HIV screening among TB patients and level of antiretroviral therapy and co-trimoxazole preventive therapy for TB/HIV patients in Hawassa University Referral Hospital: a five year retrospective study

HIV screening among TB patients and level of antiretroviral therapy and co-trimoxazole preventive therapy for TB/HIV patients in Hawassa University Referral Hospital: a five year retrospective study

Asnake Simieneh¹, Mengistu Hailemariam^1,&, Anteneh Amsalu²

 

¹Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Hawassa University, Ethiopia, ²Department of Medical Microbiology, University of Gondar, Ethiopia

 

 

^&Corresponding author
Mengistu Hailemariam, Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Hawassa University, Ethiopia

 

 

 

 

Tuberculosis (TB) ranks alongside human immunodeficiency virus (HIV) as a leading cause of death worldwide. It causes ill-health among millions of people each year. Globally, 9.6 million new TB cases were estimated, in 2015. Of these, 28% were from the African region. In the same year 12% of the total new TB cases were HIV-positive. The African region accounted for 74% of the estimated number of HIV-positive incident TB cases [1]. The interaction between TB and HIV infection is complex; HIV infection weakens the immune system and increases the susceptibility to TB. The presence of HIV enhances the reactivation and progression of latent Mycobacterium tuberculosis to overt TB disease, and having TB disease accelerates HIV disease progression [2]. The first key intervention for reducing the burden of HIV-associated TB is HIV testing for TB patients. Globally, 51% of notified TB patients had a documented HIV test result in 2014, of these 16% were HIV positive [1]. The prevalence of HIV co-infection among TB patients is highest in the African region, where it continues to increase and reached 79% in 2014, up from 78% in 2013 [1]. In Ethiopia, 10-67% of TB patients with an HIV test result were HIV positive [3-6]. Collaborative TB/HIV activities are essential to reduce the burden of HIV among TB patients [7]. The first priority as soon as HIV is identified in a TB patient is to initiate TB treatment, followed by CPT as soon as possible and ART within the first two to eight weeks of treatment, regardless of the CD4 count [8]. According to the WHO report in 2014, about 77% and 87% of HIV positive TB patients were enrolled on CPT and ART, respectively [1]. Despite, the implementation of TB/HIV collaborative activities in Ethiopia [9], few studies have reported prevalence of HIV among TB patients and level of HIV positive TB patients enrolled on CPT [4], to our knowledge, there are no reports in the study area. Therefore this study was conducted to determine the prevalence of HIV among TB patients and level of HIV positive TB patients enrolled on CPT and ART in Hawassa university referral hospital, southern Ethiopia.

 

 

Study design, area and period

 

A five year document review was conducted on 1961 tuberculosis patients diagnosed at Hawassa University referral Hospital from September 2009 to August 2014. The hospital is located in Hawassa city 273 km south of Addis Ababa. This hospital serves the population of Hawassa and extends to include surrounding areas encompassing roughly 17 million people.

 

Study population

 

The study population included all TB cases registered from September 2009 to August 2014 at Hawassa University referral hospital DOTs clinic. Patients were diagnosed, registered, treated and referred to other DOTs clinics following the national tuberculosis, leprosy and TB/HIV prevention and control program guideline [8].

 

Data collection

 

Data on socio-demography (age and sex), type of tuberculosis infection, patient’s category, treatment follow-up center, baseline ART and CPT provision for HIV-infected TB patients and were collected from April to May 2015 using a checklist prepared for this purpose. Patients with incomplete information were excluded.

 

Data analysis

 

The data was coded, entered and analyzed by using IBM SPSS version 20 (IBM, USA). We used frequency to compare patient characteristics and logistic regression model was used to determine the predictors of TB/HIV co-infection. Linear trends for TB/HIV co-infection, initiation of ART, provision of CPT and frequency TB patients across the year were explored using chi-square tests. Statistical significance for all analyses was set at the p = 0.05 level and 95% confidence intervals (CI) were calculated throughout.

 

HIV testing and status

 

HIV testing in Hawassa university referral hospital was performed following the national HIV test algorithm in Ethiopia, where KHB (Shangai Kehua Bio-engineering Co, Ltd. China) was used for the first screening and positive samples were re-tested with STAT pack (Chembio HIV1/2 STAT pack Assay, USA). Samples giving discordant results in the two tests (KHB and STAT pack) were retested using tie-breaker (Unigold).

 

Ethical consideration

 

The study was approved by the Department of Medical Laboratory Sciences ethics committee, College of Medicine and Health Sciences, Hawassa University. After obtaining permission and waiver from the hospital administration, we started data collection from DOTS clinic. Patient records/information was anonymized and de-identified prior to analysis. All information obtained from patient’s record was kept confidential.

 

Abbreviations: ART: Antiretroviral treatment; CPT: Co-trimoxazole prophylaxis treatment; DOTS: Directly observed therapy short-course; EPTB: Extra-pulmonary tuberculosis; HIV: Human immunodeficiency virus; SNPTB: Smear-negative pulmonary tuberculosis; SPPTB: Smear-positive pulmonary tuberculosis; TB: Tuberculosis

 

 

Characteristics of patients

 

A total of 1961 TB patients data was reviewed. Of these, 1157 (59%) were male, with male to female ratio 1.4:1.Their mean age was 27.3 (standard deviation (SD),) years, range (0–100 years), and majority of the study participants 1297(66.1%) were aged from 15-39 years old. Among the total TB patients, 49.3% (966) had extra pulmonary TB followed by 33.3% (653) smear negative pulmonary TB patients and 16.8% (329) smear positive pulmonary while, only 0.7% (13) were unknown. The majority of TB patients were new 1572(80.2%) and only 273(13.9%) had followed their treatment in the hospital TB clinic while the rest 1688(86.1%) were transferred out to other health institution (Table 1).

 

HIV screening at TB clinic

 

Out of the total 1961TB patients 94.7% (1858/1961) had offered HIV test by healthcare providers. Of whom 95.0% (1765/1858) were tested for HIV and 13.9% (246/1765) were positive for HIV. While 93 (4.8%) were refused the test and 10(0.5%) have unknown HIV test result (Table 2). Among HIV positive TB patients, 37.4% (92) were linked for CPT provision. Regarding ART initiation, 17.9% (44/246) were known to have started and 13.8% (34) had already started ART before diagnosed for TB disease; hence a total of 78(31.7%) TB patients were on ART treatment and the rest 68.3% (168) had no known records of ART initiation (Table 2).

 

Trends of HIV, initiation of ART and CPT for co-infected patients

 

In this study, high proportion of TB patients were diagnosed in September 2011 to August 2012, 606(30.9%) and in September 2012 to August 2013, 619(31.6%). Significantly declining trends of TB/HIV co-infection (p=0.006) and increasing trends of CPT provision (p = 0.0001) among co-infected patients were observed over the five years of study period. The seroprevalence of HIV was 18.9% in 2009/10 and increased to 23.6% in 2010/11 however, subsequently decreased to 14.3% in 2011/12 to 11.5% in 2012/13 and slightly increased 12.9% in 2013/14. Provision of CPT for TB/HIV co-infected patients was increased from 20.8% in 2009/10 to 46.2% in 2010/11 and further increased to 72% in 2013/14 except in the year 2011/12 in which significantly decreased to 13%. The initiation of ART for TB/HIV co-infected patients was not regular across the year (Figure 1).

 

Predictors of TB/HIV co-infection

 

In this study as shown in Table 3, relative to extra pulmonary TB patients, the odds of TB/HIV co-infection were about 1.5 times higher among smear-negative pulmonary TB (SNPTB) patients (aOR = 1.51; 95% CI 1.107-2.066; p = 0.009) and 2 times higher among smear-positive pulmonary TB(SPPTB) patients (aOR =1.94; 95% CI 1.348-2.790; p = 0.001). Female TB patients were more likely HIV infected than male TB patients though the difference was marginally non–significant (aOR =1.29; 95% CI 0. 983-1.702; p = 0.067) and preponderance of TB/HIV co-infection occurs with increasing of age, but the difference was not statistically significant.

 

 

HIV testing for all TB patients followed by provision of CPT and early initiation of ART for those found to be HIV positive has dramatically reduce mortality [6, 8]. In this study, 95% of TB patients knew their HIV status. Of these, 13.9% were positive for HIV. Out of the co-infected patients, 37.4% and 31.7% were linked to start CPT and ART respectively at the time of anti-TB treatment follow-up. Being SNPTB and SPPTB patient are predictors of TB/HIV co-infection. Significantly declining trends of TB/HIV co-infection and increasing trends of CPT linkage were observed among co-infected patients. In this study, 95% of TB patients were screened for HIV in agreement with a study in Arsi Negele Health center (94.7%) [3] and Oromia region (98%) [10]. This result is higher than the WHO report for Ethiopia (71%) [11], a national TB/HIV sentinel surveillance report from 2011-2012(86%) [8] and a study in Addis Ababa (87.1%) [4]. However, WHO were planning to screen 100% of the TB patients for HIV by 2015. On the other hand, 4.6% of TB patients refused the test in this hospital, which deserves concern. The sero-prevalence of HIV in the current study was in agreement with the previous study conducted at Arsi Negele Health center (10%) [3] and Enfrazh Health center (11.7%) [6] but lower as compared to several previous studies in Ethiopia in which the sero-prevalence of HIV positivity among TB patients ranges from 18.5% to 67% [5,12] and in other African countries such as: 42% in Uganda [13], 47.2% in Ghana [14], 61% in Kenya [15] and 56% in Malawi [16]. These differences may be attributed to differences in the prevalence of HIV infection at the community level [17]. This study also demonstrated that TB/HIV co-infection rate was significantly decreased across the years consistent with the declining trend of national HIV infection in the general population from 1.5% in 2011 to 1.1% in 2015(2014 spectrum projection) in Ethiopia [18]. To prevent opportunistic infections, the WHO recommends CPT prophylaxis for HIV-infected individuals [19]. CPT is a combination of two antimicrobial drugs that is active against a range of bacterial, fungal, and parasitic infections; prophylactic antimicrobials are taken to prevent infection [19]. In this study, 37.4% of the HIV positive TB patients have been linked for CPT. This finding is lower than previous studies in a referral hospital in North-West Ethiopia (45.9%) [20], Addis Ababa (81%) [21] and health facilities in Addis Ababa (54.3%) [4]. Recent WHO report also revealed high levels of enrolment on CPT [1]. This might be due to large number of transfer out cases and poor feedback system.

 

Despite the well-known benefit of ART and the integrated TB/HIV care in our hospital, only 31.7% of TB/HIV co infected patients were enrolled for ART treatment. This finding is lower than a study in Malawi(38%) [22]. The low ART enrollment is likely due to the patients might be reluctant to take ART and TB drugs simultaneously due to concerns about pill burden and drug interactions. The occurrence of TB/HIV co-infection was almost 2 times higher in SPPTB cases and 1.5 times higher in SNPTB cases than EPTB cases. This finding was in contrast with studies conducted elsewhere in Ethiopia [17,23] which showed that high prevalence of co infection was observed in patients with extra-pulmonary cases. This difference might be due to the proportion of SPPTB cases were small as compared to EPTB cases in our study. Moreover, high percentage of SPPTB cases refused HIV test as compared to EPTB cases which might decrease the prevalence of HIV among SPPTB cases (data not shown). The preponderance of TB/HIV co infection among women compared to men in our study was concordant with findings reported elsewhere [24]. In contrast, similar rate of infection by gender was also shown in Ethiopia [23,25]. In Ethiopian context where HIV is contracted primarily by heterosexual exposure and women are disproportionally infected. This study has some limitations which need to be noted while interpreting the findings. As this study was based on a retrospective review of TB registers and only 13.9% of the TB patients initiate and continue TB treatment at Hawassa university referral hospital TB clinic; the rest diagnosed at this hospital but choose to continue their treatment at the peripheral health facilities around Hawassa, we didn’t assess the effect of ART and CPT provision on treatment outcome of co-infected patients.

 

 

Despite, integrated TB/HIV setting, expanded ART coverage and decreased trend of TB/HIV co-infection, only a minority of co-infected patients were linked to start ART and CPT. Therefore, screening of all TB patients for HIV and linkage of co-infected patients to HIV care to start ART and CPT should be strengthened in-line with the national guidelines.

 

 

The authors declare no competing interest.

 

 

AS in consultation with MH and AA: conceived the idea and developed the proposal. AS, MH and AA: Contributed from inception of the research question to the design, proposal development, analysis, and preparation of the manuscript. AA: analyzed the data, involved in the interpretation of results and critically reviewed the manuscript. All authors read and approved the final manuscript for publication.

 

 

We are most grateful to express our gratitude to staff members of Hawassa university referral hospital TB DOTs clinic for facilitating the data collection. We also acknowledge the Hawassa University for logistic support.

 

 

Table 1: characteristics of the study participant registered at TB clinic, Hawassa university referral hospital from September 2009 - August 2014

Table 2: HIV testing and status among TB patients at Hawassa University referral hospital from September 2009 – August 2014

Table 3: predictors of TB/HIV co-infection (n=1765) among TB patients at Hawassa university referral hospital from September 2009 - August 2014

Figure 1: trends of HIV among TB patients and initiation of ART and CPT for TB/HIV patients at Hawassa University referral hospital from September 2009 – August 2014

 

 

1. World Health Organization. Global tuberculosis report 2015. Geneva, Switzerland: World Health Organization (WHO). 2015. Google Scholar


2. Mayer KH, Hamilton CD. Synergistic Pandemics: confronting the Global HIV and Tuberculosis Epidemics. Clin Infect Dis. 2010 May 15; 50 Suppl 3:S67-70. PubMed | Google Scholar


3. Gebremariam G, Asmamaw G, Hussen M, Hailemariam MZ, Asegu D et al. Impact of hiv status on treatment outcome of tuberculosis patients Registered at Arsi Negele Health Center, Southern Ethiopia: A Six Year Retrospective Study. PLoS One. 2016 Apr 20; 11(4): e0153239. PubMed | Google Scholar


4. Denegetu AW, Dolamo BL. HIV screening among tb patients and co-trimoxazole preventive therapy for tb/hiv patients in addis ababa: facility based descriptive study. PLoS One. 2014 Feb 3; 9(2): e86614. PubMed | Google Scholar


5. Cheru F, Mekonen D, GirmaT, Belyhun Y, Unakal C et al. Comparison of treatment outcomes of tuberculosis patients with and without HIV in Gondar University Hospital: a retrospective study. J Pharm Biomed Sci. 2013; 34: 1606-1612. Google Scholar


6. Endris M, Moges F, Belyhun Y, Woldehana E, Esmael A et al. Treatment Outcome of Tuberculosis Patients at Enfraz Health Center, Northwest Ethiopia: A Five-Year Retrospective Study. Tuberculosis Research and Treatment. 2014; 2014: 7. Google Scholar


7. WHO/UNAIDS. UNAIDS/WHO policy statement on HIV testing. WHO/HTM/TB. 2004; 330.


8. Federal Ministry of Health of Ethiopia. National TB/HIV sentinel surveillance: One year Report (July 2011 - June 2012). Addis Ababa, Ethiopia. 2013. Google Scholar


9. Federal Ministry of Health of Ethiopia. Manual of Tuberculosis, Leprosy and TB/HIV prevention and control programme. 4^th edition. Addis Ababa, Ethiopia. 2008. Google Scholar


10. Yadeta D, Alemseged F, Biadgilign S. Provider-initiated HIV testing and counseling among tuberculosis patients in a hospital in the Oromia region of Ethiopia. J Infect Public Health. 2013 Jun; 6(3): 222-9. PubMed | Google Scholar


11. World health organization. Global tuberculosis report 2014. Geneva, Switzerland: WHO. 2014. Google Scholar


12. Fiseha T, Gebru T, Gutema H, Debela Y. Tuberculosis Treatment Outcome among HIV Co-infected Patients at Mizan- Aman General Hospital, Southwest Ethiopia: a retrospective study. J Bioengineer & Biomedical Sci. 2015; 5: 139. Google Scholar


13. Srikantiah P, Lin R, Walusimbi M, Okwera A, Luzze H et al. Elevated HIV sero-prevalence and risk behavior among Ugandan TB suspects: implications for HIV testing and prevention. Int J Tuberc Lung Dis. 2007 Feb; 11(2): 168-174. Google Scholar


14. Adjei AA, Adiku TK, Ayeh-Kumi PF, Hesse IF. Prevalence of human immunodeficiency virus infection among tuberculosis suspect patients in Accra, Ghana. West Afr J Med. 2006 Jan-Mar; 25(1): 38-41. PubMed | Google Scholar


15. Odhiambo J, Kizito W, Njoroge A, Wambua N, Nganga L. Provider-initiated HIV testing and counseling for TB patients and suspects in Nairobi, Kenya. Int J Tuberc Lung Dis. 2008 Mar; 12(3 Suppl 1): 63-8. Google Scholar


16. Munthali L, Mwaungulu JN, Munthali K, Bowie C, Crampin AC. Using tuberculosis suspects to identify patients eligible for antiretroviral treatment. Int J Tuberc Lung Dis. 2006 Feb; 10(2): 199-202. PubMed | Google Scholar


17. Datiko DG, Yassin MA, Chekol LT, Kabeto LE, Lindtjørn B. The rate of TB-HIV co-infection depends on the prevalence of HIV infection in a community. BMC Public Health. 2008 Jul 30; 8: 266. PubMed | Google Scholar


18. World health organization [Ethiopia]. Update sheet on epidemiology of HIV/AIDS Progress in 2014. WHO Country Office for Ethiopia. 2015.


19. World Health Organization. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults: recommendations for a public health approach. Geneva: World Health Organization. 2006. Google Scholar


20. Alemayehu YK, Bushen OY, Muluneh AT. Evaluation of HIV/AIDS clinical care quality: the case of a referral hospital in North West Ethiopia. Int J Qual Health Care. 2009 Oct; 21(5): 356-62. PubMed | Google Scholar


21. Kassa A, Jerene D, Assefa Y, Teka A, Assefa A et al. Evaluation of collaborative TB/HIV activities in a general hospital in Addis Ababa, Ethiopia. BMC Res Notes. 2012 Jan 26; 5: 67. PubMed | Google Scholar


22. Tweya H FC, Phiri S, Ben-Smith A, Fenner L, Jahn A, Kalulu M, Weigel R, Kamba C, Banda R, Egger M, Keiser O. Comparison of Treatment Outcomes of New Smear-Positive Pulmonary Tuberculosis Patients by HIV and Antiretroviral Status in a TB/HIV Clinic, Malawi. PLoS One. 2013; 8(2): e56248. Google Scholar


23. Esmael A, Tsegaye G, Wubie M, Endris M. Tuberculosis and Human Immune Deficiency Virus Co-infection in Debre Markos Referral Hospital in Northwest Ethiopia: A Five Years Retrospective Study. J AIDS Clin Res. 2013; 4: 12. Google Scholar


24. Pefura Yone EW, Kuaban C, Kengne AP. HIV testing, HIV status and outcomes of treatment for tuberculosis in a major diagnosis and treatment centre in Yaounde, Cameroon: a retrospective cohort study. BMC Infect Dis. 2012 Aug 15; 12: 190. PubMed | Google Scholar


25. Demissie M, Lindtjørn B, Tegbaru B. Human immunodeficiency virus (HIV) infection in tuberculosis patients in Addis Ababa. Ethiop J Health Dev. 2000; 14: 277-282. Google Scholar