RESEARCH PROPOSAL

ON

PREVALENCE OF TUBERCULOSIS AMONG HIV INFECTED INDIVIDUAL

ATTENDING CTC CLINIC AT MBEYA REFERRAL HOSPITAL

STUDENT NAME: MAYUFE.K. RAMADHANI

CANDIDATE NUMBER: NS3535/0032/2017

Purpose: “A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILMENT OF

THE REQUIREMENTS FOR THE ORDINARY DIPLOMA OF MEDICAL
LABORATORY AT MBALIZI INSTITUTE OF HEALTH SCIENCE

YEAR OF COMPLETION: 2023

i
 CERTIFICATION

The undersigned certifies that he has red and here by recommends for acceptance by mbalizi
institute of health science. A study topic entitled assessment of nursing practices on post-
operative wound care on surgical word at mbalizi-designated hospital, Mbeya region
Supervisor name: Dr. MGIMBA
Signature.......................
Date.................................

ii
 DECLARATION
I MAYUFU K RAMADHANI declare that this research proposal is my own work. It has not
been and will not be presented for any other course of study. We confirm that appropriate
credit has been given where references has been made to the work of others.

Signature_____________________

Date_______________________

iii
 ACKNOWLADGEMENT

First, I would like to thank God for keeping us healthy and strong from beginning up to now,
Also special thanks to ministry of health community gender elderly and children for giving us
this opportunity of research study as a part of learning program
Secondly, I would like to thank our research tutor sir KOMBO JUMA and all staff of Mbalizi
Institute of Health Science and staff of Mbalizi hospital.
Lastly, I would like to thank my parents for their contribution to my work and thanks to all
my classmates and friends.

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TABLE OF CONTENTS
CERTIFICATION.....................................................................................................................II

DECLARATION......................................................................................................................III

ACKNOWLADGEMENT.......................................................................................................IV

ABBREVIATIONS...................................................................................................................V

ABSTRACT.............................................................................................................................VI

CHAPTER ONE.........................................................................................................................1

I.0 NTRODUCTION..............................................................................................................1

1.2 PROBLEM STATEMENT...............................................................................................3

1.3 RATIONALE OF THE STUDY:.....................................................................................4

1.4 OBJECTIVES...................................................................................................................4

1.4.2 SPECIFIC OBJECTIVES..........................................................................................4

1.5 RESEARCH QUESTIONS..............................................................................................4

CHAPTER TWO........................................................................................................................5

2.0 LITERATURE REVIEW............................................................................................5

CHAPTER THREE................................................................................................................10

3.0 METHODOLOGY.........................................................................................................10

3.1 CHAPTER OVERVIEW................................................................................................10

3.2 STUDY AREA................................................................................................................10

3.3 RESEARCH DESIGN....................................................................................................10

3.4 METHODS OF DATA COLLECTION.........................................................................10

3.5 DATA COLLECTION TOOLS AND METHODS........................................................11

3.6 SAMPLING TECHNIQUE..............................................................................................11

3.7 DATA COLLECTION TOOLS AND METHODS........................................................11

3.8 METHODS FOR ENSURING VALIDITY AND RELIABILITY................................11

3.8.1 RELIABILITY.........................................................................................................11

3.8 .1 VALIDITY..............................................................................................................12

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 3.9 DATA ANALYSIS METHODS AND PLAN...............................................................12

3.10 ETHICAL CONSIDERATIONS..................................................................................12

3.11 PLANS FOR DISSEMINATION OF RESEARCH RESULTS...................................12

3.12 LIMITATIONS AND DELIMITATIONS OF THE STUDY..................................12

3.13 CHAPTER SUMMARY...............................................................................................13

REFERENCES:........................................................................................................................14

APPENDICES..........................................................................................................................17

APPENDIX 1:.......................................................................................................................17

APPENDIX 2:.......................................................................................................................20

APPENDIX 3:.......................................................................................................................23

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 ABBREVIATIONS

AIDS - Acquired Immune Deficiency Syndrome

ART - Anti-Retroviral Therapy
ARV - Antiretroviral drugs
CD4 - Cluster of Differentiation 4
CTC - Care and Treatment Centre
CPT - Cotrimoxazole Preventive Therapy
DTLC - District Tuberculosis and Leprosy Coordinator
EMB - Ethambutol
EPTB - Extra Pulmonary Tuberculosis
HIV - Human Immunodeficiency Virus
HIV/AIDS - Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
IDI - In-Depth Interview
IEC - Information Education Communication
INH - Isoniazid
IRIS - Immune Reconstitution Inflammatory Syndrome
MUHAS - Muhimbili University of Health and Allied Sciences
NACP - National AIDS Control Program
NTLP - National Tuberculosis and Leprosy Program
PI - Principal Investigator
PITC - Provider Initiative Testing and Counselling
PLWH - People Living With HIV/AIDS
PTB - Pulmonary Tuberculosis
PZA - Pyrazinamide
RMP - Rifampicin
RTLC - Regional Tuberculosis and Leprosy Coordinator
TB - Tuberculosis

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 ABSTRACT

Background: In 2015, there were an estimated 10.4 million new cases of Tuberculosis
(TB) worldwide of which 1.2 million (11%) were associated with HIV. In Tanzania, the
prevalence for TB is estimated at 164 per 100,000 population and about 50% of all TB
patients are HIV positive. TB and HIV are overlapping epidemics where HIV is known for
being the strongest risk factor for developing TB disease. TB disease is also more common
in people living with HIV and accelerates progression of HIV infection. Several studies
have shown early antiretroviral therapy (ART) reduces both morbidity and mortality in TB
patients co-infected with HIV, hence improving the quality of life. Tanzania started
offering HIV services in TB clinics in 2008 as per the World Health Organization
recommendations; however, no systematic assessment on the extent of integration of HIV
services in TB clinics has been done to date.

Objective: To determine the prevalence of tuberculosis to HIV patient in Mbeya zonal

hospital

Methodology: A retrospective cohort was established with all adult TB infected patients
registered in selected TB clinics from January to December 2016. Data was extracted from
facility records using a data compilation sheet and qualitative interviews were held with
TB focal persons. Cumulative proportion of TB registered clients provided with HIV
counselling and testing and/or initiated on ART was calculated. Survival analysis to
determine time to integration was run. Cox regression models were used to identify
independent predictors of overall integration of HIV services. Significance level was set at
alpha = 5%.

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 CHAPTER ONE

I.0 NTRODUCTION

1.1 BACKGROUND INFORMATION

Globally worldwide data on TB/HIV burden (TB/HIV estimates doubled between 2006 and
2007)1.4 million (15%) TB cases occurred in people living with HIV 0.5 million TB deaths in
people living with HIV (23% of all HIV deaths)

People living with HIV are six times more likely to die during TB treatment is the "Achilles
heel" of HIV care and treatment (major cause of death and can undermine the effectiveness of
ART outcomes).

Tuberculosis (TB) is a global public health concern. It is even more so as its incidence seems
to be increasing in South Africa from 2010 to 2013, the number of new cases increased from
981 to 1000 cases per 1000,000 people. As a disease that primarily affects the lungs, it can be
transmitted from person to person via the air-borne particles during normal social
interactions. Thus, it poses a serious risk to uninfected people who come into contact with
infected but undiagnosed people. For this reason, health care workers are even at a greater
risk as they meet such people on a routine basis as they perform their duties. Unfortunately, a
number of studies from other countries have found that health care workers do not always
have sufficient knowledge and the right attitude in order to adopt acceptable practices for
preventing the spread of resistant tuberculosis and treat-ing tuberculosis adequately.

In sub Saharan Africa Yet, high rates of resistant tuberculosis have been notified for the
Western Cape, Eastern Cape as well as KwaZulu-Natal (KZN) provinces. Moreover, there is
evidence that resistant tuberculosis in South Africa is spread mostly by the transmission of
MDR strains [6-10]. It is noted that, conceptually, several individual characteristics of
healthcare workers, institutional and managerial systems in place as well as the regulatory
frameworks affect the implementation of infection control measures [11,12].

In Tanzania, the process of reviewing implementation of collaborative TB/HIV activities

was done in 2005 however; there was no framework for the implementation process at that
time (11). Collaborative TB/HIV management is necessary to ensure TB patients who are
HIV positive are identified and treated accordingly, and preventing TB in HIV infected
patients (10). Integrated TB/HIV services enable presumptive and diagnosed TB patients

1
to receive timely diagnosis and treatment of HIV infection that would otherwise have had a
delayed diagnosis or died of undiagnosed HIV infection. It allows TB/HIV co-infected
patients to receive HIV treatment and care at TB clinics during the period of TB treatment.
This leads to timely ART initiation as well as preventing TB transmission in HIV care
settings, by limiting contact of TB patients with large number of persons with HIV
infection (who are already at higher risk of acquiring TB) during early TB treatment when
they are most infectious. Hence an integrated TB/HIV service not only lead to TB and HIV
control, but also leads to dramatic scaling up of life saving HIV care and treatment in the
population.

At the time of this assessment and in accordance with the national guidelines of the
Ministry of Health Tanzania, all HIV infected patients including TB/HIV co-infected
patients are to receive daily CPT and ART irrespective of their CD4 cell count or WHO
clinical stage (12).

The delivery of integrated TB and HIV services involves referral of TB suspects from all
care points in health facilities to the laboratory for sputum microscopy and/or radiological
examinations. Adults newly diagnosed with TB were to be initiated on 2 months of
Rifampicin (RMP), Isoniazid (INH), Ethambutol (EMB) and Pyrazinamide (PZA),
followed by 4 months of RMP and INH. All presumptive TB cases and newly diagnosed
TB patients are to be offered HIV testing and, if found positive, initiated on CPT and ART
within 2 weeks of commencing TB treatment. For those who are already HIV positive at
the time of TB diagnosis, are to be linked to CTC.

2
1.2 PROBLEM STATEMENT.

Tanzania is one of the 30 countries with a high TB and TB/HIV burden and a high HIV
associated TB case fatality rate. Following the WHO recommended collaborative TB/HIV
services to improve TB/HIV service delivery; Tanzania started to implement integrated
TB/HIV services in 2008 to reduce the dual burden of TB and HIV in the country. As of
2015, 64% of TB patients remain unaware of their HIV status and up to 15% of those eligible
are not on ART, indicating multi-factorial challenges with integration. In some parts of
Tanzania, there is still program cross referrals for management of TB and HIV co-infections
with some projects promoting integration of TB and HIV services.

Poor implementation of integrated TB/HIV services has been linked to poor advocacy of the
existing policy, poor dissemination of guidelines, poor knowledge of health care providers on
management of TB/HIV co-infections, staff attitude towards offering both services, staff
overload, no availability of ARVs in TB clinics, and patients’ reluctance to take both anti TB
drugs and ARVs at the same time leading to missed opportunity in HIV case identification
among TB patients. Several studies have been conducted on TB screening among HIV
patients, ART adherence and CPT prophylaxis coverage.

However, few studies have systematically assessed the prevalence of TB among affected
attending CTC.

Therefore, using a retrospective cohort study we aimed to assess prevalence of TB among

HIV individual attending CTC at Mbeya zonal hospital.

3
1.3 RATIONALE OF THE STUDY:

Integrating TB and HIV activities in health care provision is crucial so as to reduce the burden
of HIV infections in patients with TB disease to reach the 90/90/90 UNAIDS goal. Early
detection of HIV among patients with presumptive and diagnosed TB is important to improve
prognosis hence improve quality of life. It is also a gateway into the HIV care continuum.

Findings from this study will inform stakeholders and policy makers on the performance of
this initiative and identify areas that need to be addressed to improve and scale up integration
of TB/HIV services. It will provide local information on how to design effective interventions
to promote provision of integrated TB/HIV services. It will also create awareness on
integrated TB/HIV services.

1.4 OBJECTIVES

1.4.1 BROAD OBJECTIVE.

To determine the prevalence of tuberculosis among HIV infected individual attending CTC
clinic at Mbeya zonal referral hospital.

1.4.2 SPECIFIC OBJECTIVES.

1. To assess reasons for Tb to susceptible to HIV infection at Mbeya zonal referral

hospital

2. To assess control measures to control TB among HIV infected individuals at Mbeya

zonal referral hospital
1.5 RESEARCH QUESTIONS

1. What are reasons for Tb to susceptible to HIV infection at Mbeya zonal referral
hospital

2. What are control measures to control TB among HIV infected individuals at Mbeya
zonal referral hospital

4
 CHAPTER TWO

2.0 Literature Review.

It is estimated 10.4 million TB cases were diagnosed in 2015 of which 1.2 million (11%) TB
cases were associated with HIV worldwide. TB is still the leading cause of mortality among
people living with HIV that accounted for 390,000 (one third) of HIV-associated TB deaths in
2015. Africa region accounted for 75% of all deaths. Globally people living with HIV are 19
times (17 – 22) more likely to fall ill with TB than those without HIV (1) (13). Tanzania is
among 30 countries listed as TB/HIV high Burden Countries based on the 2015 WHO report
(1).The number of people living with HIV (PLWH) who presented with TB and received
treatment for HIV and TB increased from 25.9% in 2012 to 54% in 2013. Nonetheless, there
is still a large portion of people with TB/HIV co-infection without comprehensive treatment
(13).Delays in identifying HIV cases among TB patients leads to delays in offering care and
treatment to those in need hence increase in morbidity and mortality(10), an economic burden
to families and country in terms of health financing and planning.

HIV testing in TB patients is an important route into integrating TB and HIV services
meaning that a new TB diagnosis presents an important opportunity to detect and treat HIV.
Active screening for HIV infection among patients with TB disease is recommended to be
done on a routine basis once the TB diagnosis is made (14). This is crucial in the reduction of
burden of HIV in TB patients thus improving the quality of TB care. There is greater risk of
death for patients with unknown HIV status than patients with HIV negative test results (the
group with unknown HIV sero-status probably contained people with undiagnosed HIV), this
was revealed in another study. Screening for HIV among TB patients has been shown to be
feasible with high acceptability rate (>90%) among patients who were offered this service.
Studies have also revealed a higher prevalence (threefold) of HIV among TB patients
compared with the general population (15) (16).

In 2004, WHO together with United Nations Programmed on HIV and AIDS (UNAIDS)
issued a joint policy statement recommending routine provider-initiated HIV testing and
counselling (PITC) for all TB patients as a standard of care (10). PITC is when health care

Providers offer HIV counselling and testing to all people attending health facilities. This
presents an opportunity to ensure that patients have access to the needed HIV prevention,
treatment, care and support services hence increasing uptake of HIV testing among TB

5
patients. This strategy has enabled TB treatment centers to serve as an important media for
identifying patients with HIV infection hence increasing uptake of HIV testing among TB
patients.

Studies done on acceptability of PITC at TB health facility level revealed a high acceptance
rate (>90%) among patients and willingness to test and receive their HIV status results. They
also showed majority of the health care workers were willing to offer HIV testing services to
TB patients. For patients who did not accept HIV testing their reasons were mainly to wait
until finishing TB treatment and not being able to cope with positive results (16)(17). This
shows that expanding HIV screening services among TB patients is feasible thus scale up of
life saving HIV care and treatment services that coincides with a decline in the risk of death
among patients with TB/HIV co-infections.

It is recommended to emphasize provision of HIV counselling and testing to all TB patients

to ensure proper management and early initiation of ART to TB/HIV co-infected patients in
order to improve treatment outcome and reduce mortality.

HIV testing and counselling acts as a gateway towards accessing care, treatment and
prevention services for HIV/AIDS that includes diagnosis of HIV infection, linkage to care,
initiation of Cotrimoxazole prophylaxis and antiretroviral therapy (ART) to achieve and
maintain viral load suppression status as illustrated in Figure 2 below (18). Most countries
with high burden of TB/HIV infections have policies and guidelines on promoting HIV
testing to all presumptive and confirmed TB cases and initiating ART to all ART naïve
TB/HIV co-infected patients irrespective of their immunological status (CD4 cell count)(19).

Early ART initiation in TB/HIV co-infected patients is needed in order to contribute towards
improving their quality of life. Several studies have attributed early ART initiation to better
treatment outcomes especially in patients with severe immune suppression (CD4 cell
count<50cells/µl) and improved uptake and continuation of ART (20) (21) (22). The

WHO and Ministry of Health Tanzania guidelines recommend TB/HIV co-infected patients to
be initiated on ART within the first 2 weeks of starting TB treatment irrespective of the CD4
cell count or clinical stage (23)(12). This enables scaling up of ART coverage even in low and
middle-income countries where CD4 measurement is not widely available. Much as several
studies have showed ART to TB patients improves survival, when to start ART is still a
debate. Clinicians’ decisions to start ART early in TB/HIV co-infected patients may be
compromised based on their fears of drug-drug interaction, TB-Immune reconstitution
inflammatory syndrome (TB-IRIS), pill burden as well as programmatic challenges (20).

6
However, early ART initiation has been found to lower mortality in TB/HIV patients as
compared to those who started late. This was showed by a meta-analysis evaluation where
122 deaths occurred in the early ART initiation group and 155 deaths occurred in the delayed
ART initiation group (pooled IRR =0.75, 95%CI: 0.59 to 0.95) (24) (25).

With the presence of both WHO guidelines and national guidelines supporting co-
management of TB/HIV patients, ART initiation is still deferred until completion of the first 2
months of TB treatment. Several barriers have been associated with early ART initiation
including poor integration between Inpatient and Outpatient HIV and TB care, lack of trained
staff during weekends, and lack of awareness and/or acceptance of new WHO guidelines was
cited in a study done in Buganda hospital (26). However, such barriers can be tackled through
continuing medical education for healthcare workers.

ART usage in HIV infected patients is attributed with reduction of risk of TB disease by
approximately more than 50% (27). Other benefit of early ART to TB patients with CD4
count <50 cells/µl was reduction of mortality as shown in a study done in Kenya (21). A
study done in South Africa revealed uptake of ART during TB treatment was significantly
associated with improved mortality rates (28). This was inconsistence with another study in
Rwanda that showed an increased risk of death during anti-TB treatment for people living
with HIV.

There has been marked reduction in TB mortality with increase in ART coverage among high
TB/HIV burden countries (29) (9). However other studies showed no difference or increase in
mortality rate in spite of high ART coverage among TB/HIV co-infected patients (28) (30).
This could be as a result of other confounding factors contributing towards high case fatality
rate among TB/HIV co-infected individuals.

Improved data management system in terms of linkage between HIV documentation and TB
data has been associated with increase in uptake of HIV identification, care and treatment
among patients with TB disease (31). All the above stresses the importance of routine HIV
testing that aids in minimizing delays in HIV diagnosis in addition to initiation of ART to
reduce the risk of death among TB/HIV co-infected patients. This can effectively be achieved
through integrated TB/HIV services. In order for the integration of TB/HIV services to be
successful, a multi-disciplinary approach has to be applied. Management of TB/HIV co-
infections remains a major problem especially in sub-Saharan Africa, causing challenges to
HIV programmers in terms of infection control and risks of TB transmission and acquisition
to the HIV population.

7
Hence a drive towards integrated services for TB and HIV infections (10) i.e. providing
services for both infections at the same health facility. This has been associated with scale up
of HIV screening services and ART uptake in TB facilities (16) (32).

The integration process involves relocation of clinics under one roof or in close proximity,
improving staff interaction, TB/HIV focal person, pharmacy services (TB, ART, CPT and
other drug refills), laboratory services (HIV testing, sputum examination and other laboratory
tests), synchronized clinic appointment dates, training and mentorship, supervision as well as
joint record keeping (10)(33).

The lack of knowledge and skills of health providers on TB/HIV co-management, under-
staffing, lack of infection control measures, lack of guidelines on TB/HIV co-management,
lack of laboratory technicians amongst others were identified as hindrance towards provision
of TB/HIV integrated services. However, strengthening of infrastructure and improving
health care worker capacity can improve integration of TB/HIV services (34) (35).

In the view of patient perspective, receiving mixed information regarding co-management of

the diseases, challenges in coordinating TB and HIV appointments and reluctance to disclose
HIV status to non-HIV health providers unless asked were some of challenges identified. In
spite of this, majority of patients prefer to access TB and HIV care from a single health
facility (36).

Different measures especially at the health facility level have to be put in place to facilitate
effective implementation and strengthening of integration of TB/HIV services in order to
deliver health care services effectively and efficiently to patients co-infected with TB and
HIV
.
Currently, about 1.1 million HIV-positive people have also developed Tuberculosis (TB). 1 of
these; about 80% of them belong to Sub-Saharan Africa.1 Among the people living with the
human immune deficiency virus (HIV), about 380,000 of them are dying because of the
development of TB in addition to HIV.2 On the other hand, an estimated number of 36 million
people lived with HIV globally in 2017.3 Approximately, one-third of these people are being
co-infected with TB.3

Ethiopia is one of the Sub-Saharan African countries with the high development of TB
among people living with HIV.4 This accounts for the country to be 10th in the world and 4th
in Africa, after Nigeria, South Africa, and the Democratic

8
Republic of Congo.4 About 85% of the country’s population is living in rural areas with low
living standards, where TB is highly distributed.5

Amhara region, one of the regions in Ethiopia, has about 30% of the people living with
HIV, followed by the Oromia region (26%). 6 Research conducted previously declared that TB
development is high in areas where there is a great prevalence of HIV but with poor
adherence.7 Hence, people living with the human immune deficiency virus (PLWHIV) in the
region are also extra vulnerable to TB development. 8 HIV is the first and TB is the second
important reason for death from infectious illness in the region.9

Even though studies have been conducted on the development of TB in HIV-infected

people in Ethiopia, risk factors for the development of TB in HIV patients with
comprehensive data at the regional level are not conducted in the study area. 10 Studies
including the large mass of data with many treatment sites may reveal evidence-based
information as compared to data taken from a single treatment site.11

As far as our knowledge is concerned, there is a shortage of regional wide research done
recently on factors affecting the development of TB among HIV-infected adults under
HAART in the study area.12 Therefore, this research has been conducted with the objective to
investigate factors affecting the development of TB among HIV patients under treatment
followed in 17 government hospitals in the region. The current investigation also aimed to
triangulate whether previously identified factors in developed countries also worked in the
study area (low-income country). It is anticipated that the finding in this investigation will be
used as the source of information for the knowledge that promotes HIV/TB program planners,
decision-makers, and project implementers.
Both TB and HIV drastically affect the host’s immune system because they can evade
immune surveillance and clearance, although the mechanism is not fully under-stood [6]. In
individuals co-infected with HIV and TB, the two pathogens potentiate each other and
accelerate the deterioration of immunological functions, resulting in poor outcomes [6].
Compared with that in non-HIV-infected populations, the risk of latent TB activation in-
creases 20-fold in HIV-infected patients [7]. TB infection has also been reported to
exacerbate HIV replication [8]. With TB infection, the cytokines induced by immune
responses could enhance the replication of HIV and accelerate AIDS progression [9]. For this
reason, TB infection has been one of the most common causes of death in HIV-infected

9
patients, accounting for 26% of AIDS-related deaths [7, 10], almost (99%) of which occurred
in developing countries [6].

Even in the era of combination antiretroviral therapy (cART), TB infection still places a
great burden on people living with HIV (PLWH) in mainland China, a developing country.
As revealed in a meta-analysis including 29 studies conducted in mainland China, the overall
prevalence of TB infection among PLWH was estimated to be 7.2% (range: 4.2%–12.3%)
and was even

CHAPTER THREE

3.0 METHODOLOGY

3.1 Chapter overview

This chapter includes the description of research design, location of the study, study
population, sample and sampling process, sample size and recruitment procedures. Also it
describes the data collection methods, methods for ensuring validity and reliability, Data
analysis methods, Ethical consideration including informed consent, confidentiality issue,
risk-benefit analysis, protection of human subject and dissemination of results and over all
limitation of the study.

3.2 Study area

The study will be conducted at Mbeya Hospital in s situated 20km east of Mbeya,
one of the largest cities in Tanzania, in southwestern highlands. It was opened as a
mission hospital from the Mbalizi Evangelistic Church (MEC) beginning of 2007
because the previous smaller hospital was always overcrowded Mbeya Region is
one of Tanzania's 31 administrative regions. The region covers an area of 35,954
km2 (13,882 sq mi) and 33 26 59.99 E latitude 8 53 59 99 E. The region is
comparable in size to the combined land area of the nation state of Guinea Bissau.
Mbeya Region is bordered to the east by Singida Region, Iringa Region and Njombe
Region. The region is bordered to the south by Malawi and Lake Nyasa.To the north
the region borders southern Tabora Region. Lastly, Mbeya is bordered to the west
by Songwe Region. The regional capital is the city of Mbeya. According to the
2022 national census, the region had a population of 2,343,754(National beural of
statistic 2022)

10
3.3 Research design
The study will use cross sectional study design which will help to collect data from large
population or group of people at a short period of time from various respondents from
Mbeya zonal referral hospital.

3.4 Methods of data collection

Structured questionnaire as a primary data collection method will employ in data collection,
questionnaires will be used because a lot of information’s will be collected within a short
period of time with minimal resources.
3.5 Data collection tools and methods

Questionnaires will be used as a tool of data collection with open and closed ended
questions and will be self-administrative paper-pen questionnaire, where the participants
will be reading and answering the questions by themselves and then submitting it to the
researchers. Questionnaires on Swahili will be used for the handling of data because this is
the common language to most of people in the study.

3.6 Sampling technique

The procedure that will be used in research is based on non-probability random
sampling; stratified sampling will be used to select respondents.

During sampling process, stratified sampling technique will be used to select sample
because the participants have different key characteristic, by using this technique, each
individual from each stratum will have an equal chance of being selected in the study.

Lottery method will be used where each member of the population will be assigned a
number. There after the numbers will be written on separate pieces of paper. These pieces
of paper will be mixed and placed into a box and the numbers of assigned People will be
drawn out of the box in a random manner. Regarding the nature of a study population, each
individual who will meet criteria from particular university and college will be chosen
randomly.

3.7 Data collection tools and methods

Questionnaires will be used as a tool of data collection with open and closed ended questions and will
be self-administrative paper-pen questionnaire, where the participants will be reading and answering
the questions by themselves and then submitting it to the researchers. Questionnaires on English will
be used for the handling of data because this is the common language to most of people in the study.

3.8 Methods for ensuring validity and reliability.

11
3.8.1 Reliability
To ensure the consistence of the results in this study, adopted structured questionnaire will
be assessed by a research supervisor to determine if it will be effective to enhance
comprehensive collection of information required. Before being administered, the
questionnaire will be pre-tested by 20 students of college student at Mbalizi institute of
health science to evaluate the prepared adopted structured questionnaire to determine any
error and time consumed to obtain answers from respondents. To know any areas of the
questionnaire that will be inadequate.

3.8 .1 Validity
In this study, the validity will be ensured by accommodating comments from supervisor and
look for the answers of pre-tested respondents by comparing it with other research to find
out whether the information that will be given will be consistent with the information
expected. During the analysis of the data, the validity of the findings will be done by
dismissing the responses that will not be compatible with the responses given by the
particular respondent.

3.9 Data analysis methods and plan

Data collected from the study will be computerized and followed by data analysis by using
the SOCIAL PACKAGE FOR STATISTICAL SCIENCE (SPSS) VERSION 23.
Questionnaires will be checked for completeness and errors will be rectified before being
processed.

3.10 Ethical considerations

The study will be anonymous; informed consent will be obtained from all participants after
explaining the aim of the study before administering the questionnaires. Permission to
conduct the study will be sought from collage administration office and finally the ethical
clearance will be obtained from Mbalizi institute of health science ethical committee before
starting the research. To ensure confidentiality, names will not be used instead; numbers
will be used to locate participants for the purpose of gathering information. Participants will
be free to accept or not to accept from being in the study

3.11 Plans for dissemination of research results

The results of this study will be disseminated to the universities for educational purpose and
the ministry of health for policy making and the publication.

12
3.12 Limitations and delimitations of the study

Limitation of the study

The well-known issue of religious beliefs and knowledge deficit attached to Reproductive
Health Education and collage Especially Family planning methods and their use, will hinder
some of the respondents from giving consent and participating freely on the study. Counsel
the participants on the importance of the study to their health and still insist on the
objectives of the study.

Delimitation of the study

The data collected from the study will be important to the university students and the
Ministry of Health as it will enlighten challenges or barriers in accessing Reproductive
Health education among university students.

3.13 Chapter summary

This chapter described the research methodology of this study, explaining the Selection of
sample, describing the procedure used in designing the instruments and Collecting data and
provide an explanation of the statistical procedures used to analyze Data.

13
 REFERENCES:

1. World Health Organization (WHO). Global Tuberculosis Report 2016. 2016.

2. Pustil R. Global AIDS. Aids. 2016;17 Suppl 4:S3-11.

3. AIDS (TACAIDS) Tanzania Commission for HIV/AIDS and Malaria Indicator

Survey 2011–12, Tanzania. Dar es Salaam, Tanzania: Tanzania 2013. 103-110 p.

4. Narasimhan P, Wood J, Macintyre CR, Mathai D. Review Article Risk Factors for
Tuberculosis. Pulm Med. 2013;2013.

5. Kirenga BJ, Ssengooba W, Muwonge C, Nakiyingi L, Kyaligonza S, Kasozi S, et al.

Tuberculosis risk factors among tuberculosis patients in Kampala, Uganda:
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8. Nagu TJ, Aboud S, Mwiru R, Matee MI, Rao M, Fawzi WW, et al. Tuberculosis
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2015.
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 APPENDICES

Appendix 1: Informed consent form (English version)

MBALIZI INSTITUTE OF HEALTH SCIENCE

CONSENT FORM

Greetings, my name is MAYUFE RAMAFHANI, I am from Mbalizi institute of health

science objective of PREVALENCE OF TUBERCULOSIS AMONG HIV INFECTED
INDIVIDUAL ATTENDING CTC CLINIC AT MBEYA REFERRAL HOSPITAL

Purpose of the study

The purpose of this study is to determine the prevalence of tuberculosis among hiv infected
individual.

What participation involves.

If you agree to participate in this study you will be required to answer a series of questions
that have been prepared for the study through interview.

Confidentiality.

All information collected from you will be kept confidential and used only for this study.
Your name will not be used anywhere in the interview guide. Only authorised persons will
have access to the data collected. They study will need to write a report of its findings.
Code names and group summaries will be presented.

17
 Risks.

This study involves no invasive procedures so we expect that no physical harm will be
done to any participants.

Benefits.

If you agree to participate in this study, the information collected from this study will be
beneficial to you, health care workers in Tanzania. It will also improve the quality of
health services resulting in improved quality of life for people with TB/HIV co-infections.

Right to withdraw and alternatives

Participation in the study is entirely voluntary. You have a choice to participate or not to
participate in the study and to quit at any time you feel to do so if you agree to participate.
Refusal to participate or withdraw from the study will not involve penalty or loss of any
benefit.

In case of injury

We do not anticipate that any harm will occur to you or your family as result of
participating in this study. There will therefore be no compensations to you or your family.

Who to contact

If you ever have any questions about this study you may ask those now or later. In case
you wish to find out more or ask any questions later, you may contact any of the following:

1. The principal investigator Mayufe Ramadhani, Mbalizi institute of health science,

P.O. Box 6117 Mbeya.

This proposal has been reviewed and approved by the Mbalizi institute of health science
.

18
Agreement:

Do you agree to participate in this study? Yes…… No…... (Tick that applies)
If you agree to participate in this study, please fill in the form below
I __________________________________________ have been explained the contents in

this form and my questions have been answered. I agree to participate in the study. Signature

of Participant___________________________ Date ____________________ Signature of

Research

19
Appendix 2: Informed consent form (Swahili version)

TAASI YA AFYA ZA SAYANSI MBALIZI

KURUGENZI YA UTAFITI NA MACHAPISHO

FOMU YA RIDHAA

Namba ya Mshiriki ----/----/----

Habari za leo! Jina langu ni MAYUFE RAMADHANI natoka Taasisi ya afya za sayansi
Mbalizi nafanya utafiti huu kwa lengo la KUFAHAMU KIWANGO CHA USHIRIKIANO
WA HUDUMA ZA VVU KATIKA KLINIKI ZA KIFUA KIKUU NA MAMBO
YANAYOHUSIANA KATIKA HOSPITAL YA RUFAA YA KANDA NYANDA ZA JUU
KUSINI 2023.

Lengo la utafiti

Lengo la utafiti huu ni kufahamu kiwango cha watu walioambukizwa ugonjwa wa tb

wanaoishi na ukimwi

Nini kitakacho ambatana

Kama utakubali kushiriki kwenye utafiti huu utahitajika kujibu baadhi ya maswali
yaliyoandaliwa kwa utafiti kupitia mahojiano.

Usiri

20
 Taarifa zote zitakazokusanywa kutoka kwako zitawekwa kwa usiri na kutumika tu kwa ajili ya
utafiti huu. Watu husika tu watakuwa na uwezo wa kufikia data zilizokusanywa. Utafiti huu
unahitaji kuandika ripoti ya matokeo yake. Kanuni za majina na muhtasari wa makundi
utawasilishwa.

Madhara

Utafiti huu hauhusishi kitendo chochote cha kudhuru mwili wako kwa hiyo hatutegemei
mshiriki yeyote kupata madhara ya kimwili.

Faida

Kama utakubali kushiriki katika utafiti huu itakuwa ni vyema kwa vile taarifa utakazotoa
zitasaidia katika kuchangia uboreshaji wa huduma yako, wafanyakazi wa afya wa Tanzania.
Pia kuongeza ubora wa huduma za afya na kusababisha kuboresha hali ya maisha ya watu
wenye maabukizo ya virusi vya ukimwi pamoja na kifua kikuu.

Haki ya kushiriki au kujitoa au vinginevyo

Ushiriki katika utafiti huu ni wa hiari kabisa. Wewe una uchaguzi wa kushiriki au
kutokushiriki katika utafiti na kuacha wakati wowote ukijisikia kufanya hivyo kama wewe
utakubali kushiriki. Kutoshiriki au kujitoa kutoka kwenye utafiti hakutakuwa na adhabu
yeyote na hutapoteza stahili zako, ambapo utaona ni vema kufanya hivyo.

Endapo utapata madhara

Hatutegemei kama utapata madhara yoyote wewe au familia yako kutokana na kushiriki kwako
katika utafiti huu. Hakutakuwa na fidia yoyote kwako au kwa familia yako.

Nani wa kuwasiliana nae

21
 Kama utakuwa na maswali yoyote kuhusu utafiti huu, unaweza kuyauliza sasa au hata wakati
mwingine. Ukitaka kuelewa Zaidi au kuuliza maswali wakati mwingine unaweza kuwauliza
wafuatao:

1. Mtafiti mkuu wa utafiti huu Mayufe Ramadhani, Taasisi ya sayansi za afya

Mbalizi, P. O. Box 6117, Mbeya.
s
Huu utafiti umehakikishwa na kuhidhinishwa na Kamati ya Maadili ya Utafiti ya taasisi ya
afya ya sayansi Mbalizi Chuo Kikuu cha Sayansi ya Afya

Je, unakubali kushiriki katika utafiti huu? Ndiyo____ Hapana____ (weka alama ya

tiki)
Ukikubali kushiriki katika utafiti huu, tafadhali jaza fomu hapa chini

Mimi _______________________________________nimeelezwa yaliyomo yote katika

fomu hii na maswali yangu yote yamejibiwa. Nakubali kushiriki katika utafiti huu.

Sahihi ya mshiriki _______________________ Tarehe_________________________ Sahihi

ya mtafiti msaidizi ______________________ Tarehe___________________

22
Appendix 3: Data extraction form

S/No Question Response Code

1. Name of health facility ________________________ NAMEHF

2. Date when data extraction was ___/___/______ (dd/mm/yyyy) INTERVDATE

done


Section A: Place an X or fill in the space with the most correct information

3. ID ____________ PID

4. Date patient diagnosed with TB ___/___/______ (dd/mm/yyyy) DATEDIAGN

5. Date of registration ___/___/______ (dd/mm/yyyy) DATEREG

6. Age of patient _____________ years AGE

1. Male ☐
7. Sex of patient SEX
2. Female ☐

1. Pulmonary TB ☐
8. Type of TB TYPETB
2. Extra-pulmonary TB ☐

9. Was the patient tested for HIV HIVTEST

1. Yes ☐
2. No ☐

23
10. If patient was tested for HIV, DATEHIVTEST
what was the date of testing?
___/___/______ (dd/mm/yyyy)

11. If the patient was tested for HIV, 1. Positive ☐ HIVSTATUS

what was the diagnosis? 2. Negative ☐

12. Was the patient informed of his 1. Yes ☐ KNOWHIV

HIV status 2. No ☐

13. Was the patient started on 3. Yes ☐ COTRIMOX

Cotrimoxazole prophylaxis 4. No ☐

14. What date was the patient started ___/___/______ (dd/mm/yyyy) DATECOTRIMOX
on Cotrimoxazole

15. Was the patient started on ART? 1. Yes ☐ ART

2. No ☐

16. What date was the patient started ___/___/______ (dd/mm/yyyy) DATEART
on ART?

17. Was CD4 count done? 1. Yes ☐ CD4

2. No ☐

24
18. What date was CD4 count done ___/___/______ (dd/mm/yyyy) DATECD4

19. What were the CD4 count results __________________/μL RESCD4

20. Was the viral load done 1. Yes ☐ VIRALOAD

2. No ☐

21. What date was viral load done ___/___/______ (dd/mm/yyyy) DATEVIRALOAD

22. What were the viral load results __________________/ml RESVIRALOAD

25