical stage 3 or 4 at presentation

for care. All children aged under 5 years .
Remark
• For PLHIV whose HIV status is unknown but who present with strong clinical
evidence of HIV infection, in settings where there is a high prevalence of HIV or
among members of a high risk group for HIV; recommended to Perform HIV test-
ing in accordance with national guidelines.
1. Hospitalized PLHIV who are evaluated for TB and are positive for signs and symp-
toms of TB,
A. Collect a urine specimen and conduct the LF-LAM assay and collect a Sputum
specimen and conduct mWRD testing, If the mWRD test is available on site.
Remark (21,24):
A. In settings where access to mWRDs such as Xpert service on same day is not feasi-
ble, do Bacteriological test such as AFB smear microscopy on two samples on spot,
and send specimen for mWRDs. If Smear results turns positive rifampicin resis-
tance need to be ruled out.
For individuals being evaluated for pulmonary TB, the following samples may be used for
the molecular WRD test: induced or expectorated sputum (preferred), Bronchoalveolar
lavage, Gastric lavage or aspirate, Nasopharyngeal aspirate and stool samples can be used
in line with LF-LAM. .
B. For individuals being evaluated for EPTB, theGeneXpert MTB test is recommend-
ed to diagnose TB from specimen such as CSF , lymph node aspirates and lymph
node biopsies, pleural fluid, peritoneal fluid, pericardial fluid, synovial fluid , Blood
may also be considered to diagnose of disseminated TB using solid TB Culture
methods only.
C. The LF-LAM result (test time <15 minutes) is likely to be available before the
molecular WRD test result, and should be interpreted in the context of clinical
judgment, chest X-ray findings (if available) and any available bacteriological results.
D. All patients eligible for testing requirements who have a positive LF-LAM result
should be initiated on TB treatment immediately, while awaiting results of the mo-
lecular WRD test .
E. TB is not ruled out if the LF-LAM test result is negative. Evaluate the results of
the molecular WRD test, and follow Nation Diagnostic Algorithm (Algorithm 1
Annex ) for interpretation of results and follow-up testing.
6
F. Treat all patients with a molecular WRD test result of “MTB detected” for TB, re-
gardless of LF-LAM result.
G. TB is not ruled out if both the LF-LAM result and molecular WRD test results are
negative (or if no molecular WRD test is performed). Re-evaluate the patient and
conduct additional testing in accordance with national guidelines. Further inves-
tigations for TB may include chest X-ray, additional clinical assessments or cultur
1.3. Scope of the implementation guideline
• The Guideline is designed

9 To provide key information on Global and country specific recommendation
and application to use LF–LAM for PLHIV in advanced disease conditions in
Ethiopian.
9 To use for HIV care service decision-making process, particularly for all clini-
cians especially ART focal persons, TB focals, laboratory professionals, TB and
HIV control program managers monitoring & evaluation, pharmacy and supply
management staff.
9 To provide guidance to health care workers in out- and inpatient Care settings,
in line with the current national Guideline for programmatic management of TB
in PLHIV and the national comprehensive HIV guideline.
9 To provide role and responsibility of Health care service providers and adminis-
trators at each tire system of health care service delivery in Ethiopia.
9 To provide key Indicators for Programmatic and operational tool for Monitor-
ing& Evaluation of appropriate utilization and performance.
1.4. Objectives of the implementation guidelines
9 To review and recommend strategic approach for implementation and application

of LF-LAM for PLHIV in advanced disease state in Ethiopian health care setting .
9 To review and recommend clinical use and application of LF–LAM in advanced

PLHIV disease conditions in Ethiopian context.
9 To review and recommend minimum laboratory operational standard to use LF–

LAM in assisting TB diagnostic strategy for PLHIV in advanced disease state .
9 To assess and recommend minimum operational standard, implementation cost ,

affordability and supply chain management strategy of LF-LAM implementation

in Ethiopia .
9 To review and set key Indicators of Monitoring&Evaluation and impact assess-

ment standard.

8
2. Strategic approach
2.1. Eligible PLHIV for LF_LAM Test
WHO 2019 policy update on LF-LAM recommends(21)the currently available urinary

LAM assays have suboptimal sensitivity, and are therefore not suitable as general diag-
nostic tests for TB. However, unlike traditional diagnostic methods, they demonstrate
improved sensitivity for the diagnosis of TB among individuals coinfected with HIV. The
estimated sensitivity is even greater in patients with low CD4 cell counts.
Therefore, HIV-positive adults, adolescents and children with the following criteria are
eligible for Urine LF_LAM test to assist in the diagnosis of active TB:
2.1.1. In outpatient settings
• With signs and symptoms of TB (pulmonary and/or extrapulmonary) or seriously ill

• Irrespective of signs and symptoms of TB and with a CD4 cell count of less than 100
cells/mm3
In outpatient settings, WHO recommends against using LF-LAM to assist in the diag-
nosis of:
Active TB in HIV-positive adults, adolescents and children:
• Without assessing TB symptoms

• Without TB symptoms and unknown CD4 cell count or without TB symptoms and
CD4 cell count greater than or equal to 200 cells/mm3
• without TB symptoms and with a CD4 cell count of 100–200 cells/mm3

Remarks
a. The reviewed evidence and recommendations apply to the use of AlereLAM

only, because other in-house LAM-based assays have not been adequately vali-
dated or used outside limited research settings. Any new or generic LAM-based
assay should be subject to adequate validation in the settings of intended use.
b. All patients with signs and symptoms of pulmonary TB who are capable of pro-
ducing sputum should have as their initial diagnostic test at least one sputum
specimen submitted for Xpert® MTB/RIF (Ultra) assay. This also includes chil-
dren and adolescents living with HIV who are able to provide a sputum sample.
c. These recommendations also apply to adolescents and children living with HIV,

based on generalization of data from adults, while acknowledging very limited
data for these population groups.
d. LF-LAM should be used as an add-on to clinical judgement in combination
with other tests. It should not be used as a replacement or triage test. More de-
tails are given in Algorithms for LF-LAM use.
2.1.2. In inpatient settings
• With signs and symptoms of TB (pulmonary and/or extrapulmonary)

• With advanced HIV disease or who are seriously ill
• Irrespective of signs and symptoms of TB and with a CD4 cell count of less than
200 cells/mm3
a. “Seriously ill” is defined based on four danger signs: respiratory rate of more than 30/
minute, temperature of more than 39 ° heart rate of more than 120/minute and unable
to walk unaided.
b. For adults, adolescents, and children aged 5 years or more, “advanced HIV disease”
is defined as a CD4 cell count of less than 200 cells/mm3 or a WHO clinical stage 3
or 4 event at presentation for care. All children with HIV who are aged under 5 years
should be considered as having advanced disease at presentation.
(Further descriptionon of the strategies is available in Annex 1 and Annex 2.)
Note for using LF_LAM test for children less than 5 years:
Latest WHO guideline consider all HIV infected children age <5 years old to follow as
advanced HIV disease , besides nationally we have a limited number of under 5 children
on ART. Hence setting other criteria may limit the Urine LF_LAM utilization. Until fur-
ther guidance given by WHO, the team suggested to conduct LF_LAM test for all HIV
infected children under 5 years at least once as per below criteria:
• To offer LF_LAM for all HIV infected <5 years children backlog/currently on treat-
ment once irrespective of clinical stage or CD count/CD 4 percentage
• All newly enrolled under 5 HIV infected children (at Enrollment) irrespective of clini-
cal stage or CD count/CD4 percentage
• Once cleared the backlog, offer LF_LAM at any time when children presented with
TB symptoms, or serious illness or advanced HIV stage or CD4 percentage.

10
2.2. National TB Diagnostic Algorithm for PLHIV Incorporating Urine LAM
test
2.2.1. Algorithm for LF-LAM testing to aid in the diagnosis of TB among PLHIV in
outpatient settings
Adults, adolescents and children LHIV including: 1. All newly diagnosed HIV patients who are ART naive 2. HIV patients returning for care
following a treatment interruption 3. HIV patients receiving ART regimen that is failing 4. HIV Patients presenting at the clinic and unwell
Assess patient for (TB signs and symptoms/ severity of illness/ Stage of HIV Disease/ CD4 status)
Positive for TB signs and symptoms No TB signs or symptoms and

and/or Seriously ill Not seriously ill
Perform urine LF-LAM4 CD4 Assessment OR

Collect a sample & perform mWRD test Clinical staging
CD4 100-200 or CD4 >200 or

LF-LAM LF-LAM CD4<100 or WHO Clinical Stages unknown or WHO
-VE Stage 3 or 4 1&2 Clinical Stages 1&2
Initiate TB TB is not ruled out, Perform LF-LAM

treatment Evaluate mWRD
Evaluate result
mWRD result LF-LAM LF-LAM
+VE -VE
mWRD mWRD
+Ve -Ve
mWRD mWRD Initiate TB
+Ve -Ve
treatment,
adjust based
on mWRD
result
Adjust Initiate Apply Advanced HIV

Clinical Management,
treatment Continue TB Disease (AHD) Clinical management
TB is not ruled out.
based on TB treatment package of Care
Conduct additional
mWRD treatment based on
evaluations for TB
results if mWRD
(CXR, ….)
needed result

2.2.2. Algorithm for LF-LAM testing to aid in the diagnosis of TB among PLHIV in
inpatient settings
All hospitalized patients, including adults, adolescents, and children living with HIV
Assess patient for TB signs and symptoms, severity of illness, HIV disease stage and CD4 status
Positive for TB signs and symptoms No TB signs or symptoms, No TB signs or symptoms and or
butAdvanced HIV Disease (AHD)+ CD4 > 200
or seriously ill or CD4 < 200
Collect a urine sample & perform urine

Collect a urine sample & perform urine Clinical management
LF-LAM4 Collect a sample & perform
LF-LAM
mWRD test
LF-LAM LF-LAM LF-LAM

LF-LAM
+VE -VE -VE +VE
Initiate TB TB is not ruled Evaluate CD4

Count Initiate TB treatment Collect
treatment out. Evaluate
specimen & perform mWRD
Evaluate mWRD result test
mWRD result CD4 <200 CD4>200
mWRD mWRD
+Ve -Ve
mWRD mWRD
+Ve -Ve mWRD mWRD
+Ve -Ve
Clinical Apply
Continue Management, Continue TB
Adjust Advanced Adjust
TB TB is not ruled treatment.
treatment Initiate TB HIV treatment
treatment out. Perform
based on treatment Disease based on
Perform Conduct workup to
mWRD based on (AHD) WRD result
workup to additional exclude DR-
results if mWRD package if needed
exclude evaluations for TB
needed of Care
DR-TB TB.

12
2.3. Laboratory order and result interpretation
2.3.1. Urine LAM test workflow
The urine LF-LAM test is ordered by Health Care Workers (preferably by those received
orientation on the test) using standard lab request form. The request is usually anticipated
to come from ART clinics or In-Patient facilities but can also come from any department
where ART clients are receiving service. Urine LAM test kits and sample collection con-
tainers should be available at the laboratory at all times (including weekends and duty
hours). Urine LF-LAM test result takes only 25 minutes so the standard Turn Around
Time (TAT) for result reporting should be not more than 1 hour as the result is usually
required urgently for treatment decision on seriously ill patients. The lab personnel should
communicate Urine LF-LAM positive results immediately by phone to the attending
clinician till the result paper is ready following lab registration process.
2.3.2. Result interpretation
Urine LF_LAM positive test can aid diagnosis of TB through appropriate use of the
algorithm. However, it should be well underscored that Urine TB LAM test is a rule-in
test, meaning a negative test doesn’t exclude TB disease. Therefore, in addition to clinical
parameters, the clinicians should make every effort to use other bacteriologic, histo-patho-
logic, imaging, etc. tests to establish the diagnosis of TB. The following results are expected
for urine LF test and recommended measures to be taken by the clinician:
• Positive: Manage as TB case in line with the LF-LAM algorithm recommendation
• Negative: The clinician should use other clinical and diagnostic test result findings to
decide further management. Test may be repeated as required if the
• Equivocal/indefinite/Indeterminate: Means unclear to confidently say positive or

negative. For better clinical decision, the test should be repeated on a fresh sample;
early morning urine sample is best.
• Invalid: This result is normally not reported to the clinician but this may prompt the
lab technician to do some quality assurance measures and repeat the test on the same
or other fresh sample.

2.4. Case definition, classification,treatment follow up, case registration and rel-
evant indicators
Monitoring the implementation of newer WHO-approved diagnostic tools, such as Xpert

MTB/RIF and urine LAM (lipoarabinomannan assay), is important, as they offer advan-
tages over other diagnostic modalities. Understanding of TB burden among people living
with HIV should inform program management and planning. The WHO policy update
(21) on LF-LAM test and other WHO documents didn’t provide guidance on case defi-
nition and classification of TB cases diagnosed by Urine LF-LAM test. The 2020 WHO
consolidated Strategic Information guidelinehowever provided some guidance regarding
indicator definition for measuring performance for use of newer molecular TB diagnostic
tests in different indications and diagnostic yield. Therefore the guideline development
task team has made the following recommendations in relation to case definition, classi-
fication and indicators for recording and reporting of Urine LAM test use at the health
facilities till further guidance is available for standardized M&E at global level:
2.4.1. Case definition:
The national TB guideline defines bacteriologically confirmed TB as follows:
A bacteriologically confirmed TB case: Refers to a patient from whom at least one biological
specimen is positive for mycobacterium TB by either smear microscopy, Xpert MTB/RIF, culture
or other WHO approved bacteriologic detection tests.
(For full detail of TB case classification(25).
Urine LF-LAM test is a WHO approved ‘bacteriologic detection’ diagnostic test based
on the detection of mycobacterial lipoarabinomannan (LAM) antigen in urine. Therefore,
based on the national TB case definition, the national guideline development task team
recommends that TB patients diagnosed using solely on the basis of positive urine LF-
LAM test following the national algorithm are ‘bacteriologically confirmed TB cases’
till further guidance from WHO is available for standardized case definition.
2.4.2. Classification
• Classification based on previous treatment history follows same principle also

for urine LAM diagnosed cases(25).
• For practical purpose, classification based on anatomic site of involvement will be
decided as follows:
9 Pulmonary: TB cases diagnosed based on positive Urine LAM test with any
of the following evidence of pulmonary involvement are classified as pulmo-
14
nary TB cases:
9 Signs and symptoms of pulmonary TB (cough, hemoptysis, chest findings,
etc.)
9 CXR Abnormality on the lungs (other imaging tests)
9 Bacterial confirmation of MTB from sputum sample (or other similar e.g.
bronchio-alveolar lavage) by smear microscopy, mWRDs or Culture
NB: when result of positive sputum test is received at a later time, the case classification
should be updated as ‘Pulmonary’ on the registers accordingly; similarly if DST result
shows Rif resistance, we should refer classification for DR-TB cases (25) for appropriate
case classification amendment and subsequent action. Treatment regimen should also be
modified as necessary based on DST result.
• Extra-Pulmonary:Patients diagnosed as TB case, solely by Urine LAM positive result

but not fulfilling the criteria for ‘pulmonary TB’ cases as above are classified as ex-
tra-pulmonary TB cases.
2.4.3. Treatment follow up of Patients diagnosed using Urine LF-LAM test algorithm
The guideline development task team recommended the following treatment monitor-
ing and documentation of treatment outcome till monitoring guidance is available from
WHO for standardized approach.
• Urine LAM test Negative and mWRDs test Negative: treatment decision can still
be made based on other tests e.g. imaging, histopathologic test, etc. If the clinician
decides to initiate treatment in such instances, treatment follow up can be made clin-
ically and successful treatment will be documented as ‘Treatment Completed’
• Urine LAM test Positive but mWRDs test Negative: For both pulmonary and
EPTB, monitor patients clinically and report successful treatment outcome as ‘Treat-
ment Completed’
• Urine LAM test Negative but mWRDs test Positive from sputum sample: Treat-
ment follow up will be by sputum smear test and treatment outcome will be deter-
mined in the same way as other bacteriologically confirmed pulmonary TB patients
(see national guideline).
NB: If patient diagnosed using the Urine LF-LAM test algorithm and solely based on
positive Urine LAM test show worsening of TB symptoms while on TB treatment the
patient should be investigated for superimposed infections/illnesses and anti TB drug
resistance. In such instances, genotypic DST should be done for identifying Rifampicin

resistance. Patient’s TB case classification and anti-TB regimen should be modified in case
the mWRD test result turns out to be positive and Rifampicin resistance is detected.
2.4.4. Indicators and definitions for PLHIV evaluated with Urine LAM test
The following indicators adopted to the country program context will be used for moni-
toring appropriate use of Urine LAM as part of the PLHIV TB screening clinical cascade:
Indicator: TB testing among those symptom-screened positive
Indicator definition:
Percentage of people living with HIV newly initiated on ART and screened positive for
TB symptoms who then are tested for TB.
Numerator
Number of people living with HIV on ART who are investigated for active TB
disease with appropriate diagnostic testing
Denominator
Number of people living with HIV on ART and screened positive for TB symp-
toms during the reporting period
What it measures
This indicator measures the percentage of people living with HIV newly initiated on ART
and screened positive for TB symptoms who then had clinical evaluation and/or appro-
priate TB diagnostic testing.
Rationale
Appropriate TB diagnostic testing is essential for people living with HIV who symp-
tom-screen positive for TB. It is important to understand the cascade from ART enrol-
ment to treatment of active TB disease; this indicator will shed light on any obstacles
between positive screening for TB symptoms and proper diagnostic testing, based on na-
tional clinical guidelines.
Method of measurement
For the numerator. Program records (ART register, EMRs). “Appropriate” diagnostic
testing refers to WHO & Nationally recommended testing modalities.
For the denominator. Program records (ART registers, EMRs)

16
Disaggregation
• ART status (New, & already on ART)

• Gender (male, female)
• Age (<15, 15+).
• Type of diagnostic test (Xpert MTB/Rif (including Ultra), Urine LF-LAM, Other.
2.5. Patient Management
Patients diagnosed as TB cases as per the national Urine LAM algorithm shall follow the
management and follow up protocol described in the national comprehensive ART guide-
line - Advanced care package and the national TB/HIV guideline(25).
Treatment outcome will also be determined using similar parameters like in the other TB
cases.

3. Laboratory testing of LF-LAM for PLHIV
3.1. The LF-LAM Assay
Lipoarabinomannan (LAM) is a major lipopolysaccharide component of the outer cell

wall of mycobacteria has a 17.5 kDa glycoprotein found on the surface of the cell(21,26).
It is an immunogenic virulence factor that is released from metabolically active or those
that are being degraded and is specific for mycobacteria species(21,26). It has character-
ized as a potential marker of active TB, and it is the most-studied TB biomarker to date.
Factors that make LAM an attractive biomarker for TB include that it is derived from
and specific to mycobacteria species; it is abundant in the cell wall of MTB; it is heat and
protease stable; and it has structural epitopes that are unique to MTB(21,26).
In people living with HIV who are seriously ill, TB can disseminate into various organs.
Since LAM is filtered by the kidneys, it is detectable in urine, particularly in patients with
advanced HIV disease and disseminated TB. Finding LAM in urine typically indicates
severe disease that requires immediate treatment. In addition, in patients with TB who are
immunocompromised, the bacilli are not contained by typical immune responses due to
the patient’s low CD4 cell count and impaired response; thus, TB bacilli can be degraded
and excreted by normal body processes. In both scenarios, the MTB LAM antigen can be
present in urine, making detection viable for diagnosis.
Test principle
LF-LAM consists of an immunochromatographic assay for the qualitative detection of

LAM antigen of mycobacteria in human urine specimens. The test uses highly purified
polyclonal antibodies to capture LAM molecules (the target antigen) with a lateral flow,
sandwich-based enzyme-linked immunosorbent assay (Figure. A below). The specimen
is added to the test strip and capillary flow moves the LAM antigen across the strip so
that (A) it binds to a colloidal gold conjugate antibody to form an immunocomplex; (B)
capillary flow moves the immunocomplex past the control and patient windows where
it is captured by an anti-LAM antibody fixed to the nitrocellulose membrane; and (C)
the presence of LAM is confirmed by the colloidal gold label. A purple–grey band in the
patient window indicates a positive result, showing that LAM antigen from mycobacteria
is present in the sample at or above the detection limit of the test. If no band is visible,
then LAM either is not present or possibly present below the detection limit, and thus the
result is presumed to be negative. A control window has been added to ensure the validity
of the test; a line should be visible in the control window for every test. The control band
uses an antibody with specificity to the colloidal gold(27).
18
A
Figure A: General principles for detecting the lipoarabinomannan (LAM) antigen(27).
Performance and operational characteristics:- According to the WHO review of 2019,

there were 15 included studies involving 6814 participants, of whom 1761 (26%) had
TB(21). Eight of the studies evaluated the accuracy of AlereLAM for TB diagnosis in
participants with signs and symptoms suggestive of TB; these studies involved 3449 par-
ticipants, of whom 1277 (37%) had TB. Seven studies evaluated the accuracy of AlereLAM
for diagnosis of unselected participants who may or may not have had TB signs and symp-
toms at enrolment; these studies involved 3365 participants, of whom 439 (13%) had
TB(21).
The study further summarized the sensitivity and specificity of AlereLAM for the diagno-
sis of TB among PLHIV based on inpatient and outpatient settings, sign and symptoms
of TB, CD4 count and adult and children categories as presented in tables below(21).

Table 1: Performance characteristics of LF LAM for the diagnosis of TB among adult PLHIV
Setting Performance characteristics
Sensitivity Specificity
with sign Irrespective Advanced disease with sign Irrespective Advanced disease
and of TB sign irrespective of sign and of TB sign irrespective of sign and
symptom and and symptom (based symptom and symptom (based
of TB symptom on CD4 count) of TB symptom on CD4 count)
≤ 200 ≤ 100 ≤ 200 ≤ 100
cells/ul cells/ul cells/ul cells/ul
Outpatient 29% 31% 21% 40% 96% 95% 96% 87%
(17-47%) (18-47%) (8–48%) (40-64%) (91-99%) (87-99%) (89-99% (68-94%)
Inpatient 52% 62% 64% 57% 87% 84% 82% 90%
(40-64%) (41-83%) (35-87%) (33-79%) (78-93%) (48-96%) (67-93%) (69-97%)
All 42% 35% 26% 47% 91% 95% 96% 90%
(31-55%) (22-50%) (9-56%) 30-64%) (85-95%) (89-98%) (87-98%) (77-96%)
Data source: Lateral flow urine lipoarabinomannan assay ( LF-LAM ) for the diagnosis of ac-
tive tuberculosis in people living with HIV Policy update 2019.
Table 2: Performance characteristics of LF LAM for the diagnosis of TB among children living
with HIV
Setting Sensitivity Specificity
Outpatient 42% (15-72%) 94% (73-100%)
Inpatient 56% (21-86%) 95% (90-98%)
All 43% (23-66%) 80% (69-88%)
Data source: Lateral flow urine lipoarabinomannan assay ( LF-LAM ) for the diagnosis of ac-
tive tuberculosis in people living with HIV Policy update 2019.

20
3.2. Laboratory infrastructure and Supplies needed for testing
Urine LF-LAM test Minimum Requirements
Human Resource • Laboratory professional and/or HCWs received
onsite/offsite orientation
National Guidelines, • National TB guideline
SOP, and PSTs • Urine LF-LAM job aid
• LF-LAM implementation guideline
• Urine LF-LAM SOPs
Equipment and sup- • LF-LAM test kit
plies • Urine cup
• Timer
• Pipette or other device capable of accurately
delivering 60 µL of urine (this could be a cali-
brated 100 µL micropipette with filter tips or a
dual-bulb 60 µL micropipette
• Glove
Register and Forms • TB Laboratory registration logbook
• TB laboratory requisition and reporting format
In addition, workstation with adequate light and waste disposal system for both sold and
liquid waste should be readily available.
3.3. Sample collection, testing and interpretation for LF-LAM

Sample collection and storage
The required sample for LF-LAM testing is urine(freshly colleted, catheterized and urine
bag). Before collecting the urine sample, it is highly recommended that the urogenital
areas are cleaned with a cleansing wipe.Midstream urine should be collected in a standard
urine specimen cup.It is recommends using early morning urine to ensure optimal test
performance( 26,27).
Whenever feasible, fresh samples should be tested, ideally immediately after collection. If
immediate testing is not possible, urine can be stored at room temperature for a maximum
of 8 hours or at 2–8 °C for a maximum of 3 days. If testing is delayed more than 3 days,
the samples should be frozen (-20°C or colder). For frozen or refrigerated urine bring
all samples to room temperature one hour prior to testing. Frozen samples may contain
aggregates. For internal quality control and research purposes, samples can be frozen at
−20°C.

However, freezing can cause the formation of uncharacterized precipitates. Thus, un-
thawed samples require centrifugation at 10,000 g for 5 minutes at room temperature and
then a 60 µL aliquot can be drawn from the clear supernatant for testing. Avoid multiple
freeze–thaw cycles (i.e. allow only a maximum of three) as the LAM antigen can deterio-
rate. Specimens that have been frozen and thawed more than 3 times cannot be used. Note
that some studies have indicated that urine LAM reactivity disappears in samples stored
for 3 years at −20 °C.
Supplies needed for LF-LAM testing
The following supplies are required for LF-LAM testing are
• LF-LAM kit
• Clean urine collection cup;
• Pipette or other device capable of accurately delivering 60 µL of urine (this could
be a calibrated 100 µL micropipette with filter tips or a dual-bulb 60 µL micro-
pipette
• Timer
• Reference Scale Card
• Package insert with instructions
Figure B .The items required for the Alere Determine TB LAM Ag assay include the test card, the
reference Scale Card, a sterile urine collection cup, a pipette and a timer(10).

22
Procedure
The basic procedure is indicated in Figure C, and the standard operating procedure is out-
lined in Annex 9. The test strip should be used within 2 hours after removing it from the
protective foil cover. If more than one sample will be tested, be sure to properly label each
test strip so that it can be linked correctly to each patient’s sample. The workbench should
be cleared of materials not used for testing and cleaned with disinfectant. It is important
to follow an organized workflow for testing and timing to ensure the accuracy of the test.
The basic steps are:
(1) Remove the protective foil cover for each test strip needed and ensure they are properly
labelled for each patient’s sample;
(2) Add 60 µL of urine to the sample pad using a precision pipette or alternative device;
(3) Wait 25 minutes and then read the results. Results are stable for a total of 35 minutes.
Do not read after 35 minutes;
(4) Check the results against the Reference Scale card included in the test kit.
Figure C.Testing procedure for the Alere Determine TB LAM Ag assay

Result Reading, interpretation and Reporting
Read the strip using the naked eyes in well lit room, NOT in direct sunlight
Purple/grey bands will appear in the windows on the test strip
1. Check if there is a band visible in the
control window of the test strip.
2. If there is a band visible in the control

window, then check the patient window
for a visible band
• If a band is visible in this window, the

test is positive
• If there is no band in this window, the

test is negative
• If the band in this window is incom-

plete or not clear, the test is indeter-
minate. Repeat the test on another
urine specimen.
3. To assist with the reading match the
intensity of the band in the patient win-
dow of the test strip against the reference
scale card to determine the positivity.
• if the intensity of the band in the pa-

tient window is lower than any of the
coloured bands in the section marked
positive in the Reference scale card.
The test is indeterminate and must be
repeated on another sample of urine.
4. A log should be kept of all LAM pos-

itive results together with the patient de-
tails and folder numbers as a record for
the purposes of future reference and in
case results are required by another centre
or during a following admission(30).

24
Quality control testing
Conduct quality control testing for LF-LAM when new batch/lot isopened(26,27). Re-
cord the results of the quality control testing in the IQC log ( Annex 10).
The following procedure should be used to evaluate the AlereLAM quality controls.
For the AlereLAM positive control:
(1) First, label the test strip as the TB LAM positive control;
(2) Add 60ul of the TB LAM Ag positive control to the labelled test strip;
(3) Read the results after 25 minutes.
For the LF-LAM negative control:
(1) First, label the test strip as the TB LAM negative control;
(2) Add 2 drops of saline solution or distilled water;
3.4. Biosafety requirements and waste disposal
Safety precautions are essential and should be followed at all points in the testing process
from specimen reception to testing, storage, and disposal of biohazard wastes so as to
minimize occupational risk. Conduct testing in a clean workstation. Gowns and gloves
must be worn awhile working in the laboratory. After use, removed gloves aseptically and
washhands.
• All procedures must be performed in such a way as to minimize or prevent the forma-
tion of aerosols and splash.
• All contaminated materials, Pasture pipete and urine collection container must be de-
contaminated appropriately using 1:10 diluted 5 % hypoclorite solution before dispos-
al or cleaning for reuse.diluted solutions should be prepared daily.
• Work stations must be decontaminated before and at the end of each work session
,after any spill of potentially infectious material.
• The Specimen or materials should effectively decontaminated or disinfected using
proper procedures.
Materials that are decontaminated or disposed of outside the laboratory should be placed
in a strong, leak-proof waste container
o Waste materials must be packaged in a closed container or bag for immediate onsite
incineration.

4. Human Resource Development
4.1. Technical Training on LF-LAM
Before implementation LF-LAM, a one-day training and practical session should be pro-
vided for regional laboratory professionals.The training will provide information on cas-
cading, patient eligibility, how to perform the test, test application and the visual interpre-
tation .In addition the training will provide guidance on how to integrate LF-LAM with
other TB laboratory trainings andsupervisions.
4.2. Sensitization Workshop on LF-LAM
As with any new technology being implemented, a sensitization workshop will be provid-
ed for respective stakeholders.Theone daysensitization workshopis recommendedforclini-
cians, regional health bureau TB and HIV focal, zone TB and HIV focal, EPSA, HAPCO
and EFDA so that the specifics of each setting can be understood and to ensure user
capability and understanding.

26
5. Supply chain management for LF-LAM
In order to achieve sustainable LF-LAM implementation, it is very important to ensure
the availability of the supplies. The current procurement, storing and distribution system
for TB diagnostic supplies in most cases is done by EPSA. Therefore, it would be better to
address and include the supply system for LF-LAM into the existing IPLS. To improve
the role and active engagement of EPSA hubs and health facilities, the distribution will be
based on the requesting and reporting form (RRF) provided from the facilities.
To initiate the LF-LAM testing for the first time during the implementation period, the
estimated stock will be distributed to the region based on the request received from each
RHBs. The regional estimation and the distribution plan for the first time to initiate the
test at selected heath facilities till IPLS take place, MOH, EPHI and partners will prepare
the regional quota based on the patient enrollment and stock status. The Disease Pre-
vention and Control Program issue the letter to the central EPSA for the distribution of
LF-LAM supplies. The central EPSA in turn will issue the quantity to respective EPSA
hubs and they will deliver the health facilities every two- months. Sometimes, the health
facilities can collect the supplies from the Hubs to avoid any delay.
As it is expected to do the test in the laboratory, the Head of health facility laboratory
or any appointed personnel will fill the Internal Facility Reporting and Resupply Form
(IFRR) and send the request to the pharmaceutical main store based on the stock on hand
at laboratory.
In order to timely deliver and refill of the supplies, either electronically or manual reports
can be employed. Therefore, each health facility can fill excel based format and send it to
RHBs through email or the hard copy every two months and as the same time RRF to
respective Hubs for the resupply. The RHBs will aggregate the report in both soft and
hard copy and share it to FMOH for monitoring purpose. All health facilities will align
the requesting and reporting of the products with the existing IPLS schedule to ensure
the sustainable LF-LAM supplies.For the next refill period, each health facility will be
responsible to correct the report based on the feedbacks from RHB.
In case of an emergency order, if needed, the report format to place an order will be the
same as with the routine reporting RRF and excel based format.

Figure D: LF-LAM Supply Distribution flow from the National to Health Facilities
FMOH/EPHI Central EPSA
Regional Health EPSA Hubs

Bureaus
Health Facilities
Keys:
• Flow of LF-LAM kit :
• Report and Request:
• Approval of Request:

28
6. Quality Assurance
LF-LAM quality assurance aim to ensure high accuracy of tests in the hands of end-us-
ers. This will include both monitoring of the technical standard of the processes, moni-
toring of preparation and interpretation at all LF-LAM implementation sites describes
all the activities taken by a laboratory to monitor each stage of a test procedure to ensure
that tests are performed correctly and are accurate and precise maintain a quality ser-
vice and provide for continuing improvement to provide reliable, relevant, timely test
results(27,28).
The two quality assurance methods are implemented for LF-LAM test
¾ Internal Quality Control (IQC)

¾ External quality Assessment (EQA)
• Panel testing (PT)
• On-site Supervision & Evaluation

6.1. Internal quality control
IQC is used to demonstrate that a test is functioning properly and can produce a valid re-
sult. Each LF-LAM test strip includes in built internal quality control and result bar that
should be evaluated for each test, as described in the interpretation section. When a new
batch opened lot testing conducted by using known LAM positive and LAM negative
urine samples(27,30).

6.2. External quality control
External Quality assurance performed to evaluate testing site’s performance and identify
any site-level needs not captured via routine reporting practices. EQA will be conducted
by using on site evaluation and Proficiency testing.
6.2.1.On-site supervisory and evaluaton visits
On site supervision and evaluation conducted by EPHI and RRL biannually as per the
schedule of National EQA Programme using modified existing supervisory checklists to
ensure a standardized tool is used during supervisory visits across the network so that
findings can be compared over time and between testing sites. The use of LF-LAM can
be evaluated and reports incorporated into the existing schedule for supervisory visits(31).
6.2.2. Proficiency testing
EPHI NTRL prepares and distruibutesprofieciency testing samples on annual basis. Pro-
ficiency testing evaluates the accuracy and timeliness diagnostic serves as an efficient tool
for monitoring and evaluation of testing networks. Profieciency testing results from test-
ing facilitis will be sent back to NTRL.
6.3. Quality indicators
To monitor LF-LAM testing service quality each facility should select and monitor labo-
ratory quality indcators. The following quality indicators shoud be monitored on reguarba-
seis this are turnaround time, customer satisfaction, test interruption, internal and external
quality control.

30
7. Monitoring and Evaluation (M&E) Plan for
LF-LAM Implementation
Performance of LF-LAM at the site and network levels should be regularly evaluated using
routinely collected and reported data obtained from supervisory visits, quarterly reports and
proficiency testing and other reports received from existing channels of documentation. Un-
expected changes in performance or performance that is below targets for quality should be
promptly investigated for remediation.
Monitoring and Evaluation
Strong monitoring and evaluation system needs to be put in place which is important to
monitor the effect of LF-LAM
Urine TB LAM test quarterly reporting tool
TB-LAM indicators Total Both Only Both LF- Positive

eligible for LF-LAM LF-LAM LAM and only by
LF-LAM and Gen- tested GeneXpert
testing eXpert LF-LAM
(C) positive
(A) tested ( E)
(D)
(B)
Outpatient TB symp-
tomatic HIV positive
(New/treatment inter-
rupted /treatment fail-
ing / clinically unwell )
clients in the quarter
Outpatient HIV posi-

tive clients with CD4 <
100 and or stage 3/4 in
the quarter
TB symptomatic inpa-
tient HIV positive cli-
ents in the quarter
Inpatient HIV positive
clients with Advance
HIV disease or seriously
ill or CD4 < 200 in the
quarter
Supportive Supervision: Ministry of Health and EPHI in collaboration with RHB, RRL
and Partners will conduct a separate specific supportive supervision at the beginning of the
implementation plan whereas RHB will conduct biannually. In addition, the checklist will in-
clude the monitoring tools of LF-LAM at all levels for the proceeding supportive supervision.

Review meeting: The annual meeting will be conducted at national level. Participants will
be experts from FMOH, EPHI, EPSA, RHB, RRL, FHAPCO, EFDA and Partners.
The best experience will be shared during the review meeting.
Reporting: Standardized recording and reporting formats( Annex 12) will be available to
implementing health facilities. Each site will compile and summit report to the existing
reporting system every quarter. The facility ART focal is responsible to compile the report
and send to respective region and EPHI. Since it is a new initiative, the FMOH, EPHI
and the development partners will follow the implementation status, so the report proba-
bly requested when needed or during the supporting supervision.
• Indicators are selected to monitor and evaluate the impact, outcome, output and input
of the LF-LAM techniques
Data Sources:ART register, TB unit register and TB laboratory registration book

32
8. Roles and Responsibilities
Ministry of Health
• Develops and issues policy documents and guidelines on the introduction of urine
LF-LAM and ensure the integration with the existing diagnostic methods
• Prepares and coordinates the national implementation plan in collaboration with
EPHI and Developing Partners
• Mobilizes resources for the expansion of the LF-LAM test
• Leads the sensitization workshop or by providing the circulars to ensure the test
implementation
• Defines the national algorithms, eligibility criteria and placement strategies and
oversees the rollout plan
• Develop the requesting and reporting tools
Ethiopian Public Health Institute (EPHI)
• Develops training and implementation materials on the use of LF-LAM test and
leads the training of laboratory professionals and program officers in collaboration
with NTP and partners
• Prepare the launching ceremony for the test implementation in collaboration with
EPHI and patners
• Develops quality assurance guideline for the use of the test and oversees the quality
assurance of the test and produce proficiency test (PT)
• Leads the evaluation of the impact of introduction of the LF-LAM test on TB case
finding
• Develops standard operating procedures (SOP) for use of LF-LAM test
• Strengthen the specimen referral and laboratory networking, and results delivery
for the test
• Conducts operational and other programmatic and non programmatic researches.
• Monitoring and evaluation of LF-LAM test implementation in the country
Ethiopian Pharmaceuticals supply Agency (EPSA)
• Organize annual forecasting and quantification of the required supplies for the LF-
LAM assay
• Procures, stores and distributes the required supplies for the assay as per the national
quantifications
• Regular stock status update to FMOH, EPHI, RHBs
Ethiopian Food and Drug Authority (EFDA)
• Undertakes inspections of the laboratories with the assay and ensures adherence to
the national standards
• Registration and certification of the LF-LAM supplies for use in Ethiopia
Regional Health Bureaus (RHB)
• Ensure the ownership and coordination of the use of the LF-LAM implementation
• Prepare the regional launching ceremony for the test implementation in collabora-
tion with EPHI and patners
• Ensure the enrollment of all the diagnosed TB cases to treatment
• Monitor the stock status of the required supplies at HFs in all sites and ensure time-
ly request as per the IPLS
• Conduct regular supportive supervisions with RRL to the sites
• Monitoring and evaluation of LF-LAM test implementation in the region
Regional Reference Laboratories (RRL)
• Coordinates the regional laboratory networking specimen referral linkage

• Conduct External Quality Assurance (EQA) at testing sites
• Provides the training/sensitization workshop of laboratory professionals and pro-
gram officers in collaboration with RHB and partners
• Conduct regular supportive supervisions in collaboration with RHB and partners
Testing Health Facilities
• Distribute the testing circulars to all the outlet services

• Assign staffs to conduct the tests and ensures the implementation of tests
• Identify the eligible clients for the test as per the national guidelines and algorithms
• Conduct the tests and record the results as per the national guidelines
• Monitor the stock status of the required supplies in the site and ensure timely re-
quest to EPSA through the IPLS
• Participate in quality assurance activities
• Ensure the diagnosed cases are enrolled on treatment
Development Partners
• Provides technical support for the rollout plan and development of guidelines, train-
ing materials and to develop monitoring tools
• Provides financial support for the procurement of the LF-LAM
• Provides financial support for trainings and sensitization workshops
34
9. LF-LAM Implementation steps
• Resource mobilization and stake holder coordination
• Procurement of the LF-LAM test kit
• Conduct site assessment for placement
• Complete the LF- LAM implementation guideline
• Develop one day training material for program staffs, lab professionals and clini-
cians
• Conduct national LF-LAM technology launching workshop
• Provide one day training/ Sensitization for TB program staffs, lab professionals
and clinicians at regional and zonal levels and district level
• Distribute the LF-LAM test kit to eligible health facilities as per the assessment
• Distribute recording and reporting formats, registration book and job aids
• Implement Quality Assurance programs (Panel tests, On-sites Evaluation)
• Ensure the implementation of the M & E system
• Conduct Operational Research

10. References
1. World Health Organization. Global tuberculosis report 2020. 2020 p. 1–232.
2. Teweldemedhin M, Asres N, Gebreyesus H, Asgedom SW. Tuberculosis-Human

Immunodeficiency Virus ( HIV ) co-infection in Ethiopia: a systematic review
and meta-analysis. BMC Infect Dis. BMC Infectious Diseases; 2018;18:676.
3. Gelaw Y, Assefa Y, Demissie M, Dhewantara P, Williams G. TB and HIV Ep-

idemiology and Collaborative Service: Evidence from Ethiopia, 2011 – 2015.
HIV/AIDS-Research Palliat Care. 2020;12:839–47.
4. Gupta RK, Lucas SB, Fielding KL, Lawn SD. Prevalence of tuberculosis in
post-mortem studies of HIV-infected adults and children in resource-limited
settings : a systematic review and meta-analysis. AIDS. 2015;29:1987–2002.
5. Letang E, Ellis J, Naidoo K, Casas EC, Sánchez P, Hassan-moosa R, et al. Tu-

berculosis-HIV Co-Infection : Progress and Challenges After Two Decades
of Global Antiretroviral Treatment Roll-Out. Arch Bronconeumol [Internet].
SEPAR; 2020;56(7):446–54. Available from: https://doi.org/10.1016/j.ar-
bres.2019.11.015
6. Trinh QM, Nguyen HL, Nguyen VN, Nguyen TVA. Tuberculosis and HIV
co-infection— focus on the Asia-Pacific region. Int J Infect Dis [Internet]. Inter-
national Society for Infectious Diseases; 2015;32:170–8. Available from: http://
dx.doi.org/10.1016/j.ijid.2014.11.023
7. Eddabra R, Benhassou HA. Rapid molecular assays for detection of tuberculosis.

Pneumonia. Pneumonia; 2018;10:4.
8. Sabur NF, Esmail A, Brar MS, Dheda K. Diagnosing tuberculosis in hospital-

ized HIV-infected individuals who cannot produce sputum : is urine lipoarab-
inomannan testing the answer ? BMC Infect Dis. BMC Infectious Diseases;
2017;17:803.
9. alzl G, Mcnerney R, Plessis N, Bates M, Mchugh TD, Chegou NN, et

W
al. Series Tuberculosis 2 Tuberculosis : advances and challenges in develop-
ment of new diagnostics and biomarkers. Lancet Infect Dis [Internet]. El-
sevier Ltd; 2018;3099(18):1–12.Available from: http://dx.doi.org/10.1016/
S1473-3099(18)30111-7
10. World Health Organization. WHO operational handbook on tuberculosis Mod-

36
ule 3: Diagnosis - Rapid diagnostics for tuberculosis detection. 2020.
11. World Health Organizatio. Xpert MTB / RIF implementation: Technical and
Operational “how-to”: Practical considerations. 2014.
12. Creswell J, Codlin AJ, Andre E, Micek MA, Bedru A, Carter EJ, et al. Results
from early programmatic implementation of Xpert MTB / RIF testing in nine
countries. BMC Infect Dis. 2014;14:2.
13. Albert H, Nathavitharana RR, Isaacs C, Pai M, Denkinger CM, Boehme CC.
Development , roll-out and impact of Xpert have we learnt and how can we do
better ? Eur Respir J [Internet]. 2016;48:516–25. Available from: http://dx.doi.
org/10.1183/13993003.00543-2016
14. Muttamba W, Ssengooba W, Sekibira R, Kirenga B, Katamba A, Joloba M. Ac-

curacy of different Xpert MTB / Rif implementation strategies in programmatic
settings at the regional referral hospitals in Uganda : Evidence for country wide
roll out. PLoS One. 2018;13(3):e0194741.
15. Gupta-wright A, Corbett EL, Oosterhout JJ Van, Wilson D, Grint D, Alufand-

ika-moyo M, et al. Rapid urine-based screening for tuberculosis in HIV-positive
patients admitted to hospital in Africa ( STAMP ): randomised controlled trial.
Lancet [Internet]. The Author(s). Published by Elsevier Ltd. This is an Open Ac-
cess article under the CC BY 4.0 license; 2018;392(10144):292–301. Available
from: http://dx.doi.org/10.1016/S0140-6736(18)31267-4
16. Bjerrum S, Schiller I, Kohli M, Nathavitharana R, Zwerling A, Denkinge C, et

al. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis
in people living with HIV (Review ). Cochrane Database Syst Rev. 2019;(10).
17. Singhroy DN, Maclean E, Branigan D, England K, Gemert W Van, Pai M, et al.
Adoption and uptake of the lateral flow urine LAM test in countries with high
tuberculosis and HIV/AIDS burden: current landscape and barriers. Gates Open
Res. 2020;4:24.
18. Broger T, Sossen B, Toit E, Kerkhoff AD, Schutz C, Reipold EI, et al. Novel
lipoarabinomannan point-of-care tuberculosis test for people with HIV : a diag-
nostic accuracy study. Lancet Infect Dis. 2019;19(August):852–61.
19. Bjerrum S, Broger T, Székely R, Mitarai S, Opintan JA, Kenu E, et al. Diagnostic
Accuracy of a Novel and Rapid Lipoarabinomannan Test for Diagnosing Tuber-

culosis Among People With Human Immunodeficiency Virus. OFID. 2019;1–
11.
20. Boyles TH, Griesel R, Stewart A, Mendelson M, Town C, Africa S, et al. Incre-
mental yield and cost of urine determine TB-LAM and sputum indeuction in
seriously ill adults with HIV. Int J Infect Dis. 2018;75:67–73.
21. World Health Organization. Lateral flow urine lipoarabinomannan assay ( LF-
LAM ) for the diagnosis of active tuberculosis in people living with HIV Policy
update. 2019.
22. Peter JG, Zijenah LS, Chanda D, Clowes P, Lesosky M, Gina P, et al. Eff ect on
mortality of point-of-care , urine-based lipoarabinomannan testing to guide tu-
berculosis treatment initiation in HIV-positive hospital inpatients : a pragmatic
, parallel-group , multicountry , open-label , randomised controlled trial. Elsevier
Ltd; 2016;6736(15):1–11.
23. Ricks S, Denkinger C, Schumacher S, Hallett T, Arinaminpathy N. The poten-

tial impact of urine-LAM diagnostics on tuberculosis incidence and mortality :
A modelling analysis. PLoS Med [Internet]. 2020;17(12):e01003466. Available
from: http://dx.doi.org/10.1371/journal.pmed.1003466
24. Ethiopian Federal Ministery of Health. Guidelines for Clinical and Program-
matic Management of TB , DR-TB and Leprosy in Ethiopia 7 th edition Octo-
ber 2020. Addis Ababa, Ethiopia; 2020.
25. Ethiopian Federal Minsitry of Health. Guideline for TB/HIV Collaborative ac-
tivities. 2021.
26. Medines Sans Fronteries. TB LAM Ag lateral flow assay standard operating
procedure. 2019;
27. Practical implementation of lateral flow urine lipoarabinomannan assay (LF-

LAM) for the detection of active tuberculosis in people living with HIV. Avail-
able from http://www.stoptb.org/wg/gli/assets/documents/practical-implemen-
tation-lf-lam.pdf ).
28. The use of lateral flow urine lipoarabinomannan assay (LF-LAM) for the diag-
nosis and screening of active tuberculosis in people living with HIV. Available
from https://www.who.int/tb/publications/use-of-lf-lam-tb-hiv/en/ (Accessed
Jan 21/2021).

38
29. Lateral flow urine lipoarabinomannan assay (LF-LAM) for the diagnosis of ac-
tive tuberculosis in people living with HIV Policy update (2019). Available from
https://www.who.int/tb/publications/2019/LAMPolicyUpdate2019/en/ (Ac-
cessed on Jan 12/2021).
30. Health department, R. (2018) LF-LAM GUIDE FINAL-revised Final

11July20181 (002). Health department, republic of South africa
31. GLI Practical Guide to TB Laboratory Strengthening, http://stoptb.org/wg/gli/

assets/documents/GLI_practical_guide.pdf

ANNEXES
Annex 1: Algorithm for LF-LAM testing to
aid in the diagnosis of TB among PLHIV in
outpatient settings
Adults, adolescents and children LHIV including: 1. All newly diagnosed HIV patients who are ART naive 2. HIV patients returning for care
following a treatment interruption 3. HIV patients receiving ART regimen that is failing 4. HIV Patients presenting at the clinic and unwell
Assess patient for (TB signs and symptoms/ severity of illness/ Stage of HIV Disease/ CD4 status)
Positive for TB signs and symptoms No TB signs or symptoms and

and/or Seriously ill Not seriously ill
Perform urine LF-LAM4 CD4 Assessment OR

Collect a sample & perform mWRD test Clinical staging
CD4 100-200 or CD4 >200 or

LF-LAM LF-LAM CD4<100 or WHO Clinical Stages unknown or WHO
-VE Stage 3 or 4 1&2 Clinical Stages 1&2
Initiate TB TB is not ruled out, Perform LF-LAM

treatment Evaluate mWRD
Evaluate result
mWRD result LF-LAM LF-LAM
+VE -VE
mWRD mWRD
+Ve -Ve
mWRD mWRD Initiate TB
+Ve -Ve
treatment,
adjust based
on mWRD
result
Adjust Initiate Apply Advanced HIV

Clinical Management,
treatment Continue TB Disease (AHD) Clinical management
TB is not ruled out.
based on TB treatment package of Care
Conduct additional
mWRD treatment based on
evaluations for TB
results if mWRD
(CXR, ….)
needed result

40
Annex 2: Algorithm for LF-LAM testing to
aid in the diagnosis of TB among PLHIV in
inpatient settings
All hospitalized patients, including adults, adolescents, and children living with HIV
Assess patient for TB signs and symptoms, severity of illness, HIV disease stage and CD4 status
Positive for TB signs and symptoms No TB signs or symptoms, No TB signs or symptoms and or
butAdvanced HIV Disease (AHD)+ CD4 > 200
or seriously ill or CD4 < 200
Collect a urine sample & perform urine

Collect a urine sample & perform urine Clinical management
LF-LAM4 Collect a sample & perform
LF-LAM
mWRD test
LF-LAM LF-LAM LF-LAM

LF-LAM
+VE -VE -VE +VE
Initiate TB TB is not ruled Evaluate CD4

Count Initiate TB treatment Collect
treatment out. Evaluate
specimen & perform mWRD
Evaluate mWRD result test
mWRD result CD4 <200 CD4>200
mWRD mWRD
+Ve -Ve
mWRD mWRD
+Ve -Ve mWRD mWRD
+Ve -Ve
Clinical Apply
Continue Management, Continue TB
Adjust Advanced Adjust
TB TB is not ruled treatment.
treatment Initiate TB HIV treatment
treatment out. Perform
based on treatment Disease based on
Perform Conduct workup to
mWRD based on (AHD) WRD result
workup to additional exclude DR-
results if mWRD package if needed
exclude evaluations for TB
needed of Care
DR-TB TB.

Annex 3: ART Register

42
44
Annex 4: Unit TB Register

46
Annex 5: HIV/ART Follow Up Form

48
Annex 6: HIV Care /Follow up form 2

Annex 7: TB Laboratory reqeust and report form
TB Laboratory Requesting and reporting For
Ethiopian Public Health Institute

MOH- ---Tel: 251 (0) 11 551 7011 Fax: 251 (0) 11 551 9366 E-mail: moh@ethionet.et P. O. Box 1234, Addis Ababa, Ethiopia
EPHI--- Tel. +251 112 78 08 45 Email: ephi@ethionet.gov.et p.o. box:1242 , Addis Ababa, Ethiopia
TB Diagnostic Service Request and Report Form

1. PATIENT ADDRESS: Patient Full Name: _____________________________ Age: ______ Sex: _____ Region: __________
Tel: ____________ Name of contact person: _______________ Tel: _____________ Referring HF: ______________ MRN: ______
TB registration No/DR- TB No: _________
2. TB DISEASE TYPE & TREATMENT HISTORY:
❖ Site: i. Pulmonary _________________________ ii. Extra pulmonary (specify): __________ Co-infection _______ CD4 count: __________
❖ Patient Registration Group:  New  Relapse  Treatment after lost to follow-up  After failure of first line treatment  After failure
of Second line treatment  Other
❖ Previous TB drug use:  New,  1st line treatment,  2nd line treatment,  DR-TB contact,  Other, _______
3. REQUEST FOR TESTING AT TB LABORATORY:
❖ Reason: I. Diagnosis: If Diagnosis,  Presumptive TB,  Presumptive DR, II. Follow up: If follow up,  at_______ months of 1st
line treatment,  MDR Follow up, at _____ months after treatment,  Presumptive XDR, _______
❖ Specimen Type: Sputum  Urine/LF-LAM  Other, Specify: ____________________________________
❖ Requested tests:  Microscopy,  GeneXpert MTB/RIF assay  Culture,  Phenotypic DST (First Line _____, Second Line_____)  Line
Probe Assay (First Line _____, Second Line_____) LF-LAM ________
Requested Clinician: Name: ___________________Signature _____________Tel:_____________ Date of Request _________
………………………………………………………………………………………………………………………………………………………………
4. LABORATORY RESULT (for Laboratory use only) :
Laboratory Number: _________ Date of specimen collected (E.C): ___/____/_______ Date of sputum received (E.C): ____/___/____
4.1 Microscopic examination:
❖ Specimen Quality: bloody, saliva, purulent or semi-purulent Positive
Result Negative
❖ Method used: Scanty 1+ 2+ 3+
✓ Ziehl-Neelsen  Direct Smear  Concentrated Smear 1st Spot
✓ Fluorescence  Direct Smear  Concentrated Smear 2 Spot
nd
Name of the Examiner: ___________ Signature: __________ Date: __________
4.2 GeneXpert MTB/RIF Assay Result:

Result Detected Not detected Indeterminate Trace Remark
M. Tuberculosis (MTB)
Rifampicin Resistance (RR)
Name of the Examiner: _________________ Signature: __________ Date: ____________
4.3 Alere LF-LAM ( for PLHIV)
Indication 1-Outpatient TB symptomatic HIV positive (New/treatment interrupted /treatment failing / clinically unwell )
2-Outpatient HIV positive clients with CD4 < 100 and or stage 3/4
3- TB symptomatic inpatient HIV positive clients
4- Inpatient HIV positive clients with Advance HIV disease or seriously ill or CD4 < 200
Result:- Positive Negative Invalid
4.4 TB Culture result: Method used MGIT LJ

Positive for Mycobacterium tuberculosis Complex (MTBC) Negative Contaminated
Non tuberculous
1-9 colon 10 – 99 colonies ≥100 colonies ( Confluent
Result Mycobacteria
ies Actual Count (1+) 2+) growth (3+ )
(NTM)
4.5 TB Drug Susceptibility Testing (DST) result:

.
Result 1st line drugs 2nd line drugs Other
INH RMP STM EMB PZA OFL LFX MXF AM CAP KM EA
Line Probe Assay
Phenotypic DST
Legend: INH=Isoniazid RMP= Rifampicin PZA= Pyrazinamide EMB=Ethambutol STM = Streptomycin OFL= Ofloxacin LE=Levofloxacin
MO=Moxifloxacin AK=Amikacin CAP=Capreomycin KM= Kanamycin EA= Ethionamide
S=Sensitive; R = Resistant; C = Contaminated; ND = Not done.
Name of Examiner ______________________________ Date_________________ sig._______________
Comment: _________________________________________Date reported: ____/____/____
GeneXpert Reviewed by: ____________________________ Date ________________Signature__________________ .
LF-LAM Reviewed by: ____________________________ Date ________________Signature__________________ .
Culture Reviewed by: _______________________________ Date ________________Signature__________________.
LPA Reviewed by: ________________________________ Date ________________Signature__________________.
Phenotypic DST Reviewed by: _______________________ Date _______________ Signature_______________

50
Annex 8: Job aid forLF-LAM testing
JOB AID FOR ALERE DETERMINE TB LAM ANTIGEN RAPID SCREENING TEST IN
ETHIOPIA
January 2021
Alere Determine TB LAM Ag is a qualitative rapid test for the detection of lipoarabinomannan (LAM) antigen of Mycobacteria in human urine as an aid in the diagnosis of active
mycobacterial infection in HIV positive individuals with clinical symptoms of tuberculosis
1: Who to be Tested? 3. Specimen Type and Procedure
PLHIV Inpatients: with signs and symptoms of TB or who are seriously ill or irrespective of whether
there are TB symptoms if they have CD4 counts < 200 cells/mm3. Specimen: Use urine only
PLHIV Outpatients: with signs and symptoms of TB or who are seriously ill or irrespective of whether
there are signs and symptoms of TB if they have a CD4 count < 100 cells/mm3
Procedure: Label test strip with patient number on urine sample container and
2. Materials needed: test strip, add 60µL urine specimen to the sample pad (see the figures below).
Alere Determine TB LAM test strips, urine cap, transfer pipette or paste pipettes, timer and gloves. Read results at the 25th minute.
4. Test Result Interpretation
LAM Antigen POSITIVE (Two Bars - Control and Patient Bars)
Purple/gray bars appear in both the control window (labelled “Control”) and the
Patient window (Labelled “Patient”) of the strip. Note: The test result is positive even
if the patient bar appears lighter or darker than the control bar.
NEGATIVE (One Bar)
One purple/gray bar appears in the control window of the strip (labelled “Control”)
and no purple/gray bar appears in the Patient window of the strip (labelled
“Patient”).
INVALID (No Bar)
If there is no purple/gray bar in the control window of the strip, even if a

purple/gray bar appears in the patient window of the strip, the result is invalid and
the test should be repeated. If the problem persists, contact your local distributor or
call Alere Technical Support as detailed below.
INDEFINITE: 2. Quality Control:
One purple/gray bar appears in the control window of the strip (labelled “Control”)
Conduct QC for TB LAM test for new shipment and/or new lot of test kits.
with unclear or incomplete purple/gray bar in the patient window of the strip
Follow steps in the SOP to evaluate accuracy of the test kit using +ve and –ve
(labelled “Patient”). For a better clinical decision, the test should be repeated.
controls.
Alternatively, collect a new urine sample in the following days from the patient and
test. Early morning urine is recommended.

Annex 9: Standard operating procedure for
performing the Alere determine TB LAM Ag
lateral flow assay
Purpose
The purpose of this standard operating procedure1is to detail the steps for correctly per-
forming, interpreting and documenting valid results for the Alere DetermineTM TB LAM
Ag assay (AlereLam). AlereLAM is an immunoassay used to detect the lipoarabinoman-
nan (LAM) antigen (Ag) in human urine as an aid in diagnosing TB in persons living
with HIV.
Scope
This standard operating procedure applies to all facilities performing AlereLAM to assist
in diagnosing TB in HIV-positive adults who have signs and symptoms of TB (pulmonary
or extrapulmonary) and who have a CD4 count < 100cells/ mm3 or who are seriously ill
(WHO stage 3 or 4 disease).
Responsibility and authorization
The persons responsible for performing this test are laboratory professionals.
Materials
o LF-LAM test kit and Reference Scale Card

o AlereLAM antigen test strips
o AlereLAM positive TB control sample (1 mL).
o Materials required but not provided in the kit
o Timer
o Gloves
o Pipette or delivery device capable of accurately delivering 60 µL of urine (this
could be a calibrated micropipette with filter tips or a dual-bulb 60 µL pipette)
o Pipette filter tips if a micropipette is used
o Sharps disposal container
o Pen and permanent marker
o Biohazard disposal bags.
Safety, health and the environment
Treat all urine specimens as potentially infectious and follow basic universal precautions.

52
Wear protective clothing (i.e. a coat or apron and gloves) when handling the specimens.
Principles
AlereLAM is an immunochromatographic test for the qualitative detection of LAM an-

tigen in human urine. AlereLAM employs highly purified antibodies specific to the major
polysaccharide antigen of Mycobacterium: LAM. These antibodies are used for both the
capture and the detection tracer. The capture antibodies are adsorbed onto the nitrocellu-
lose membrane of the test strip. The detection antibody is labelled through conjugation to
colloidal gold particles (Figure E).
After a urine specimen is added to the test strip, the colloidal gold–conjugated antibod-
ies attach to the LAM antigen and are released by the specimen from the test strip. This
immunological complex is then captured by anti-LAM antibodies immobilized on the
nitrocellulose membrane and made visible due to the presence of the colloidal gold label.
A positive result (a purple–grey band) indicates that LAM antigen is present in the sample
at or above the detection limit of the test; a negative result (no purple–grey line) indicates
it is not present or is present only below the detection limit. To ensure assay validity, a
procedural control window is incorporated into the assay device.
Fgiure E. General principles* for detecting the lipoarabinomannan antigen

*
Sample containing the analyte of interest moves by capillary action across an internal membrane when applied to the assay where
it will bind first to capture antibodies which have a reporter molecule attached. The analyte-antibody complex then continues to
migrate until reaching another set of detection antibodies fixed to the membrane which binds the complexed molecules, concen-
trating them in one place (test line) for detection. Any remaining unbound capture antibodies continue to migrate and complex to
a second set of fixed antibodies at a control line which validates the test.
Specimen collection and storage
Collect midstream urine in a clean, standard urine collection container. Fresh urine sam-
ples can be used within 8 hours if kept at room temperature.
(1) Urine samples should be stored at 2–8 °C if the test is to be run within 3 days of
collection.
(2) If testing will be delayed more than 3 days, the samples should be frozen (−20 °C
or colder). For frozen or refrigerated urine, bring the sample to room tempera-
ture 1 hour prior to use. Frozen samples may contain aggregates.
(3) All thawed samples must be centrifuged at 10 000 g for 5 minutes at room tem-
perature; the 60 μL test sample should be carefully collected from the clear su-
pernatant. Avoid repeated freeze–thaw cycles. Specimens that have been frozen
and thawed more than three times cannot be used.
Reagent storage and preparation
AlereLAM test cards must be stored at 2–30 °C until they are used. Kit components are
stable until the expiration date when handled and stored as directed. Do not use kit com-
ponents beyond the expiration date. Immediately reseal all unused tests in the foil pouch
containing the desiccant by pressing the seal from end to end to close. Do not use strips
that have become wet, and do not use strips if the packaging has become damaged.
Test procedure
(1) Remove the desired number of test strips from the 10-test card by bending and
tearing at the perforation. Test strips should be removed starting from the right
side of the test card to preserve the lot number, which appears on the left side of
the card.
(2) Remove the protective foil cover from each test strip. Label the strip with a
unique patient identification number. The assay should be initiated within 2
hours of removing the protective foil cover from the strip.
(3) Add 60 μL of the sample (or 2 drops of urine) to the test strip (Figure C. ; the
white pad marked with an arrow symbol).
54
(4) Wait a minimum of 25 minutes and a maximum of 35 minutes, and then read
the result. Evaluate the strip under standard indoor lighting conditions or in the
shade. Do not evaluate the strip in direct sunlight. Results are stable for up to 35
minutes after sample application. Do not read the strip after 35 minutes.
Interpreting the results
To assist with reading and interpreting the results, use the Reference Scale Card that is
provided in the kit by holding it alongside the patient window (Figure. F).
Source: reproduced with permission of the publisher from EurRespir J. 2012;40;1211–20.

doi:10.1183/09031936.00201711
Figure F. Using the Reference Scale Card to determine band intensity and validity of the
Alere Determine TB LAM Ag assay(26).
LAM antigen positive result (showing two bands, the control and patient band)
If a test is positive, then purple–grey bands appear in both the quality control window and
the patient window of the strip. Note that the test result is positive even if the patient band
appears lighter or darker than the control band.

Note: The reference card must be used to correctly identify the intensity of the bands ap-
pearing in the patient window. Bands that are lighter than the bands in the positive box
of the reference card must be considered as negative or indeterminate results. Only bands
that are as dark as or darker than the first band in the positive box of the reference card
should be considered positive.
Negative result (only one band showing)
The result is negative if a purple–grey band appears only in the quality control window of
the strip and no band or only a band of Grade 1 intensity appears in the patient window.
Invalid result (no band)
The test is invalid if there is no purple–grey band in the quality control window of the strip,
even if a band appears in the patient window; in this case, the test should be repeated. If
the problem persists, contact your local distributor or call Alere Technical Support.
Indeterminate result
The result is indeterminate if one purple–grey band appears in the control window of the
strip with an unclear or incomplete band in the patient window. To ensure that a better
clinical decision is made, the test should be repeated. Alternatively, collect a new urine
sample from the patient on a different day and test that sample. Early morning urine is
recommended.
Quality control testing
Conduct quality control testing for AlereLAM weekly, before the first specimen is anal-
ysed for a particular week. If no specimens are to be test using the AlereLAM assay, then
quality control testing need not be undertaken for that week. Record the results of the
quality control testing in the TB LAM result logbook.
The following procedure should be used to evaluate the AlereLAM quality controls.
For the AlereLAM positive control:
(1) First, label the test strip as the TB LAM positive control;
(2) Add 1 drop of the TB LAM Ag positive control to the labelled test strip;
For the AlereLAM negative control:

56
(1) First, label the test strip as the TB LAM negative control;
(2) Add 2 drops of saline solution or distilled water;
Further information can be found on the Alere Determine LAM Ag package insert, avail-
able at https://www.alere.com/en/home/product-details/determine-tb-lam.html.

Region________________Zone__________ Facility Name ___________________________
QC IQC Result Test done by Initial

Date Analyte/ Kit information Indeterm Action taken for Failed IQC s
sheet for LF-LAM test
tested test name Positive Negative Invalid inate

Positive Lot#/batch#______
Negative Ex. date_________

58
Annex 10: Internal Quality Control (IQC) log
61
59
Name of Health facility_________________________ Year (EC) ____________________
Lab S. Date Patient Name Age Name of Name of MRN HIV If pos for If pos TB sign Patient Reason for Examination Result Test Remark
No Specimen Contact referring Status HIV, for HIV, and Registrat examination done by Address
Receiveda Person unit (Pos/Neg/ CD4 Indicatio sympto ion (Initial) of the
(IPD/OPD Unknown) count n for m Group d e f Patient
Address of Sex Address Diag Follow Xpert LF Smear
the Patient of the ) /facility (Cells/µ) LF- (Yes/No) (N, R, D, nosis Up LAM Microscop
Contact LAM F)g (P/N) y
testing) c
Month 1 2
(1-4)b
a
For diagnostic testing employing serial sputa or other specimens this is the date of receipt of the first set of specimens.
b
If positive for HIV, Indication for LF-LAM testing
1-Outpatient TB symptomatic HIV positive (New/treatment interrupted /treatment failing / clinically unwell )
2-Outpatient HIV positive clients with CD4 < 100 and or stage 3/4
3- TB symptomatic inpatient HIV positive clients

Annex 11: Laboratory Register for Smear
4- Inpatient HIV positive clients with Advance HIV disease or seriously ill or CD4 < 200
c
Patient of TB treatment ; indicate month of treatment at which follow-up examination is performed.
d
XPERT MTB/RIF test result reported as follows: T=MTB detected, rifampicin resistance not detected, RR= MTB detected, rifampicin resistance detected, TI= MTB detected, rifampicin resistance indeterminate, N= MTB not detected, I= invalid/no result/error-specify error code
e
LF-LAM test result reported as follow p=positive for LAM antigen, N= Negative for LAM antigen
f
Smear results reported as follows: 0= No AFB (1-9)= exact number if 1-9/100HPF(scanty), +=10-99AFB/100HPF, ++=1-10AFB/HPF, +++= >10AFB/HPF
g
Patient/Registration Group: N-New case, R-Relapse, D-Treatment after loss to follow-up, F-Treatment after failure (F2-for retreatment failure
Microscopy, LF-LAM and GeneXpert MTB/RIF

62
Annex 12: LF-LAM monthly reporting form
Name of facility :______________________ Region:-____________ Zone:________________

Woreda:_______________________ Reporting quarter :______________
Date from ________________ to ____________________
TB-LAM indicators Total eligible Both LF- Only Both LF-LAM Positive only by
for LF-LAM LAM and LF-LAM and GeneXpert LF-LAM
tested
testing GeneXpert (C) positive ( E)
(A) tested (D)
(B)
Outpatient TB symptomatic HIV
positive (New/treatment interrupted
/treatment failing / clinically unwell )
clients in the quarter
Outpatient HIV positive clients with
CD4 < 100 and or stage 3/4 in the
quarter
TB symptomatic inpatient HIV
positive clients in the quarter
Inpatient HIV positive clients with
Advance HIV disease or seriously ill
or CD4 < 200 in the quarter
Report compile by:-
Name:___________________________ Date:-___________________ signature;__________
63

60

Implementation Guidelines For Lateral Flow Urine Lipoarabinomannan

Uploaded by

Copyright:

Available Formats

Implementation Guidelines For Lateral Flow Urine Lipoarabinomannan

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Implementation Guidelines For Lateral Flow Urine Lipoarabinomannan

Uploaded by

Copyright:

Available Formats

Implementation Guidelines for

Lateral Flow Urine Lipoarabinomannan

ADDIS ABABA, ETHIOPIA

ADDIS ABABA, ETHIOPIA

1.2. WHO policy recommendation for the use of LF-LAM. . . . . . . . . . . 3

1.3. Scope of the implementation guideline. . . . . . . . . . . . . . . . . . . . . . . . . 7

1.4. Objectives of the implementation guidelines. . . . . . . . . . . . . . . . . . . . 7

2.1.1. In outpatient settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.1.2. In inpatient settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2.2. National TB Diagnostic Algorithm for PLHIV Incorporating Urine

2.2.1. Algorithm for LF-LAM testing to aid in the diagnosis of TB among

2.2.2. Algorithm for LF-LAM testing to aid in the diagnosis of TB among

2.3. Laboratory order and result interpretation. . . . . . . . . . . . . . . . . . . . . . 13

2.3.1. Urine LAM test workflow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.3.2. Result interpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.4. Case definition, classification,treatment follow up, case registration and

2.4.3. Treatment follow up of Patients diagnosed using Urine LF-LAM test

2.5. Patient Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

3. Laboratory testing of LF-LAM for PLHIV. . . . . . . . . . . 18

3.2. Laboratory infrastructure and Supplies needed for testing. . . . . . . . . 21

3.3. Sample collection, testing and interpretation for LF-LAM. . . . . . . . 21

3.4. Biosafety requirements and waste disposal. . . . . . . . . . . . . . . . . . . . . . 25

4. Human Resource Development. . . . . . . . . . . . . . . . . . . . . 26

4.2. Sensitization Workshop on LF-LAM. . . . . . . . . . . . . . . . . . . . . . . . . . 26

5. Supply chain management for LF-LAM. . . . . . . . . . . . . . 27

6.2. External quality control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

6.2.1.On-site supervisory and evaluaton visits. . . . . . . . . . . . . . . . . . . . . . . 30

6.2.2. Proficiency testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

6.3. Quality indicators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

7. Monitoring and Evaluation (M&E) Plan for LF-LAM

Annex 2: Algorithm for LF-LAM testing to aid in the diagnosis of TB among

Annex 3: ART Register . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Annex 4: Unit TB Register . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Annex 5: HIV/ART Follow Up Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Annex 6: HIV Care /Follow up form 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Annex 7: TB Laboratory reqeust and report form. . . . . . . . . . . . . . . . . . . . 50

Annex 8: Job aid forLF-LAM testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Annex 9: Standard operating procedure for performing the Alere determine

Annex 11: Laboratory Register for Smear Microscopy, LF-LAM and

Annex 12: LF-LAM monthly reporting form. . . . . . . . . . . . . . . . . . . . . . . 60

I Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

III Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

Lack of an effective diagnostic test for smear-negative TB cases is a major contributor to

Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

V Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

1 Implementation Guidelines for Lateral Flow Urine Lipoarabinomannan Assay

1.2. WHO policy recommendation for the use of LF-LAM

For out patient setting use of LF-LAM

WHO suggests(21) using LF-LAM to assistin the diagnosis of active TB in HIV-positive

• With signs and symptoms of all forms TB or seriously ill.

WHO recommendation against(21) using LF-LAM toassist in the diagnosis of active

For outpatient settings not to use LF-LAM

• without assessing TB symptoms not recommended .

Key WHO Remark:

WHO strongly recommends(21)using LF-LAM to assistin the diagnosis of active TB in

• Patient with signs and symptoms of TB (pulmonary and/or extra pulmonary).

Ethiopian contextual update and recommendation to use AlereLAM.