Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa.

BACKGROUND: Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV) infected individuals in South Africa. Despite the implementation of HIV/TB integration services at primary healthcare facility level, the effect of HIV on TB treatment outcomes has not been well investigated. To provide evidence base for TB treatment outcome improvement to meet End TB Strategy goal, we assessed the effect of HIV status on treatment outcomes of TB patients at a rural clinic in the Ugu Health District, South Africa. METHODS: We reviewed medical records involving a cohort of 508 TB patients registered for treatment between 1 January 2013 and 31 December 2015 at rural public sector clinic in KwaZulu-Natal province, South Africa. Data were extracted from National TB Programme clinic cards and the TB case registers routinely maintained at study sites. The effect of HIV status on TB treatment outcomes was determined by using multinomial logistic regression. Estimates used were relative risk ratio (RRR) at 95% confidence intervals (95%CI). RESULTS: A total of 506 patients were included in the analysis. Majority of the patients (88%) were new TB cases, 70% had pulmonary TB and 59% were co-infected with HIV. Most of HIV positive patients were on antiretroviral therapy (ART) (90% (n = 268)). About 82% had successful treatment outcome (cured 39.1% (n = 198) and completed treatment (42.9% (n = 217)), 7% (n = 39) died 0.6% (n = 3) failed treatment, 3.9% (n = 20) defaulted treatment and the rest (6.6% (n = 33)) were transferred out of the facility. Furthermore, HIV positive patients had a higher mortality rate (9.67%) than HIV negative patients (2.91%)". Using completed treatment as reference, HIV positive patients not on ART relative to negative patients were more likely to have unsuccessful outcomes [RRR, 5.41; 95%CI, 2.11-13.86]. CONCLUSIONS: When compared between HIV status, HIV positive TB patients were more likely to have unsuccessful treatment outcome in rural primary care. Antiretroviral treatment seems to have had no effect on the likelihood of TB treatment success in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients emphasizing the need for enhanced integrated management of HIV/TB in rural South Africa through active screening of TB among HIV positive individuals and early access to ART among HIV positive TB cases.

Knowledge and perception about tuberculosis among children attending primary school in Ntcheu District, Malawi.

BACKGROUND: Knowledge and perceptions about tuberculosis (TB) can influence care-seeking behavior and adherence to treatment. Previous studies in Malawi were conducted to assess knowledge and attitudes regarding TB in adults, with limited data on knowledge in children. OBJECTIVES: This study assessed knowledge and perceptions about TB in children aged 10-14 years attending primary school in Ntcheu District, Malawi. DESIGN: A cross-sectional study was conducted in four primary schools in Ntcheu District. Data on knowledge and perception of TB were collected using a structured questionnaire. Pearson chi-square test was used to determine the association between socioeconomic factors and TB knowledge and perception. A P<0.05 was considered significant. RESULTS: The study found that the learners had high knowledge regarding the cause, spread, and TB preventive measures. Almost 90% of learners knew that TB is caused by a germ, however, a lower proportion knew about TB symptoms ie, night sweats (49%) and enlarged cervical lymph nodes (40%). We found that 68% of learners did not know the duration of anti-TB treatment. No association was found between age, learners' grade, and knowledge (P>0.05). CONCLUSION: Lack of knowledge regarding TB and gaps identified, may be due to a deficiency in the content of the school curriculum or the availability of information, education, and communication materials. This is the first study to report on knowledge and perceptions of TB among primary school learners in Malawi. These results will inform the development of relevant information, education, and communication materials to enhance awareness about TB among school going children.

Treatment outcomes in multidrug resistant tuberculosis-human immunodeficiency virus Co-infected patients on anti-retroviral therapy at Sizwe Tropical Disease Hospital Johannesburg, South Africa.

BACKGROUND: Multidrug resistant-tuberculosis (MDR-TB) is a threat to global tuberculosis control which is worsened by human immune-deficiency virus (HIV) co-infection. There is however paucity of data on the effects of antiretroviral treatment (ART) before or after starting MDR-TB treatment. This study determined predictors of mortality and treatment failure among HIV co-infected MDR-TB patients on ART. METHODS: A retrospective medical record review of 1200 HIV co-infected MDR-TB patients admitted at Sizwe Tropical Disease Hospital, Johannesburg from 2007 to 2010 was performed. Chi-square test was used to determine treatment outcomes in HIV co-infected MDR-TB patients on ART. Multivariable logistic regression and Poisson models were used to determine predictors of mortality and treatment failure respectively. RESULTS: Mortality was higher (21.8% vs. 15.4%) among patients who started ART before initiating MDR-TB treatment compared with patients initiated on ART after commencing MDR-TB treatment (p = 0.013). Factors significantly associated with mortality included: the use of ART before starting MDR-TB treatment (OR 1.65, 95% CI 1.02-2.73), severely-underweight (OR 3.71, 95% CI 1.89-7.29) and underweight (OR 2.35, 95% CI 1.30-4.26), cavities on chest x-rays at baseline (OR 1.76, 95% CI 1.08-2.94), presence of other opportunistic infections (OR 1.80, 95% CI 1.10-2.94) and presence of other co-morbidities (OR 2.26, 95% CI 1.20-4.21). Factors predicting failure were severe anaemia (IRR (OR 4.72, 95% CI 1.47-15), other co-morbidities (OR 2.39, 95% CI 1.05-5.43) and modified individualised regimen at baseline (OR 2.15, 95% CI 0.98-4.71). CONCLUSIONS: High mortality among patients already on ART before initiating MDR-TB treatment is a worrisome development. Management of adverse-events, opportunistic infections and co-morbidities in these patients is important if the protective benefits of being on ART are to be maximized. There is the need to intensify intervention programmes targeted at early identification of MDR-TB, treatment initiation, drug monitoring and increasing adherence among HIV co-infected MDR-TB patients.

Determinants of Pulmonary Tuberculosis among Inmates at Mangaung Maximum Correctional Facility in Bloemfontein, South Africa.

Introduction. Correctional facilities house large number of inmates who are at high risk of developing tuberculosis (TB); however factors associated with TB among inmates at Mangaung Correctional Centre have not been studied. Study Population and Methods. We undertook a case control study and reviewed a total of 1140 medical records of inmates treated for TB between 2009 and 2010. Cases were selected randomly from the medical records of inmates who were treated. Data collected were analysed using STATA version 12.0 and determinants of TB were evaluated using multiple logistic regression analyses. Factors with P < 0.05 were considered significant. Results. Prevalence of TB was 8.8% and 52% of inmates with TB were aged 31-40 years; 58% of the TB cases were HIV positive and 34% of them had CD4 cell count 350 cells/mm(3). Factors associated with TB among inmates were HIV coinfection (OR: 4.2; 95% CI: 2.64-7.00); previous history of TB disease (OR: 3.58; 95% CI: 2.25-5.70); and smoking (OR: 2.1; 95% CI: 1.16-3.81). Conclusion. Interventions to improve TB detection such as regular screening of inmates with such factors need to be reinforced to control transmission of TB among inmates and the community.

Predictors of cure among HIV co-infected multidrug-resistant TB patients at Sizwe Tropical Disease Hospital Johannesburg, South Africa.

BACKGROUND: The global incidence of multidrug-resistant tuberculosis (MDR-TB) is rising, especially among HIV infected patients, despite intervention programs. Limited data are available on outcomes of MDR-TB treatment, specifically in a cohort of HIV co-infected patients in sub-Saharan Africa. The objective of this study was to determine the predictors of cure among MDR-TB HIV co-infected patients. METHODS: A retrospective review of 1200 medical records of HIV co-infected MDR-TB patients was performed at Sizwe Tropical Disease Hospital, Johannesburg covering the period 2007 to 2010. Logistic regression analysis was done to identify predictors of cure. RESULTS: Of 1137 patients included in the analysis, 29.8% (339/1137) were cured, 16.5% (188/1137) completed treatment, 22.3% (254/1137) defaulted treatment, 2.9% (33/1137) failed treatment and 22.7% (258/1137) died while on treatment. The remaining 5.7% (65/1137) were transferred-out or still-on-treatment. There was a significant interaction between sex and timing of antiretroviral treatment (ART) initiation (p=0.008). Factors predicting cure were male patients on ART prior to commencing MDR-TB treatment (OR 1.87, [1.11-3.13]), CD4(+) cell counts between 201-349 (OR 2.06, [1.10-3.84]) and ≥ 350 cells/mm³ (OR 1.98, [0.98-3.97]). Negative predictors of cure included the presence of cavitary lesions on chest x-rays (OR 0.55, [0.38-0.78]) and modified individualised regimen at baseline (OR 0.62, [0.42-0.92]). CONCLUSIONS: Cure was higher in males on ART prior to initiating MDR-TB treatment compared with males on ART after initiating MDR-TB treatment. The inverse was the case among females. Therefore, future research should explore the biological and behavioural mechanisms that may possibly be responsible for this observed trend. This will help improve MDR-TB treatment outcomes in HIV co-infected patients on ART.