PLOS ONE
RESEARCH ARTICLE
Assessing risk factors for latent and active
tuberculosis among persons living with HIV in
Florida: A comparison of self-reports and
medical records
Nana Ayegua Hagan Seneadza 1ID *, Awewura Kwara 2ID , Michael Lauzardo2, Cindy Prins3,
Zhi Zhou3, Marie Nancy Séraphin2, Nicole Ennis4, Jamie P. Morano5, Babette Brumback6,
Robert L. Cook3
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1 Department of Community Health, University of Ghana Medical School, Accra, Ghana, 2 Division of
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Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida,
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United States of America, 3 Department of Epidemiology, College of Public Health and Health Professions
a1111111111 and College of Medicine, University of Florida, Gainesville, Florida, United States of America, 4 Department
a1111111111 of Behavioral Sciences and Social Medicine, Florida State University, Tallahassee, Florida, United States of
America, 5 University of South Florida, Morsani College of Medicine, Tampa, Florida, United States of
America, 6 Department of Biostatistics, Colleges of Public Health & Health Professions and Medicine,
University of Florida, Gainesville, Florida, United States of America
* nseneadza@ug.edu.gh
OPEN ACCESS
Citation: Seneadza NAH, Kwara A, Lauzardo M,
Prins C, Zhou Z, Séraphin MN, et al. (2022) Abstract
Assessing risk factors for latent and active
tuberculosis among persons living with HIV in
Florida: A comparison of self-reports and medical
records. PLoS ONE 17(8): e0271917. https://doi. Purpose
org/10.1371/journal.pone.0271917 This study examined factors associated with TB among persons living with HIV (PLWH) in
Editor: Wenping Gong, The 8th Medical Center of Florida and the agreement between self-reported and medically documented history of
PLA General Hospital, CHINA tuberculosis (TB) in assessing the risk factors.
Received: August 30, 2021
Methods
Accepted: July 10, 2022
Self-reported and medically documented data of 655 PLWH in Florida were analyzed. Data
Published: August 4, 2022
on sociodemographic factors such as age, race/ethnicity, place of birth, current marital sta-
Peer Review History: PLOS recognizes the
tus, education, employment, homelessness in the past year and ‘ever been jailed’ and beha-
benefits of transparency in the peer review
process; therefore, we enable the publication of vioural factors such as excessive alcohol use, marijuana, injection drug use (IDU),
all of the content of peer review and author substance and current cigarette use were obtained. Health status information such as health
responses alongside final, published articles. The
insurance status, adherence to HIV antiretroviral therapy (ART), most recent CD4 count,
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0271917 HIV viral load and comorbid conditions were also obtained. The associations between these
selected factors with self-reported TB and medically documented TB diagnosis were com-
Copyright: © 2022 Seneadza et al. This is an open
access article distributed under the terms of the pared using Chi-square and logistic regression analyses. Additionally, the agreement
Creative Commons Attribution License, which between self-reports and medical records was assessed.
permits unrestricted use, distribution, and
reproduction in any medium, provided the original Results
author and source are credited.
TB prevalence according to self-reports and medical records was 16.6% and 7.5% respec-
Data Availability Statement: The data contain
potentially sensitive patient information, but data tively. Being age�55 years, African American and homeless in the past 12 months were
can be obtained upon request. Information about statistically significantly associated with self-reported TB, while being African American
PLOS ONE | https://doi.org/10.1371/journal.pone.0271917 August 4, 2022 1 / 12
PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
the process to request and receive data from the homeless in the past 12 months and not on antiretroviral therapy (ART) were statistically sig-
Florida Cohort study are available from the nificantly associated with medically documented TB. African Americans compared to Whites
Southern HIV and Alcohol Research Consortium
had odds ratios of 3.04 and 4.89 for self-reported and medically documented TB, respec-
(SHARC) at https://sharc-research.org/research/
data/sharc-concepts-system/. tively. There was moderate agreement between self-reported and medically documented
TB (Kappa = 0.41).
Funding: The Florida Cohort study was supported
by The National Institute on Alcohol Abuse and
Alcoholism (NIAAA), Grants U24AA022002 and Conclusions
U24AA022003. NAHS was supported under the
University of Florida-University of Ghana Training TB prevalence was higher based on self-reports than medical records. There was moderate
Program in Tuberculosis and HIV Research in agreement between the two data sources, showing the importance of self-reports. Estab-
Ghana, funded by the Fogarty International Center
lishing the true prevalence of TB and associated risk factors in PLWH for developing policies
at the National Institutes of Health, Grant
TW010055. may therefore require the use of self-reports and confirmation by screening tests, clinical
signs and/or microbiologic data.
Competing interests: The authors have declared
that no competing interests exist.
Abbreviations: AIDS, Acquired immunodeficiency
syndrome; ART, Anti-retroviral therapy; CD4, T
lymphocyte cells; CI, Confidence interval; FDOH, Introduction
Florida Department of Health; HIV, Human
immunodeficiency virus; LTBI, Latent TB infection; The state of Florida carries a high burden of HIV, hosting an estimated 12% of all new HIV
NPV, Negative predictive value; OR, Odds ratio; cases in the United States (US) in 2018 [1]. Similarly, Florida carries a high burden of active
PLWH, Persons living with HIV; PPD, Purified tuberculosis (TB), which since 2007 has been the leading infectious cause of death in persons
protein derivation; PPV, Positive predictive value; living with HIV/AIDS (PLWH) globally [2]. In 2018, 591 (6.5%) of all TB cases in the US [3]
TB, Tuberculosis; US, United States.
were reported in Florida representing a 7.6% increase from 2017 when 549 new cases were
reported in the state, whilst the rate of TB/HIV coinfection of 9% [4] exceeded the national
rate of 5.3% [5].
Generally, PLWH, especially with more profound immunosuppression, are more at risk for
developing active TB sometimes as a progression from latent TB infection (LTBI). This active
TB accelerates morbidity and mortality in untreated HIV disease [6].
The degree to which different data sources provide similar prevalence estimates for TB risk
factors in the same population of PLWH is unclear. Additionally, though factors such as race/
ethnicity, age, sex, excessive alcohol use, smoking, homelessness, incarceration, and diabetes
mellitus have been found to be associated with TB [5, 7, 8], only a few studies have looked at
the association between TB and substance use in the US [8–10]. Currently, no studies have
compared self-reports and medical records to examine the association between TB and sub-
stance use among PLWH in Florida. Knowing the relationship between the use of substances
such as marijuana and smoked crack cocaine and TB infection is important in developing tar-
geted prevention strategies for the comprehensive care of PLWH.
While self-reports are relatively easy and inexpensive to obtain, they may be limited by
recall and/or social desirability bias, as well as by inconsistent responses depending on how
questions are understood, and/or underreporting/overreporting depending on how measures
are assessed [11, 12]. Medical records, on the other hand, are easily accessible by trained per-
sonnel, and data can be abstracted multiple times [13] However, medical records derived from
routine care may not contain all the information relevant to a researcher and can be costly to
obtain. Further, there may be differences in the extraction process and content, especially
when different sites are involved [14, 15]. Studies have found varying agreement between self-
reports and medical records, with chronic diseases and diseases with easily distinguishable
diagnostic criteria having a higher agreement compared to acute conditions [16–18].
Thus, in this study, we measured the association between Latent TB Infection (LTBI)/TB
and sociodemographic, behavioral, and health status factors and examined the agreement
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PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
between self-reports and medical records in assessing risk factors for LTBI/TB among PLWH
in Florida.
Methods
Study design and population
This is a secondary analysis of baseline survey data from a Florida HIV cohort study. The sur-
vey was conducted from 2014 to 2018. Study participants included PLWH accessing healthcare
at county health departments and community clinics in Florida. The survey collected informa-
tion about sociodemographic characteristics lifestyle factors, comorbid conditions, and health
outcomes associated with HIV in adults. Medical records of participants were also abstracted
during the period of the survey. Details of the Florida Cohort study procedures have been pre-
viously described [19, 20].
Data included for analysis was on 655 individuals, 18 years and older, who responded to the
survey question, “Have you ever been diagnosed with TB, or been told you have a positive skin
test (sometimes called a PPD) or a positive TB blood test (called a Quantiferon Gold or T-spot
test)?,” and had medical records.
The research protocol was approved by the institutional review boards (IRBs) of the Uni-
versity of Florida (IRB201500849), Florida International University, and the Florida Depart-
ment of Health. All participants provided written informed consent before participating in the
study.
Measures
Outcome variables. Self-reported (latent or active) TB was categorized based on the sur-
vey question above into ‘yes’ or ‘no’. Medically documented TB diagnosis was also categorized
into a ‘yes’ or ‘no’ binary outcome based on whether participants had any form of TB (latent
or active) documented in their medical records using the International Classification of Dis-
eases ICD-9 codes (010–017), 795.51, 795.52 or 10 codes (A15-A19), R76.11, R76.12, Z22.7.
Sociodemographic variables. Self-reported sociodemographic factors such as age, race/
ethnicity, place of birth, current marital status, education, employment, homelessness in the
past year and ‘ever been jailed’ were examined.
Behavioral variables. Excessive alcohol use was based on whether participants were
consuming > 7 alcoholic drinks/week for women or> 14 alcoholic drinks/week for men [19].
Other variables included were ‘ever used marijuana at least once weekly,’ injection drug use
(IDU) in the past 12 months, non-injection crack cocaine use, non-injection ecstasy use, injec-
tion stimulant use, and current cigarette use.
Health status variables. Based on their health insurance status, participants were catego-
rized as ‘insured’ or ‘uninsured’.
Adherence to HIV antiretroviral therapy (ART) was categorized into ‘� 95%’ and ‘< 95%’
based on the proportion of the last 30 days that the treatment was adhered to and ‘Not on
ART.’
The most recent CD4 count, HIV viral load and comorbid conditions (hepatitis C status
and diabetes mellitus) obtained from the medical records were included in the analysis.
Statistical analyses
Demographic characteristics and risk factors for TB were similar for individuals included and
excluded from the study. The proportions of the total sample (prevalence) who had self-
reported TB and medically documented TB was computed. The associations between the
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PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
factors listed and self-reported TB or medically documented TB were determined using Chi-
square tests for categorical variables. Multivariable logistic regression analyses were conducted
using either self-reported TB or medically documented TB as the outcome variable. In each of
the two models, factors known to be associated with TB from literature with p-value� 0.1 in
the Chi-square or Fischer’s exact test analysis were included to allow for the consideration of
important factors which may not have shown significant association at p-value <0.05. Results
of the logistic regression models are presented as odds ratios (OR) and 95% confidence inter-
vals (CI). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value
(NPV) of self- reported TB compared to medically documented TB were constructed. The
Kappa (κ) coefficient was used to determine the strength of agreement between self-reported
TB and medically documented TB. Kappa coefficients were classified based on the following:
� 0.40 as no to fair agreement, 0.41–0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00
as almost perfect agreement [16, 21]. We conducted complete case analysis, using the statistical
software SAS 9.4 (SAS Institute, Cary NC). Significance level was set at p-value < 0.05.
Results
Baseline characteristics of the 655 study participants are shown in Table 1. Majority of the par-
ticipants were aged 45 years or above (59.2%), male (64.7%), African American (59.3%), US-
born (86.9%), single/divorced/widowed/separated (80.3%), and unemployed (73.6%). Being
homeless in the past 12 months was reported by 16.6%, while 65.2% reported ever being in jail.
Of the 655 participants, 109 (16.6%) had self-reported latent or active TB and 49 (7.5%) had
medically documented TB. In general, among participants who had a particular risk factor
assessed, a higher proportion had self-reported TB compared to medically documented TB
(Table 2). Compared to younger individuals, older participants (45-54years and� 55 years)
were more likely to have self-reported TB but less likely to have medically documented TB.
Being African American was more likely to be associated with both self-reported TB (22.0%)
and medically documented TB (11.1%) than the other two categories of race (White or Other
race/ethnicity) as shown in Table 2.
Participants who were US-born or who had less than a high school education were more
likely to have either self-reported TB (16.6%, and 19.4% respectively) or medically documented
TB (7.8% and 11.6% respectively) compared to other participants. Participants who had ever
been in jail or who had been homeless in the past 12 months were more likely to have either
self-reported TB (29.2% and 24.3% respectively) or medically documented TB (10.4% and
14.0% respectively). Age� 45 years, being African American, incarceration, and homelessness
were significantly associated with self-reported TB while being African American, less than
high school education and homelessness were significantly associated with medically docu-
mented TB (p-value < 0.05).
Those who reported currently using non-injection crack cocaine were more likely to self-
report TB (26.9%) or have medically documented TB in their (10.8%) compared to those who
did not have these factors. Non-injection crack cocaine use was statistically significantly associ-
ated with self-reported TB, while not being on ART was significantly associated with having
medically documented TB with p-value < 0.05 (Table 2). Other factors examined such as US
born, marital status, employment, cigarette use, ever use of marijuana at least once weekly,
injection drug use in the past 12 months, use of non-injection ecstasy and injection stimulants,
CD4 count and hepatitis C infection were not significantly associated with either self-reported
TB or TB based on medical records.
In the logistic regression model, being age�55 years compared to 18–34 years (OR = 2.79
95%CI; 1.23–6.30), African American compared to White (OR = 3.04, 95% CI; 1.65–5.59) and
PLOS ONE | https://doi.org/10.1371/journal.pone.0271917 August 4, 2022 4 / 12
PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
Table 1. Baseline characteristics of 655 persons living with HIV in the Florida Cohort who had medical records, 2014–2018.
Sociodemographic characteristics Number (%) Health status characteristics Number (%)
Age Health insurance
18–34 127 (19.4) Uninsured 44 (7.0)
35–44 140 (21.4) Insured 588 (93.0)
45–54 249 (38.0)
� 55 139 (21.2)
Sex Adherence to ART
Male 424 (64.7) � 95% 382 (61.6)
Female 231 (35.3) < 95% 175 (28.2)
Not on ART 63 (10.2)
Race/Ethnicity Viral load
White 198 (30.3) > 200 copies /ml 137 (20.9)
African American 387 (59.3) � 200 copies /ml 518 (79.1)
Others 68 (10.4)
US Born Diabetes Mellitus
Yes 565 (86.9) Yes 79 (12.1)
No 85 (13.1) No 576 (87.9)
Education
< High school 216 (33.1)
High school diploma 201 (30.8)
> High school 236 (36.1)
Ever been jailed
Yes 412 (65.2)
No 220 (34.8)
Homeless
Yes 107 (16.6)
No 539 (83.4)
Behavioral characteristics
Cigarette use
Yes 331 (47.6)
No 301 (52.4)
Excessive alcohol use (heavy drinking)
Yes 57 (9.2)
No 562 (90.8)
Ever used marijuana on a regular basis-at least once per week
Yes 358 (58.4)
No 255 (41.6)
Injection drug use in the past 12 months
Yes 38 (6.1)
No 585 (93.9)
Non injection crack cocaine use
Never 422 (67.2)
Past use—> 12months 113 (18.0)
Current use—� 12 months 93 (14.8)
https://doi.org/10.1371/journal.pone.0271917.t001
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PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
Table 2. Factors associated with TB according to self-reports and medical records among 655 persons living with HIV in Florida.
Characteristic Self-reported TB N (%) P-value TB based on medical records N (%) P-value
Sociodemographic Factors
Age (n)
18–34 (127) 13 (10.2) 0.01 9 (7.1) 0.23
35–44 (140) 16 (11.4) 6 (4.3)
45–54 (249) 49 (19.7) 19 (7.6)
�55 (139) 31 (22.3) 15 (10.8)
Race/Ethnicity (n)
White (198) 17 (8.6) <0.01 5 (2.5) <0.01
African American (387) 85 (22.0) 43 (11.1)
Others (68) 7 (10.3) 1 (1.5)
Homeless (n)
Yes (107) 26 (24.3) 0.02 15 (14.0) <0.01
No (539) 82 (15.2) 33 (6.1)
Education (n)
< High school (216) 42 (19.4) 0.12 25 (11.6) 0.01
High school diploma (201) 37 (18.4) 15 (7.5)
> High school (236) 30 (12.7) 9 (3.8)
Sexual orientation (n)
Heterosexual or straight (340) 63 (18.5) 0.11 27 (7.9) 0.18
Gay/lesbian (216) 26 (12.0) 17 (7.9)
Bisexual (64) 12 (18.8) 1 (1.6)
Behavioral factors
Non injection crack cocaine use (n)
Never (422) 56 (13.3) <0.01 30 (7.1) 0.41
Past use—>12months (113) 25 (22.1) 7 (6.2)
Current use—� 12 months (93) 25 (26.9) 10 (10.8)
Health status factors
Health insurance (n)
Uninsured (44) 3 (6.8) 0.07 3 (6.8) 1.00��
Insured (588) 101 (17.2) 43 (7.3)
Adherence to ART (n)
� 95% (382) 63 (16.5) 0.97 27 (7.1) <0.01
< 95% (175) 30 (17.1) 10 (5.7)
Not on ART (63) 11 (17.5) 12 (24.5)
Viral load
> 200 copies /ml (137) 24 (17.5) 0.76 9 (6.6) 0.65
� 200 copies /ml (518) 85 (16.4) 40 (7.7)
Diabetes Mellitus (n)
Yes (79) 18 (22.8) 0.12 9 (11.4) 0.16
No (576) 91 (15.8) 40 (6.9)
https://doi.org/10.1371/journal.pone.0271917.t002
homeless in the past 12 months (OR = 1.39, 95% CI; 0.78–2.47), were statistically significantly
associated with self-reported TB, while being African American (OR = 4.89, 95% CI; 1.67–
14.36), homeless in the past 12 months (OR = 3.00, 95% CI; 1.46–6.15), 95% CI:), and not on
ART(OR = 3.01, 95% CI; 1.31–6.91), 95% CI:), were statistically significantly associated with
medically documented TB after adjusting for the other covariates (Table 3).
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PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
Table 3. Multivariable logistic regression analysis of the association between risk factors in persons living with
HIV in Florida and data sources on TB diagnosis.
Self-reported TB (N = 581) Adjusted TB based on medical records (N = 570)
Odds ratios (95% CI) Adjusted Odds ratios (95% CI)
Characteristic
Age
18–34 reference
35–44 1.03 (0.43–2.46)
45–54 1.95 (0.91–4.17)
�55 2.79 (1.23–6.30)
Race/Ethnicity
White reference reference
African American 3.04 (1.65–5.59) 4.89 (1.67–14.36)
Others 1.46 (0.53–4.06) 0.84 (0.09–7.83)
Homeless in the past
12months
No reference reference
Yes 1.39 (0.78–2.47) 3.00 (1.46–6.15)
Education
High School diploma or reference
equivalent
<High School 1.00 (0.57–1.74) 1.79 (0.82–3.91)
>High School 0.86 (0.47–1.55) 0.81 (0.33–2.04)
Sex orientation
Heterosexual or straight reference
Gay or lesbian 0.97 (0.55–1.71)
Bisexual 1.24 (0.59–2.63)
Non injection crack
cocaine use
Never reference
Past use (>12months) 1.73(0.96–3.10)
Current use (� 12 1.45 (0.75–2.77)
months)
Health Insurance
Yes reference
No 0.31 (0.07–1.38)
Adherence
> = 95% reference
<95% 0.74 (0.32–1.66)
Not on ART 3.01 (1.31–6.91)
Diabetes Mellitus
No reference
Yes 1.23 (0.63–2.39)
https://doi.org/10.1371/journal.pone.0271917.t003
Depending on the data source being used as reference, the sensitivity, specificity, positive
and negative predictive values varied. When self-reported TB was compared to medically doc-
umented TB, these measures with their 95% CI were: sensitivity = 0.76 (95% CI = 0.61–0.87),
specificity = 0.88 (95% CI = 0.85–0.91), positive predictive value = 0.34 (95% CI = 0.25–0.44),
and negative predictive value = 0.98 (95% CI = 0.96–0.99) (Table 4). When medical records
were compared to self-reports, the measures were as seen in Table 5. The Cohen’s Kappa
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PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
Table 4. Sensitivity, specificity, positive and negative predictive values and agreement of self-reported TB compared to TB based on medical records of PLWH in
Florida.
Self-reported TB diagnosis in medical records
TB No Yes Sensitivity (95% Specificity (95% Positive Predictive Value (95% Negative Predictive Value (95% Cohen’s Kappa (95%
CI) CI) CI) CI) CI)
No 534 12 0.76 (0.61–0.87) 0.88 (0.85–0.91) 0.34 (0.25–0.44) 0.98 (0.96–0.99) 0.41 (0.31–0.51)
Yes 72 37
https://doi.org/10.1371/journal.pone.0271917.t004
statistic was 0.41 (95% CI = 0.31–0.51) showing moderate agreement between self-reported TB
and medically documented TB (Tables 4 and 5).
Discussion
We examined the prevalence of TB by self-reports and medical records, and the association
between patient factors and TB based on self-reports and medical records and the agreement
between the two data sources, The prevalence of self-reported TB (16.6%) exceeded medically
documented TB (7.5%). Being African American was statistically significantly associated with
both data sources on the history of TB. There was a moderate agreement between the two data
sources on TB status.
In addition to the higher prevalence of self-reported TB compared to medically docu-
mented TB, the prevalence rates based on the two sources exceeded the estimate of 4.2% LTBI
in PLWH [22] and TB/HIV coinfection rate of 5.3% in the US [5]. The self-reported TB rate of
16.6% in PLWH in Florida exceeded the 9% documented by the Florida Department of Health
(FDOH) in 2018 [4] while the rate of 7.5% in medical records was slightly lower than the
FDOH rate. The survey did not distinguish between LTBI and TB disease. This may explain
the higher prevalence of self-reported TB compared to medically documented TB and make it
difficult to compare the sources with respect to LTBI or TB disease prevalence. Persons diag-
nosed with LTBI or TB disease in other states or countries prior to HIV diagnosis may not
have documentation in their medical records. Overreporting in self-reports and/or underre-
porting in medical records could have also resulted in the discrepancy in TB prevalence by
data source. Patients who received testing, especially for latent TB, may report having been
diagnosed with TB, especially if the medical evaluation was begun but not completed, or if the
communication between the patient and provider was inadequate. Our findings suggest that
among PLWH in care, self-reports may overestimate TB infection or disease prevalence while
medical records of LTBI and active TB are incomplete and may lead to underreporting.
The factors associated with TB were generally similar (though not always statistically signif-
icantly) for both data sources although the proportions were higher in those who self-reported
TB than in those who had medically documented TB. Being African American was signifi-
cantly associated with TB based on both data sources. This finding is consistent with reported
Table 5. Sensitivity, specificity, positive and negative predictive values and agreement of TB based on medical records compared to self-reported TB of PLWH in
Florida.
TB diagnosis in medical Self-reported TB
records No Yes Sensitivity (95% Specificity (95% Positive Predictive Value Negative Predictive Value Cohen’s Kappa (95%
CI) CI) (95%CI) (95%CI) CI)
No 534 72 0.34 (0.25–0.44) 0.98 (0.96–0.99) 0.76 (0.61–0.87) 0.88 (0.85–0.91) 0.41 (0.31–0.51)
Yes 12 37
https://doi.org/10.1371/journal.pone.0271917.t005
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PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
risk factors for TB in the US [23]. African Americans and other racial minority populations in
the US have been documented to be disproportionately affected by TB because of the higher
prevalence of LTBI in these populations, especially among those who are non-US born [24].
However, in this study, the majority (86.9%) of participants were US-born. Homelessness is
reported to be associated with an increased risk of LTBI [5] and TB disease [25–27]. For factors
such as ‘ever been jailed’, ‘cigarette use’, ‘non-injection crack cocaine use’ and ‘non-injection
ecstasy use’ that didn’t show consistent associations with TB status in either data source, per-
sons with these factors had higher proportions of TB compared to those who did not have
these factors, irrespective of the data source.
In our study, two different logistic regression models were created for the association
between factors and the outcome variables since the factors showing significant associations
with the self-reported TB or medically documented TB were different. This explains why the
factors that remained significant after controlling for the other variables differed. In the mod-
els, reporting African American was the only factor significantly associated with TB in both
data sources while not being on ART and being homeless were significantly associated with
TB from medical records. ART adherence is important to prevent virologic failure with emer-
gence of drug resistance, HIV transmission or development of opportunistic infections,
including TB. An adherence of 95% or more is required to improve immunity and outcomes
in PLWH [28]. ART improves immune status, thereby reducing the risk of TB and TB deaths
[29, 30].
The sensitivity, specificity and positive predictive values of self-reported TB compared to
medical records were low compared to other studies that compared these two data sources on
morbidity [13]. These results should, however, be interpreted with caution as none of these
sources is the “gold standard.” This study shows that if a participant self-reported no TB, there
was a 98% chance that the medical records would also not have TB documented. Though the
percent agreement between the two data sources was 87.2%, the overall agreement between
the two data sources can be described as moderate based on the Kappa value of 0.41 [16, 21].
The lack of a strong agreement between the two sources could indicate that patients have firm
recollections of experiences from previous conditions but little control of or access to the final
information captured in their medical records.
Limitations of the study include the fact that the question used to assess self-reported TB
failed to distinguish between latent and active TB, making it impossible to look at TB infection
and disease groups separately. Recall bias could also have occurred as the participants may not
accurately recall LTBI, especially if they were not treated. Further analysis comparing the types
of medically documented TB showed that a higher proportion (86.2%) of those who had active
TB also self-reported TB while only 60% of those with LTBI had self-reported TB. This further
suggests that individuals with LTBI are less likely to self-report TB compared to those who had
active disease either because they were not told, didn’t remember, or were not treated so they
didn’t consider it important. Active TB, on the other hand, is symptomatic, often requiring at
least 6 months of directly observed therapy, lending itself to stronger recall. Though the self-
reports didn’t state any time frame for the TB diagnosis, the medical records abstraction was
based on the list of the participants’ problems during their most recent visit to the health care
provider. This could have introduced errors due to omission of information in the medical
records during the visit. The analysis conducted also assumed that the absence of documenta-
tion of TB in the medical records meant the absence of either latent or active TB diagnosis,
potentially introducing misclassification bias.
Despite the limitations, the strengths of this study are worth mentioning. This is the first
study (to our knowledge) that has compared these two data sources on TB status in PLWH in
Florida. The study allowed for the assessment of multiple factors potentially associated with TB
PLOS ONE | https://doi.org/10.1371/journal.pone.0271917 August 4, 2022 9 / 12
PLOS ONE Risk factors for tuberculosis among persons living with HIV in Florida using self-reports and medical records
using the same sample of PLWH to give a better understanding of the similarities and differ-
ences in the association between the factors and a history of TB. Non-traditional risk factors
such as marijuana and non-injection crack cocaine use were included to assess their association
with TB, adding to existing knowledge about other potential factors associated with TB. Partici-
pants were recruited from diverse settings including county health departments, the private
health sector and the community. Thus, the sample provides some insight into risk factors such
as non-injection drug use which are not captured in the routine surveillance data in Florida.
Conclusion
The prevalence of self-reported TB was higher (16.6%) than medically documented TB (7.5%).
Being African American was significantly associated with TB status from both data sources.
There was moderate agreement between the two data sources, showing the importance of self-
reports. Establishing the true prevalence of TB and associated risk factors in PLWH for devel-
oping policies may therefore require the use of both self-reports and confirmation by screening
tests, clinical signs and/or microbiologic data.
Future studies comparing these data sources with surveillance data in the TB registry in
Florida as well as LTBI test results in those without active TB are necessary to determine the
agreement between these sources of data using the same sample of PLWH. Non-traditional
factors such as non-injection crack cocaine use could be further examined for their association
with TB and considered during risk assessment during TB screening.
Acknowledgments
The authors would like to thank the participants, the research teams and the participating sites
in the Florida Cohort study, the team of the Southern HIV and Alcohol Research Consortium
(SHARC) of the University of Florida and the University of Ghana Medical School. We would
like to thank Li, Yancheng (Alex) for his support during data analysis and Dr. Carolyn Bradley
for proof reading and editing the manuscript. We would like to thank coordinators of the Uni-
versity of Florida-University of Ghana Training Program in Tuberculosis and HIV Research
in Ghana.
Author Contributions
Conceptualization: Nana Ayegua Hagan Seneadza, Robert L. Cook.
Data curation: Nana Ayegua Hagan Seneadza, Zhi Zhou.
Formal analysis: Nana Ayegua Hagan Seneadza.
Funding acquisition: Robert L. Cook.
Methodology: Nana Ayegua Hagan Seneadza, Robert L. Cook.
Supervision: Awewura Kwara, Michael Lauzardo, Cindy Prins, Robert L. Cook.
Writing – original draft: Nana Ayegua Hagan Seneadza.
Writing – review & editing: Nana Ayegua Hagan Seneadza, Awewura Kwara, Michael Lau-
zardo, Cindy Prins, Zhi Zhou, Marie Nancy Séraphin, Nicole Ennis, Jamie P. Morano, Bab-
ette Brumback, Robert L. Cook.
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