Barriers in the implementation of isoniazid preventive therapy for people living with HIV in Northern Ethiopia: a mixed quantitative and qualitative study.

BACKGROUND: Isoniazid preventive therapy is a key public health intervention for the prevention of tuberculosis disease among people living with HIV. Despite the confirmed efficacy of isoniazid preventive therapy and global recommendations existing for decades, its implementation remains limited. In resource constrained settings, few have investigated why isoniazid preventive therapy is not implemented on full scale. This study was designed to investigate the level of isoniazid preventive therapy implementation and reasons for suboptimal implementation in Tigray region of Ethiopia. METHODS: A review of patient records combined with a qualitative study using in-depth interviews and focus group discussions was conducted in 11 hospitals providing isoniazid preventive therapy in the Tigray Region. The study participants were health providers working in the HIV clinics of the 11 hospitals in the province. Health providers were interviewed about their experience of providing isoniazid preventive therapy and challenges faced during its implementation. All conversations were audio-recorded. Record review of 16,443 HIV patients registered for care in these hospitals between September 2011 and April 2014 was done to determine isoniazid preventive therapy utilization. Data were collected from April to August 2014. RESULTS: Fifty health providers participated in the study. Overall isoniazid preventive therapy coverage of the region was estimated to be 20 %. Isoniazid stock out, fear of creating isoniazid resistance, problems in patient acceptance, and lack of commitment of health managers to scale up the program were indicated by health providers as the main barriers hindering implementation of isoniazid preventive therapy. CONCLUSION: Implementation of isoniazid preventive therapy in Tigray region of Ethiopia had low coverage. Frequent interruption of isoniazid supplies raises the concern of interrupted therapy resulting in creation of isoniazid resistance. Health managers, drug suppliers and partners working in HIV and tuberculosis programs should be committed to ensure an uninterrupted supply of isoniazid and full scale implementation of isoniazid preventive therapy to eligible people living with HIV.

Population-based prevalence survey of tuberculosis in the Tigray region of Ethiopia.

BACKGROUND: Population based prevalence survey is an important epidemiological index to measure the burden of tuberculosis (TB) disease and monitor progress towards TB control in high burden countries like Ethiopia. This study was aimed to estimate the prevalence of bacteriologically confirmed pulmonary tuberculosis (PTB) in the Tigray region of Ethiopia. METHODS: Sixteen rural and urban villages were randomly selected in a stratified multistage cluster sampling. Individuals aged 15 years and older were screened by symptom inquiry for PTB. Those individuals who were symptomatic of PTB provided two sputum samples for smear microscopy, culture and molecular typing. RESULTS: The study covering 4,765 households screened a total of 12,175 individuals aged 15 years and above. The overall weighted prevalence of bacteriologically confirmed PTB in the Tigray region of Ethiopia was found to be 216/100,000 (95% CI: 202.08, 230.76) while the weighted prevalence of smear-positive PTB was 169/100,000 (95% CI: 155.53, 181.60). The prevalence of bacteriologically confirmed TB was higher amongst males (352/100 000; 95% CI: 339.05, 364.52) than females (162/100 000; 95% CI: 153.60, 171.17) and among rural (222/100,000; 95% CI: 212.77-231.53) as compared to urban residents (193/100,000; 95% CI: 183.39-203.59). CONCLUSIONS: This study found a relatively higher prevalence smear-positive PTB in the region than in a same period nationwide survey and identified a significant number of undetected PTB cases. The urgency for improved TB case detection and intensified community awareness is emphasized.

Epidemiological study of cutaneous leishmaniasis in Saesie Tsaeda-emba district, eastern Tigray, northern Ethiopia.

BACKGROUND: Cutaneous leishmaniasis (CL) is one of the endemic and neglected diseases known to exist in Ethiopian highlands. However, little is known about its epidemiological characteristics. Hence, this study was initiated and conducted from November 2011 to April 2012 to assess the epidemiological situation of CL in Saesie Tsaeda-emba District. METHODS: A cross sectional design was employed in six randomly selected Peasant associations and a house to house survey was carried out in the District. Detailed clinical assessment, and smear and culture for Leishmania parasite detection were done to confirm clinical suspension. Polymerase Chain Reaction and Restriction Fragment Length Polymorphism (PCR-RFLP) analysis of the ribosomal DNA Internal Transcribed Spacer (ITS-1) sequences was used to type isolates. Sandfly collection was also conducted in possible micro-habitats of the target areas. RESULTS: The overall prevalence of CL in the District was 14.0% (6.7% for active lesion and 7.3% for scar) with the highest prevalence amongst the age group of 10-19 years. Field isolates typed were L. aethiopica. Environmental and host risk factors significantly associated with CL distribution were age, study Peasant associations, presence of cave/gorge, walls with cracks and/or holes, presence of hyrax, animal burrow, animal dung and farm land near to residents' houses. Five phlebotomine sandflies, Phlebotomus longipes, Sergentomyia bedfordi, S.africana, S.schwetzi and S.antenata were captured. CONCLUSION: All the precipitating factors in the area are indicative of the public health importance of CL although there has been little attention given. The present study is a starter for wider investigation into the mode of its transmission, incrimination of sandfly vectors and possible animal reservoirs. Detailed information will be the basis to launch effective control of CL in the area.

Retention in Care of Adult HIV Patients Initiating Antiretroviral Therapy in Tigray, Ethiopia: A Prospective Observational Cohort Study.

INTRODUCTION: Although Ethiopia has been scaling up the antiretroviral therapy (ART) services, low retention in care of patients remains one of the main obstacles to treatment success. We report data on retention in care and its associated determinants in Tigray, Ethiopia. METHODS: We used data from the CASA project, a prospective observational and multi-site study of a cohort of HIV-infected patients who initiated ART for the first time in Tigray. Four participating health facilities (HFs) located in the South of Tigray were considered for this study. Patients were followed for one year after ART initiation. The main outcome measure was represented by the current retention in care, defined as the proportion of patients who were alive and receiving ART at the same HF one year after ART initiation. Patients who started ART between January 1, 2013 and December 31, 2013 were included in this analysis. Patients were followed for one year after ART initiation. The determinants of retention were analysed using univariate and multivariate Cox Proportional Hazards model with robust sandwich estimates to account for within HF correlation. RESULTS: The four participating HFs in Tigray were able to retain overall 85.1% of their patients after one year from starting ART. Loss to follow-up (5.5%) and transfers to other HF (6.6) were the main determinant of attrition. A multivariate analysis shows that the factors significantly associated with retention were the type of HF, gender and active TB. Alamata health center was the HF with the highest attrition rate (HR 2.99, 95% CI: 2.77-3.23). Active TB (HR 1.72, 95% CI: 1.23-2.41) and gender (HR 1.64, 95% CI: 1.10-2.56) were also significantly associated with attrition. CONCLUSIONS: Although Ethiopia has significantly improved access to the ART program, achieving and maintaining a satisfactory long-term retention rate is a future goal. This is difficult because of different retention rates among HFs. Moreover specific interventions should be directed to people of different sex to improve retention in care in male population.