Community-level variation in TB testing history: analysis of a prevalence survey in Blantyre, Malawi

Equitable access to tuberculosis testing is vital for achieving global treatment targets, but access to diagnostic services is often worse in poorer communities. The SCALE survey to estimate TB prevalence in Blantyre city, Malawi, also recorded engagement with TB services. We explored variation in self-reported TB testing history between 72 community clusters - adjusting for sex, age and HIV status - and investigated whether residual differences could be explained by household poverty. We observed substantial variation between clusters in the prevalence of ever-testing for TB, with little correlation between neighbouring clusters. Participants in poorer households had, on average, lower odds of ever-testing, yet adjusting for poverty did not reduce cluster-level variation. We conclude that, despite a decade of increased active case finding efforts, access to TB testing is inconsistent across the population of Blantyre, likely reflecting health inequities that also apply to TB testing in many other settings. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The SCALE trial was funded by the Wellcome Trust (200901/Z/16/Z). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee of the London School of Hygiene and Tropical Medicine gave ethical approval (Ref: 16228) for this work as part of the Sustainable Community-wide Active case finding for Lung hEalth (SCALE) trial (registered trial number: [ISRCTN11400592][1]). Ethics committee of the University of Malawi College of Medicine gave ethical approval for this work as part of the Sustainable Community-wide Active case finding for Lung hEalth (SCALE) trial (Ref: P.12/18/2556). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors. [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN11400592