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Survival Experience and its Predictors among TB/HIV Co-infected Patients in Southwest Ethiopia

Hailay Abrha1,2*, Birtukan Tsehayneh1,3, Desalegn Massa1, Amanuel Tesfay4 and Hafte Kahsay5

1Department of Epidemiology, Jimma University, Jimma, Ethiopia

2Discipline of Public Health, Flinders University, South Australia, Australia

3Department of Statistics, Alberta University, Canada

4Department of Population and Family Health, Jimma University, Jimma, Ethiopia

5Filtu Hospital, Somali, Ethiopia

*Corresponding Author:
Hailay Abrha
Department of Epidemiology
Jimma University
Jimma, Ethiopia
Tel: +61 470020884
E-mail: [email protected]

Received date: June 11, 2015; Accepted date: June 23, 2015; Published date: June 28, 2015

Citation: Abrha H, Tsehayneh B, Massa D, Tesfay A, Kahsay H (2015) Survival Experience and its Predictors among TB/HIV Co-infected Patients in Southwest Ethiopia. Epidemiology (sunnyvale) 5: 191. doi:10.4172/2161-1165.1000191

Copyright: © 2015 Abrha H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: HIV-TB co-infection is “bidirectional and synergistic”. HIV promotes the progression of latent tuberculosis infection to disease and tuberculosis accelerates the progression of HIV disease to its advanced stage. To date, there have been limited clinical data regarding survival rates among TB/HIV co-infected patients and the impact of antiretroviral therapy on clinical outcomes in developing countries. Therefore, this study assessed the predictors of TB/HIV associated mortality in a cohort of HIV infected patients treated with antiretroviral therapy in Jimma University Teaching Hospital.

Methods: Retrospective study was conducted in Jimma University Teaching Hospital from September 01, 2010 to August 31, 2012. All records of adult TB-HIV co-infected patients who follow TB-HIV care in Jimma University Teaching Hospital between 01 September of 2010 and 31 August of 2012 were retrieved. Data were entered by Epidata and was exported to SPSS version 19. Data were analyzed using proportional hazards cox model with stepwise variable selection to identify independent predictors. P value below 0.05 was considered statistically significant in the final model.

Results: Fifty five (20.2%) Tb HIV co-infected patients were died in the year September 2010 to August 2012, and 272 study subjects contributed 3, 082.7 person month observations. Age between 35-44 years (AHR=2.9; 95%CI: 1.08-7.6), being commercial sex worker (AHR=9.1; 95%CI: 2.7-30.7), bed ridden functional status (AHR=3.2; 95%CI: 1.2-8.7), and WHO stages 2 (AHR=0.2; 95%CI: 0.06-0.5), 3(AHR=0.3; 95%CI: 0.1-0.8) and 4(AHR=0.2; 95%CI: 0.04-0.55) were the independent factors affecting mortality of TB-HIV co-infected patients.

Conclusions: More than 1 in 5 TB-HIV co-infected individuals died. The independent predictors were age between 35-44 years, being student and commercial sex worker, bed ridden functional status, and WHO stages 2, 3, and 4. Therefore, attention should be given to reduce the considerable amount of death, and specific intervention should be designed focusing on the independent predictors.

Keywords

TB-HIV; Survival; Retrospective cohort; Ethiopia

 

Introduction

TB/HIV co-infection is “bidirectional and synergistic in which HIV promotes the progression of latent tuberculosis infection to disease, and tuberculosis accelerates the progression of HIV disease to its advanced stage [1]. HIV is the main reason for failure to meet Tuberculosis (TB) control targets in high HIV settings; as well TB is a major cause of death among people living with HIV [2]. According to 2010 WHO report on TB profiles of different countries, Ethiopia is classified as high burden TB, High burden HIV and high burden MDR-TB [2]. The prevalence rate was estimated to be 394 (173-623) per 100000 populations including those co-infected with HIV, and there were 152,030 new cases of which 3,190 are below 15 years of age [2].

 

Globally, TB remains among the leading causes of death from an infectious agent. In 2008, of the estimated 9.4 million incident cases of TB, 1.4 million were in people living with HIV and TB accounted for 23% of AIDS-related deaths [3-5]. Different studies stated that, TB is often the ?rst manifestation of HIV infection, and it is the leading cause of death among HIV-infected patients in Africa [6,7]. It is estimated that almost 33% of all people living with HIV-1 are co-infected with TB. In parts of sub-Saharan Africa up to 70% of Tb patients are co-infected with HIV [8]. In Ethiopia, a cross-sectional study revealed that the rate of HIV infection in TB patients was 18% ranging from 8.3% (in Silte zone) to 35.3% (in South Omo zone) [9].

There are different factors affecting the survival of Tb/HIV co-infection. Age, gender, marital status, level of education, religion, occupation, residence, weight, AIDS staging, TB clinical presentation and calendar year were predictors [10,11]. To date, there have been limited clinical data regarding survival rates among HIV/TB co-infected patients and the impact of antiretroviral therapy (ART) on clinical outcomes in developing countries like Ethiopia. Besides, few studies have analyzed factors associated with survival in HIV-infected TB patients taking into account drug susceptibility patterns of Mycobacterium tuberculosis. We, therefore, conducted this study to look at the survival rate of TB/HIV co-infected patients and to gain better insight on associated factors.

Methods and Participants

Study design

 

A retrospective cohort study using ART records from September 01, 2010 to August 31, 2012 was conducted in Jimma University Teaching Hospital (JUTH). The hospital is located in 355 km towards southwest of Ethiopia.

Population

All adults aged 15 years and above who follow TB-HIV care in JUTH were the population. Incomplete records were excluded from analysis.

Variables

Death due to TB/HIV co-infection was the event. Age, religion, educational level, ethnicity, marital status, employment status, residence, number of rooms past opportunistic infection, TB incidence, functional status, baseline CD4 cells count, baseline weight, drug regimen, WHO clinical stage, risk behavior and substance use were an in independent variables.

Statistical analysis

Data extraction checklist was used to extract information from the patient cards, registration and log books. Data were entered by Epi-data and was exported to SPSS version 19.0 for windows for analysis. The data were cleaned and edited before analysis. Data exploration was undertaken to see if there are odd codes or items that were not logical and then subsequent editing was made. The main end point in this study was death from TB/HIV co-infection. Individuals defaulted, lost to follow up, transfer out and survivors at the end of the study period were considered as censored. Finally, the out-come of each subject was dichotomized in to censored or recovered. The patient cohort characteristics was described in terms of mean, median, standard deviations, and range values for continuous data; percentage, frequency tables and charts/graphs for categorical data. For the comparison of time to recovery among the different groups of patients, Kaplan Meir curve was used. The proportional hazards cox model with stepwise variable selection procedural was used to identify independent predictors of survival. The assumption for proportional hazard was assessed graphically by log minus log survival curve. P-value less than or equal to 5% was considered significant.

Ethical consideration

Ethical clearance was obtained from the Office of Institutional Review Board of college of Public Health and Medical sciences, Jimma University. Consent was obtained from Jimma University Teaching Hospital.

Results

Baseline socio-demographic and economic characteristics of the study subjects A total of 272 TB-HIV co-infected patients were followed for a mean of 340 days. In this study, the mean age of the study subjects were 32(+8.53) years with a majority of them lying between 25-34 years age. Females (58.1%), daily labourers (31.6%), formally educated (51.5%), Muslim (49.3%), married (60.7%) and urban dwellers (69.5%) were the dominant study participants. Almost three fourth of them live with less than 5 people and do have water and electricity. A considerable amount (44.5%) of study participants has 1 living room (Table 1).

 

Socio-demographic variable   n=272 Percentage
Age (in years) 15-24 38 14.0
25-34 140 51.5
35-44 69 25.4
>=45 25 9.2
Sex Male 114 41.9
Female 158 58.1
Occupation Government employed 48 17.6
NGO 46 16.9
Farmer 80 29.4
Daily labor 86 31.6
Commercial sex worker 12 4.4
Educational status Illiterate 81 29.8
Read and write 51 18.8
Formal education 140 51.5
Religion Orthodox 76 27.9
Muslim 134 49.3
Protestant 50 18.4
Catholic 12 4.4
Marital status Married 165 60.7
Single 58 21.3
Divorced 36 13.2
Widowed 13 4.8
Residence Urban 189 69.5
Rural 83 30.5
Number of people living with <5 people 210 77.2
>=5 people 62 22.8
Water Yes 207 76.1
No 65 23.9
Electricity Yes 207 76.1
No 65 23.9
Room 1 121 44.5
2 110 40.5
3 31 11.4
4 10 3.7

Table 1: Baseline socio-demographic characteristics of 272 adult TB-HIV Co-infected patients enrolled to HIV at Jimma University Teaching Hospital, South West Ethiopia, 2013.

Clinical and behavioral characteristics of the study subjects In the cohort, 176 (64.7%) study subjects had disclosed about their status to the nearest person. Majority of the patients were on first line regimen, working functional status and WHO stage-III. Pulmonary TB accounted more than extra pulmonary or mixed TB type and the mode of entry was relapse in above 85% of the participants. Nearly 70% of their partners were positive and above 70% of study participants had risky behaviour. Surprisingly, 83% of them didn’t use condom (Table 2).

Variable Value/level n =272 Percentage
Disclosure Yes 176 64.7
No 96 35.3
Function Work 138 50.7
Ambulatory 95 34.9
Bed redden 39 14.3
WHO stage 1 17 6.2
2 67 24.6
3 124 45.6
4 64 23.5
Regimen First line 229 84.2
Second line 43 15.8
CD4 <200 cells/copies 163 59.9
>=200 cells/copies 109 40.1
TB type   Pulmonary 213 78.3
Extra pulmonary 14 5.1
Mixed 45 16.5
Mode of TB entry   New 232 85.3
Relapse 27 9.9
Dropout 13 4.8
Partner HIV status Positive 189 69.8
Negative 1 0.4
Unknown 82 30.1
Risky behaviour Yes 191 70.2
No 81 29.8
Condom use Yes 47 17.3
No 225 82.7
Tobacco smoking Yes 126 46.3
No 146 53.7
Alcohol drinking Yes 76 27.9
No 196 72.1

Table 2: Clinical and behavioural characteristics adult TB-HIV Co-infected patients enrolled to HIV at JUTH, South West Ethiopia, 2013.

Survival status of study participants A total of 55 (20.2%) Tb HIV co-infected patients were died in the year September 2010 to August 2012.

The 272 study subjects contributed 3, 082.7 person month observations (PMO) to this study.

The survival status by sex, functional status, WHO stage and CD4 category is described by the Kaplan-Meier figures (Figures 1-3).

epidemiology-TB-HIV-co-infection-sex

Figure 1: survivals status of TB/HIV co-infection by sex.

epidemiology-infection-WHO-stage

Figure 2: Survival status of TB/HIV co-infection by WHO stage.

epidemiology-Survival-status-TB-HIV

Figure 3: Survival status of TB/HIV co-infection by tuberculosis type.

Predictors of mortality in TB-HIV co-infected patients during TB treatment Bivariate cox regression analysis showed that the risk of death was statistically different by age, educational status, occupation and WHO stage.

After adjustment, checking for interaction and fitness of the model, age between 35-44 years, being student and commercial sex worker, bed ridden functional status, and WHO stages 2, 3, and 4 were independent predictors in the multiple Cox regression analysis (Table 3).

Variable Crude Hazard Ratio (95%CI) Adjusted Hazard Ratio (95% CI)
Age in years
15-24 1 1
25-34 1.1(0.5-2.8) 1.4(0.6-3.8)
35-44 2.2(0.9-5.4)** 2.9(1.08-7.6)**
>=45 0.6(0.1-2.7) 0.3(0.05-1.6)
Sex
Male 1 1
Female 1.1(0.7-1.9) 1.7(0.8-3.5)
Educational status
Illiterate 1 1
Read and write 0.7(0.3-1.3) 0.9(0.3-2.4)
Formal education 0.4(0.2-0.7)** 0.6(0.2-1.8)
Occupation
Gov’t employed 1 1
NGO 1.1(0.4-2.9) 0.9(0.4-2.6)
Farmer 1.06(0.4-2.6) 0.7(0.3-1.9)
Daily labour 2.4(1.04-5.3)** 2.1(0.9-4.9)
Commercial sex worker 6.7(2.2-20.9)** 9.1(2.7-30.7)**
Disclosure
Yes 1 1
No 0.7(0.4-1.1) 0.7(0.3-1.8)
Function
Work 1 1
Ambulatory 0.6(0.3-1.09) 1.05(0.5-2.1)
Bed ridden 0.5(0.2-1.05) 3.2(1.2-8.7)**
WHO stage
1 1 1
2 0.3(0.1-0.9)** 0.2(0.06-0.5)**
3 0.4 (0.2-1.02) 0.3(0.1-0.8)**
4 0.4(0.2-1.09) 0.2(0.04-0.5)**
TB type
Pulmonary 1 1
Extra-pulmonary 0.6(0.3-1.07) 2.6(0.5-12.2)
Mixed 1(0.3-3.6) 0.9(0.3-2.7)
Risky behaviour
Yes 1 1
No 0.9(0.5-1.6) 0.8(0.4-1.9)
Partner HIV status
Positive 1 1
Negative 1.4(0.8-2.5) 0.5(0.2-1.5)

Table 3: Cox regression analysis for predictors of mortality among TB-HIV coinfected patients enrolled to HIV at Jimma University Teaching Hospital, South West Ethiopia, from 2010-2012.

Discussion

This study revealed the problem of high mortality of TB-HIV co-infected patients. More than 1 in 5 TB-HIV co-infected (20.2%) individuals died during TB treatment and this is consistent with the study conducted in Bahir Dar in 2012 [12].

 

Results from this study demonstrated that age between 35-44 years, being commercial sex worker, bed ridden functional status, and WHO stages 2, 3, and 4 were independent predictors affecting mortality of TB/HIV co-infected patients.

Study participants between 35-44 years old had nearly 3 times higher risk of (95% CI: 2.9, 1.08-7.6) death than those below 25 years old and this is similar with study done in Brazil [10] but different with the study done in Bahir Dar [12] stating that people aged 45 and above is more at risk of dying.

Regarding functional status, bedridden patients had three times (AHR=3.2, 95% CI: 1.2-8.7) an increased risk of mortality than in working status. This in agreement with the study conducted in Bahir Dar [12] stating that bedridden patients were nearly 4 times at risk of dying than in work functional status (AHR=3.88; 95%CI: 2.15-7.02).

Lastly, patients in WHO stages 2, 3 and 4 compared to stage 1 were found protective for mortality risk. The risk of death in patients diagnosed as WHO stage III was decreased by 70% (AHR=0.3; 95%CI: 0.1-0.8) compared to WHO stage I patients. The possible reason could be due to Immune reconstitution syndrome during their stage I, and their experience to develop self-care. The major limitation of this study is the small sample size on top of its being retrospective study.

In conclusion, more than 1 in 5 TB/HIV co-infected individuals died during TB treatment. Age between 35-44 years, being student and commercial sex worker, bed ridden functional status, and WHO stages 2, 3, and 4 were the independent predictors affecting mortality of TB-HIV co-infected patients. Therefore, since the death is a significant number, strategies to reduce this considerable amount including availability of ARVs should be applied to. A special attention should also be given for the independently associated factors. Researchers can conduct using a primary study and/or large sample size to really deal out the predictors.

References

  1. Toossi Z (2003) Virological and immunological impact of tuberculosis on human immunodeficiency virus type 1 disease. J Infect Dis 188:1146-1155.
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  8. http://www.healthlink.org.uk/pdf/tb-hiv.pdf
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  10. Domingos MA, Caiaffa WT, Colosimo EA (2008) Mortality, TB/HIV co-infection, and treatment dropout: predictors of tuberculosis prognosis in Recife, Pernambuco State, Brazil. Cad. SaúdePública, Rio de Janeiro 24(4):887-896.
  11. Català L, Orcau A, Olalla GP, Millet JP, MondragónRA, et al (2011) TB-HIV Working Group. Survival of a large cohort of HIV-infected tuberculosis patients in the era of highly active antiretroviral treatment. Int J Tuberc Lung Dis 15 (2):263-269.
  12. Sileshi B, Deyessa N, Girma B, Melese M, Suarez P (2013) Predictors of mortality among TB-HIV Co-infected patients being treated for tuberculosis in Northwest Ethiopia: a retrospective cohort study. BMC Infectious Diseases 13:297.
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