PREVALENCE OF COMMORBIDITY BETWEEN HIV/AIDS AND TUBERCULOSIS

AMONG ADULT PATIENTS SEEKING MEDICAL CARE AT THIKA LEVEL 5

HOSPITAL

BY

EDWIN LUKALIA BSLT/2020/90698

DOUGHLAS KIMANI BSLT/2020/68613

DIANA CHEPKOECH BSLT/2020/89875

OMANYALA SHADRACK BSLT/2020/92207

A RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILMENT FOR THE

AWARD OF BACHELOR OF SCIENCE IN LABORATORY TECHNOLOGY

SEPTEMBER 2023
 DECLARATION

We hereby declare that this work is our own original work and that it has never been presented

for the fulfillment of any Bachelor degree in any institution to the best of our knowledge

EDWIN LUKALIA BSLT/2020/90698

Signature: ……………….Date………………………………….

DOUGHLAS KIMANI BSLT/2020/68613

Signature: ……………….Date………………………………….

DIANA CHEPKOECH BSLT/2020/89875

Signature: ……………….Date………………………………….

OMANYALA SHADRACK BSLT/2020/92207

Signature: ……………….Date………………………………….

RECOMMENDATION BY THE SUPERVISORS

I hereby confirm that this research project was prepared under my supervision and has my

approval to be presented for the examination as per the examination regulations of Mount Kenya

University

Signature: ……………………………… Date……………………………………

M.s Prisca Tanui

Department of Natural Sciences

MOUNT KENYA UNIVERSITY,

ii
 ACKNOWLEDGEMENT

Our sincere and profound gratitude goes to the Almighty God for His Unconditional love to us,

His merciful protection and guidance in our studies.

Our special appreciation goes to our supervisor M.s. Prisca Tanui for her valuable ideas, advice,

support, constructive and critical comments as well as her unconditional sacrifice she made

towards the success of this work

iii
 ABSTRACT

HIV infection is a potent risk factor for tuberculosis. Not only does HIV increase the risk of
reactivating latent mycobacterium tuberculosis (MTB) infection, it also increases the risk of
rapid TB progression soon after infection or reinfection with MTB. In persons infected with
MTB only, the lifetime risk of developing TB ranges between 10% and 20%. In persons co-
infected with MTB and HIV, however the annual risk can exceed 10%. The TB burden in
countries with a generalized HIV epidemic has therefore increased rapidly over the past decade,
especially in the severely affected countries of eastern and southern Africa. Tuberculosis is one
of the most common cause of morbidity and the most common cause of death in HIV-positive
adults living in less-developed countries, yet it is preventable and treatable disease (Singh et al.,
2020). It is possible that, in addition to the increasing individual susceptibility to TB following
MTB infection, the increased burden of HIV-associated TB cases also increases MTB
transmission rates at the community level, threatening the health and survival of HIV-negative
individuals as well. In several countries HIV has been associated with epidemic outbreaks of TB,
and many of the reported outbreaks involved multidrug-resistant strains responding porly to
standard therapy (Hamada et al., 2021). The study was carried out at Thika Level 5 hospital,
Kiambu county as with the main objective was prevalence of comorbidity between HIV/AIDS
and tuberculosis among adults attending the hospital. This study used a descriptive cross-
sectional study where adults living with HIV/AIDS will be sampled using convenience sampling
technique. The specimens for malaria will be sputum specimen examined by AFB smears stained
by Ziehl-Neelsen staining, culture and the Mycobacterium Tuberculosis / Resistance to Rifampin
Assay. For HIV, blood specimen is analysed through HIV p24 antigen assay, Enzyme Linked
immunosorbent assay and confirmed by western blot. The study found out that the prevalence of
TB was found to be 25% with positive cases of TB with negative cases accounting for 75% of
study respondents. Majority of the respondents indicated that the house was poorly ventilated
(45%), 40% indicated that house they were living in was moderately ventilated with the least
(15%) indicating that their houses were excellently ventilated. Majority of the respondents
indicated that Lack of Antiretroviral Therapy was the leading risk factor of contracting TB at
35%, 30% cited a weak immune system as a risk factor of TB, with 20% arguing that
malnutrition was a risk factor of TB with least indicating that smoking was a risk factor of
contracting TB at 15%. Majority of the respondents indicated that Chamas would be good
avenues to provide education on TB & HIV/AIDS (60%), 15% indicated that workshops and
seminars would provide more education with 10% indicating that medical camps create more
awareness on the comorbidity of TB & HIV/AIDS. The study recommends that The study
recommends use of programs aimed at strengthening the gender capacity of health care
providers, HIV testing counselors and community health workers through avenues such as
occupational training materials. This would provide workers with TB prevention, screening and
treatment literacy as a routine part of their work with women, particularly in areas with high HIV
prevalence. The study recommends development of targeted interventions to address behavioral
risk factors such as smoking, which increases vulnerability to TB. They may implement anti-
smoking campaigns and provide resources for smoking cessation. The study recommends further
study on the research topic which may provide additional information on where other studies
may be referenced from.

iv
v
 TABLE OF CONTENTS

ACKNOWLEDGEMENT...........................................................................................................iii
ABSTRACT..................................................................................................................................iv
TABLE OF CONTENTS..............................................................................................................v
LIST OF TABLES......................................................................................................................viii
LIST OF FIGURES......................................................................................................................ix
LIST OF ABBRAVIATIONS.......................................................................................................x
CHAPTER ONE............................................................................................................................1
INTRODUCTION.........................................................................................................................1
1.1 Background information............................................................................................................1
1.2 Statement of the problem...........................................................................................................3
1.3 Justification................................................................................................................................3
1.4 Objectives of the study..............................................................................................................4
1.4.1 Broad objective.......................................................................................................................4
1.4.2 Specific objective....................................................................................................................4
1.5 Research questions.....................................................................................................................4
CHAPTER TWO...........................................................................................................................5
LITERATURE REVIEW.............................................................................................................5
2.1 Epidemiology of Tuberculosis...................................................................................................5
2.2 Transmission of Tuberculosis....................................................................................................5
2.3 Pathogenesis of Tuberculosis....................................................................................................6
2.4 Laboratory Diagnosis of Tuberculosis.......................................................................................8
2.5 Prevention and Treatment..........................................................................................................9
2.6 Epidemiology of HIV/AIDS......................................................................................................9
2.7 Pathogenesis of HIV/AIDS......................................................................................................11
2.8 Laboratory diagnosis of HIV/AIDS.........................................................................................12
2.9 Prevention and Treatment of HIV/AIDS.................................................................................13
CHAPTER THREE.....................................................................................................................15
MATERIALS AND METHODS................................................................................................15
3.1 Study Area...............................................................................................................................15
3.2 Study design.............................................................................................................................15

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3.3 Study population......................................................................................................................15
3.4 Inclusion and Exclusion Criteria.............................................................................................15
3.4.1 Inclusion criteria...................................................................................................................15
3.4.2 Exclusion Criteria.................................................................................................................15
3.5 Sample size determination.......................................................................................................16
3.5 Sampling Technique................................................................................................................16
3.6 Data collection.........................................................................................................................16
3.7 Specimens................................................................................................................................17
3.8 Specimen processing and Laboratory investigation................................................................17
3.8.1 HIV diagnosis.......................................................................................................................17
3.8.2 Tuberculosis diagnosis..........................................................................................................18
3.9 Data analysis and storage.........................................................................................................19
3.10 Data presentation...................................................................................................................19
3.11 Ethical consideration.............................................................................................................19
CHAPTER FOUR: RESULTS...................................................................................................20
4.1 Bio Data...................................................................................................................................20
4.1.1 Gender of the Respondent....................................................................................................20
4.1.2 Residence..............................................................................................................................21
4.1.3 Education Level....................................................................................................................22
4.1.4 Family History of TB............................................................................................................23
4.2 Prevalence of TB.....................................................................................................................24
4.2.1 Cases of TB & HIV/AIDS....................................................................................................24
4.2.2 Type of Tests Done...............................................................................................................25
4.3 Risk Factors contributing to TB and HIV/AIDS.....................................................................26
4.3.1 Previously History of TB......................................................................................................26
4.3.2 House Ventilation.................................................................................................................27
4.4.3 Individual Factors of TB among HIV/AIDS Patients...........................................................28
4.5 Ways of Creating Awareness on TB & HIV/AIDS.................................................................29
4.5.1 Education on TB & HIV/AIDS............................................................................................29
4.5.2 Source of Information...........................................................................................................30
4.5.3 Possible avenues that may improve education.....................................................................31
CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS............32

vii
5.1 Discussion................................................................................................................................32
5.2 Conclusion...............................................................................................................................34
5.3 Recommendations....................................................................................................................34
REFFERENCES..........................................................................................................................35
APPENDICES..............................................................................................................................37
Appendix I: Questionnaire.............................................................................................................37
Appendix II: Work plan................................................................................................................39
Appendix III: Budget.....................................................................................................................40

viii
 LIST OF TABLES
Table 1: Gender of the Respondents..............................................................................................20
Table 2: Residence of the Respondent...........................................................................................21
Table 3: Education Level...............................................................................................................22
Table 4: Family History of TB infection.......................................................................................23
Table 5: Prevalence of TB.............................................................................................................24
Table 6: Types of Tests..................................................................................................................25
Table 7: Do you have a previous history of TB.............................................................................26
Table 8: Status of the House Ventilation.......................................................................................27
Table 9: Risk Factors of TB...........................................................................................................28
Table 10: Whether one has ever received education on TB & HIV/AIDS...................................29
Table 11: Source of Information....................................................................................................30
Table 12: Possible avenues that may improve education..............................................................31

ix
 LIST OF FIGURES
Figure 1: Gender of the Respondents............................................................................................20
Figure 2: Residence of the Respondent.........................................................................................21
Figure 3: Education Level.............................................................................................................22
Figure 4: Family History of TB.....................................................................................................23
Figure 5: Prevalence of TB............................................................................................................24
Figure 6: Types of Tests................................................................................................................25
Figure 7: Previously History of TB...............................................................................................26
Figure 8: Status of House Ventilation...........................................................................................27
Figure 9: Risk Factors of TB.........................................................................................................28
Figure 10: Whether one has ever received education on TB & HIV/AIDS..................................29
Figure 11: Source of Information..................................................................................................30
Figure 12: Possible avenues that may improve education.............................................................31

x
 LIST OF ABBRAVIATIONS

TB………………Tuberculosis
POC……………Point Of Care
CDC -Center for Disease Control and prevention
WHO - World Health Organization
PLHIV -People Living With HIV
ELISA -Enzyme Linked Immunosorbent Assay
EIAs -Enzyme Immunosorbent Assays
WE -Western Blot
ART - Antiretroviral Therapy
MTB - Mycobacterium Tuberculosis
IRIS - Immune Reconstitution Inflammatory Syndrome
TST - TB Skin Test
AFB -Acid-Fast Bacillus
ZN - Ziehl-Neelsen
NAA - Direct Nucleic Acid Amplification
DST - Drug Susceptibility Testing
BCG - Bacillus Calmette-Guerin
RIF - Resistance to Rifampin
MTBC - Mycobacterium Tuberculosis Complex
PMTCT - Prevention of Mother-To-Child Transmission
HAART - Highly Active Antiretroviral Therapy
OIs - Opportunistic Infections
HIV -Human Immunodeficiency Virus
AIDS -Acquired Immune deficiency syndrome
M-BOVIS- myco-bacterium bovis

xi
 CHAPTER ONE

INTRODUCTION

1.1 Background information

Tuberculosis (TB) is a chronic infectious disease mainly caused by mycobacterium tuberculosis

(MTB). Most cases of human tuberculosis are caused by the human tubercle bacillus,

Mycobacterium tuberculosis, but in countries where cattle tuberculosis still occurs human

tuberculosis is also caused by M bovis. In addition, some cases, principally in equatorial Africa,

are caused by a rather heterogeneous group of strains termed M africanum. Though bearing

separate species names, these are really members of a single species often termed the M

tuberculosis complex. Infection usually occurs by inhaling small droplets of cough aerosol, about

5µ in diameter, containing tubercle bacilli. Infection by M bovis is also acquired by drinking

infected milk and the primary lesions occur in the pharynx or intestine. Rarely, infection occurs

by traumatic inoculation of bacilli into the skin, particularly in butchers and others handling the

carcasses of tuberculous animals (Nyasulu et al., 2021).

Tuberculosis and HIV are strongly linked. Whereas people with healthy immune systems may

not fall ill from latent TB infection, people living with HIV with a low CD4 count are much

more susceptible to active TB. In fact, the risk of developing active TB is estimated to be 20

times greater in people living with HIV than in people who are HIV-negative ( Olarewaju et al.,

2023). In 2017, 10 million people developed active TB, 9% of whom were also living with HIV.

Around one-third of the 36.9 million people living with HIV and AIDS worldwide are co-

infected with TB. Sub-Saharan Africa is the hardest hit region, as it is home 70% of all people

living with HIV/TB co-infection in the world (Santos et al., 2022).

1
In 2014, TB surpassed HIV as the world’s leading infectious disease killer, a worrying tread for

an illness that is essentially treatable and curable. In 2017, 1.3 million people died from TB, and

an additional 300,000 TB-related deaths occurred among people living with HIV. It remains the

leading cause of death among people living with HIV (Nyasulu et al., 2021).

Globally, the proportion of people with HIV/TB co-infection who died during treatment in 2017

was 11%, about three times the level among other people with TB (4%). Progress on reducing

TB-related deaths among people living with HIV is being made, as the number of deaths

declined by 100,000 between 2015 and 2017, mainly due to the rapid expansion of antiretroviral

HIV treatment (Nyasulu et al., 2021). The 2016 United Nations Political Declaration on Ending

AIDS includes a goal to reduce TB-related deaths among people living with HIV by 75% by

2020. In addition, all countries belonging to WHO and the United Nations have committed to

ending TB as a public health problem by 2030. To reach this goal, TB deaths must reduce by

90% and incidence of active TB by 80% from 2015 levels. However, progress towards ending

TB is slow, and persistent gaps in preventing, diagnosing and treating TB remains (Shah et al.,

2022).

Kenya ranks 13 of 22 countries with high tuberculosis burden. Based on the first Kenya AIDS

Indicator Survey (KAIS 2007), the population prevalence of HIV infection was 7.1% among

adults and adolescents aged 15-64 years, indicating that Kenya ranked fourth in the world in

number of people living with HIV. The HIV prevalence in tuberculosis patients in Kenya in 2011

was 39%. Implementation of integrated tuberculosis and HIV services has improved

progressively with uptake of HIV testing in tuberculosis clinics increasing from 60% in 2006 to

at least 88% in 2009 (Shah et al., 2022).

2
1.2 Statement of the problem

Tuberculosis (TB) is the most common opportunistic infection among people living with human

immunodeficiency virus (HIV) globally. WHO estimated that around one-third of the 36.9

million people living with HIV and AIDS worldwide are co-infected with TB. Sub-Saharan

Africa is the hardest hit region, as it is home 70% of all people living with HIV/TB co-infection

in the world (Ticha et al., 2022).

Common challenges encountered in the treatment of TB/HIV coinfection include drug

interactions between antiretroviral therapy (ART) agents and anti-TB medications, particularly

rifampin and other rifamycins, a class of drugs that are an essential component of anti-TB

regimens. Potential problems resulting from co-administration of anti-TB therapy and HIV can

include: treatment failure or relapse, drug-induced liver injury, cutaneous adverse drug reactions,

TB-associated immune reconstitution inflammatory syndrome (TB-IRIS), and death (Kimani et

al., 2021). Despite this, research have been carried out on tuberculosis and HIV but no research

have determined association between HIV and tuberculosis among adults at Thika Level 5

hospital.

1.3 Justification

The research on the association between HIV and tuberculosis is very important and necessary so

as to help in appropriate control and prevention of HIV/TB coinfection. In a high-burden setting,

HIV coinfection is the most important risk factor to develop active TB, which dramatically

increases the susceptibility to the primary infection, or reinfection and also the risk of TB

reactivation for patient with latent M. tuberculosis infection (Shah et al., 2022). The result of this

study will therefore help in designing appropriate intervention programs including prevention

3
and management of patients with HIV-associated TB which includes provision of effective anti-

TB treatment, use of concurrent antiretroviral therapy (ART), prevention of HIV comorbidities,

management of drug cytotoxicity and prevention/treatment of immune reconstitution

inflammatory syndrome (IRIS)(Lawn et al.2013). This will therefore help in reducing

tuberculosis burden and the number of HIV/TB associated effects in adults.

1.4 Objectives of the study

1.4.1 Broad objective

To determine the association between HIV and tuberculosis among adults attending Thika Level

5 hospital.

1.4.2 Specific objective

i. To determine the prevalence of tuberculosis in adult patients infected with HIV at Thika

Level 5 hospital, Kenya.

ii. To determine the risk of contracting tuberculosis among patients infected with HIV

infection at Thika Level 5 hospital, Kenya.

iii. To create awareness for the presence of tuberculosis among adults infected with HIV

infection at Thika Level 5 hospital, Kenya.

1.5 Research questions

i. What was the prevalence of tuberculosis among adult patients infected with HIV at Thika

Level 5 hospital, Kenya?

ii. What is the risk of contracting tuberculosis among patients infected with HIV infection at

Thika Level 5 hospital, Kenya?

iii. How to create awareness for the presence of tuberculosis among adults infected with HIV

infection at Thika Level 5 hospital, Kenya?

4
 CHAPTER TWO

LITERATURE REVIEW

2.1 Epidemiology of Tuberculosis

Tuberculosis remains a global threat to public health and is the leading cause of death by a single

infectious agent with 1.6 million deaths in 2017. An estimate of 10 million people developed TB

disease in 2017 but only 6.4 million (61%) were notified (Singh et al., 2020). According to the

WHO, globally in 2012 there were an estimated 8.6 million new cases of active tuberculosis and

1.3 million deaths; therefore there is one new TB case every 4 seconds and more than two TB

deaths every minute. Twenty-two high-burden countries account for 80% of all TB cases, with

India and China alone contributing almost 40% (26 and 12 respectively). The TB incidence per

100,000 varies dramatically, from less than 10 per 100,000 in develop countries such as Japan,

Western Europe and Australia, to rates exceeding 1000 per 100,000 in South Africa and

Swaziland (WHO 2014).

Kenya conducted the last national TB prevalence survey in 1958 and has relied on estimates

from WHO to extrapolate TB incidence and case detecting rates. At that time, the prevalence of

TB was 3,142 per 100,000 population. In 2015, the county’s pre-TB prevalence survey incidence

of TB was 233 per 100,000 while the country was estimated to detect 80% of all TB cases

(Olarewaju et al., 2023).

2.2 Transmission of Tuberculosis

Transmission of TB is by inhalation of infectious droplet nuclei containing viable bacilli (aerosol

spread). Mycobacteria-laden droplet nuclei are formed when a patient with active pulmonary TB

5
coughs and can remain suspended in the air for several hours. Sneezing or singing may also

expel bacilli. Factors influencing the chance of transmission include the bacillary load of the

source case (sputum smear-positive or lung cavities on chest radiograph), as well as the

proximity and duration of exposure (Olarewaju et al., 2023). Transmission is dramatically and

rapidly reduced with effective treatment (Singh et al., 2020). In general, the risk of infection

among household contacts of TB patients is ~30 %.

2.3 Pathogenesis of Tuberculosis

For reasons not clearly understood, the majority of individuals infected with M.

tuberculosis (~90 %) do not develop disease. Following inhalation of M. tuberculosis an

individual may have one of the following outcomes: (1) fail to register an infection, (2) become

infected but then clear the infection, (3) successfully contain the infection but continue to

harbour bacilli in the absence of symptomatic disease (latent TB infection), or (4) develop

progressive TB disease (Hamada et al., 2021). It has been estimated that one-third of the world

population have latent TB infection and may be at risk to develop TB disease as they age, or

become immunocompromised in the future. The factors resulting in reactivation of latent TB

infection in the absence of overt immune suppression are not well understood, but the huge

reservoir of individuals with latent TB infection represents a major barrier to TB elimination

(Hamada et al., 2021).

The cycle of TB infection begins with dispersion of M. tuberculosis aerosols. A dose of one to

10 bacilli are dispersed throughout the air, making the risk of transmission likely. In the patient’s

lung, the bacilli are phagocytized by alveolar macrophage cells, which then invade the

underlying epithelium. Here, monocytes from nearby blood vessels form the beginning of a

6
granuloma, as the immune system attempts to ward off the disease. This is a hallmark

characteristic of tuberculosis.

Within the granuloma, a core of infected macrophages is surrounded by foamy macrophages,

mononuclear phagocytes, and lymphocytes. The result is a fibrous capsule with increased foamy

macrophages, presumed to create the typical caseous debris (necrotic tissue resembling cheese)

in the center of the granuloma. Although it appears contained immunologically, the caseous

center tends to liquefy and cavitate as it empties thousands of M. tuberculosis bacilli into the

airway (Singh et al., 2020). The cycle is complete as the damaged lungs produce a cough that,

once again, contains the highly transmissible infectious droplet nuclei.

Infected macrophages may be carried by the lymphatic system to the lungs, lymph nodes,

kidneys, epiphyses of the long bones, and other areas of the body. Infected macrophages may

also be carried in the blood of an immunocompromised host. After three to eight weeks, despite

widespread infection, there are no immediate symptoms or signs other than a positive TB skin

test (TST). In children, the elderly, non-white races, and AIDS patients, the disease progresses

quickly to pneumonia from hilar or mediastinal lymph nodes to cavitation in the bronchi. It is

here that the distribution of caseous material occurs, such as in acute miliary TB (disseminated

disease) or TB meningitis, particularly in children. Patients infected at ages over 30 years and

less than 65 years have a better prognosis compared to children, adolescents, young adults, and

the elderly because they have a lower risk of tissue necrosis (Hamada et al., 2021).

In general, hypersensitivity develops during the three-to-eight week period after infection,

signaling the action of cellular immunity and control of the infection. At this time, a skin test

reaction will be positive indicating latent infection exists. However, as previously stated, in high

7
risk groups, progression of disease to cavitation in the lung and hematogenous dissemination are

likely to occur.

2.4 Laboratory Diagnosis of Tuberculosis

Smear AFB Microscopy-The sputum specimens are smeared directly onto the slides (direct

smears) and subjected to Ziehl-Neelsen (ZN) staining (Expert Rev Anti Infection Ther.2007).

The sensitivity of conventional microscopy ranged from 32 to 94% and that the sensitivity of

fluorescence microscopy ranged from 52 to 97%, with the fluorescent method being on average

10% more sensitive than light microscopy (Röltgen et al., 2021). For HIV-positive patients, two

studies reported between 26 and 100% increases in the detection of AFB using fluorescence

microscopy. TB diagnosis by smear microscopy is usually confirmed by culture, followed by the

identification of the MTBC strain and drug susceptibility testing (DST) (Röltgen et al., 2021).

Direct nucleic acid amplification (NAA) testing of diagnostic specimens can reduce the overall

turnaround time for the laboratory diagnosis of tuberculosis by at least 2 to 4 weeks compared to

conventional growth detection. Growth Detection of TB in Culture-Culture is more sensitive

than AFB smear microscopy for the detection of M. tuberculosis. M. tuberculosis will grow

aerobically on a protein enriched medium, e.g. Lowenstein Jensen egg medium. The optimal

temperature for growth is 35–37 ºC. The organism is slow-growing. When cultured on

Lowenstein Jensen medium at 35–37 ºC, M. tuberculosis produces raised, dry cream (buff )

coloured colonies. Visible colonies are usually produced 2–3 weeks after incubation, but cultures

should be incubated for up to 6 weeks before being discarded (Röltgen et al., 2021).

Serology-These technologies are very attractive candidates for the simple, accurate, inexpensive,

and, ideally, point-of-care (POC) diagnosis of TB. The Xpert MTB/RIF Assay-is a new test that

8
is revolutionizing tuberculosis control by contributing to rapid diagnosis of TB and drug

resistance. The test simultaneously detects mycobacterium tuberculosis complex (MTBC) and

resistance to rifampin (RIF) in less than 2 hours. X‐ray also has a role for diagnosing TB if smear

–ve

2.5 Prevention and Treatment

Preventing Latent TB Infection from Progressing to TB Disease-Many people who have latent

TB infection never develop TB disease. But some people who have latent TB infection are more

likely to develop TB disease than others (CDC, 2016). Preventing Exposure to TB Disease-

should avoid close contact or prolonged time with known TB patients in crowded, enclosed

environments (for example, clinics, hospitals, prisons, or homeless shelters) (CDC, 2016). Finish

your entire course of medication-this is the most important step you can take to protect yourself

and others from tuberculosis. When you stop treatment early or skip doses, TB bacteria have a

chance to develop mutations that allow them to survive the most potent TB drugs. The resulting

drug-resistant strains are much more deadly and difficult to treat (Longo DL, et al, 2015).

Vaccinations-in countries where tuberculosis is more common, infants often are vaccinated with

bacillus Calmette-Guerin (BCG) vaccine because it can prevent severe tuberculosis in children.

Protect your family and friends-If you have active TB, stay home, ventilate the room, cover your

mouth when coughing to prevent spreading MTB bacteria (CDC, 2015).

2.6 Epidemiology of HIV/AIDS

The HIV epidemic has shifted over the past 30 years, from the first reported cases in the early

1980s, to an estimated high of 3.7 million new infections in 1997, to declining new infections

and AIDS-related mortality throughout the 2000s. In 2012, approximately 9.7 million people in

low- and middle-income countries were on antiretroviral drugs (ART).This expansion of ART

9
coverage has dramatically improved survival among people living with HIV (PLHIV), resulting

in an increase in the number of PLHIV to an estimated all-time high of 35.3 million in

2012 .Increased access to ART has averted an estimated 5.2 million AIDS-related deaths in low-

and middle-income countries from 1995 to 2010, with a 28% reduction in deaths from 2006 to

2012 .Even as PLHIV live longer, the incidence of new infections continues to decline. An

estimated 2.3 million new HIV infections occurred in 2012, which is a 34% decrease from

2000. Overall incidence rate for adults 15 to 49 years of age reached a peak of 0.11% in 1997

and decreased to 0.05% in 2012.The greatest decrease in HIV incidence is among children,

which has been reduced by 52% in 10 years. Many reasons exist for this decrease in incidence,

including reduced infectiousness of PLHIV on ART, expansion of programs for prevention of

mother-to-child transmission (PMTCT) of HIV, and introduction of harm-reduction programs

focusing on safer sex and outreach to high-risk populations (Olarewaju et al., 2023).

HIV prevalence and incidence estimates in many developing countries, including those in sub-

Saharan Africa, are derived using statistical models based primarily on either sentinel surveys

among pregnant women or household surveys. Overall trends in HIV epidemiology show fewer

new infections and decreased AIDS-related mortality in sub-Saharan Africa. From 2000 to 2012,

HIV incidence among adults in sub-Saharan Africa decreased by more than half, corresponding

to an estimated 1 million fewer new HIV infections in 2012 compared with 2000. The concurrent

increase in estimated number of PLHIV, from 20.8 million in 2000 to 25 million in 2012, is

largely from improved survival because of ART; AIDS-related deaths have decreased from

approximately 1.4 million in 2000 to 1.2 million in 2012. Evidence suggests that access to ART

has reduced mortality rates and contributed to lower infection rates, resulting in slowly

10
increasing HIV prevalence in most countries, with the notable exception of Angola, where new

infections and AIDS-related deaths continue to increase.

HIV continues to be a major public health challenge in sub-Saharan Africa, where an estimated

22 million people are living with HIV. In a population of 40 million in Kenya, 1.6 million people

of all ages were living with HIV in 2012 and an estimated 98,000 of these had acquired HIV

infection within the preceding year, making Kenya’s HIV epidemic the fourth largest

worldwide. For this reason, Kenya has been regarded globally as a priority country in sub-

Saharan Africa to reverse the spread of HIV in the region (Nyasulu et al., 2021).

2.7 Pathogenesis of HIV/AIDS

There are several viral and host factors determining the variability in HIV-1 infection outcome

and in rates of disease progression in HIV-1 infected individuals. Cellular tropism which defines

viral phenotype and receptorcoreceptors which determine viral entry into various cell types are

the major factors influencing HIV pathogenesis (Olarewaju et al., 2023). Despite the intense

research for the last 25 years, the exact mechanism of how these factors contribute to the

dramatic loss of CD4+ T cells and the persistence of R5 and X4 strains during the AIDS status is

still not well identified.

Infection with HIV starts without symptoms or ill-feeling and is accompanied by slight changes

in the immune system. This stage spans up to three months after infection until seroconversion

where HIV-specific antibodies can be detected in individuals following recent exposure. The

outcome of infection and duration for disease progression with clinical symptoms may vary

greatly between individuals, but often it progresses fairly slowly. It takes several years from

11
primary infection to the development of symptoms of advanced HIV diseases and

immunosuppression.

During primary infection, although individuals may look healthy, the virus is actively replicating

in the lymph nodes and blood stream of infected individuals. As a result, the immune system

may get slowly damaged by the burst of viral load in their bodies (Nyasulu et al., 2021).

Symptomatic stage of disease indicates the late phase of HIV disease (AIDS) where individuals

may be susceptible to other opportunistic infections (OIs), such as infections

with Mycobacterium avium, Mycobacterium tuberculosis, Pneumocystis carinii, CMV,

toxoplasmosis and candidiasis (J Med Liban.2006). It is agreed that infected individuals develop

an AIDS status when their plasma HIV load is high and the CD4+ T count is less than 200 mm.

The availability of the highly active antiretroviral therapy (HAART) may question the dilemma

as to whether everyone who seroconverts to HIV will develop AIDS.

One mechanism HIV weakens the immune system is by infecting and destroying CD4+ T cells,

which in turn leads to immunodeficiency at later stage of disease. 5 HIV attaches to the CD4+

protein on the surface of these and other cells to gain entry. However, the presence of CD4+

molecules alone proves to be not enough to allow viral entry into other cell types such as

monocytes and dendritic cells. Therefore, a second doorway is needed for the virus to gain

access to infect cells. This led to the discovery of the chemokine receptor as essential coreceptors

for HIV-1. There are different types of these coreceptors for different cell types that HIV variants

can use for infection of cells. Two main chemokine receptors have been identified to play a

major role in HIV entry, CCR5 and CXCR4 (or fusin) (Nyasulu et al., 2021).

12
2.8 Laboratory diagnosis of HIV/AIDS

Serological testing- Antibodies to HIV-1 and HIV-2 are detected by EIA, also known as enzyme-

linked immunosorbent assay (ELISA), simple/rapid test devices, and western blot (WB) tests

Rapid test device- Rapid HIV assays can be based on several test formats; these tests are

designed for use with individual specimens, and are quick and easy to perform, making them

more cost-effective than EIAs in low-throughput laboratories. They can be used with

serum/plasma and venous or capillary whole blood (WHO, 2020).

Immunoassay- Most EIAs have a high sensitivity and specificity, and are able to detect

HIV-1/HIV-2 and HIV variants

Western blotting- This is a very sensitive blood test used to confirm a positive ELISA test result.

(WHO, 2010).

HIV RNA assays- detect HIV viral RNA in venous/capillary whole blood dried on filter paper

and plasma using a variety of methodologies. These include RT-PCR, b-DNA, TMA and

NASBA (WHO, 2020).

PCR-Qualitative HIV DNA PCR is currently widely used as the standard method for diagnosis

of HIV infection in infants and is the assay against which other assays are usually compared in

research settings (WHO, 2020).

Ultrasensitive p24 antigen-based testing- p24 Ag assays measure the HIV core protein p24 found

in whole blood, serum or plasma, either in free form or bound by anti-p24 antibody (WHO,

2020).

13
Saliva Tests- a cotton pad is used to obtain saliva from the inside of your cheek. The pad is

placed in a vial and submitted to a laboratory for testing. Results are available in three days.

Positive results should be confirmed with a blood test.

2.9 Prevention and Treatment of HIV/AIDS

Successful HIV prevention strategies include the development and effective use of highly

sensitive and specific HIV screening tests, which have virtually eliminated infection from the

blood supply in the developed world and in most parts of the developing world (WHO 2020). In

addition, the administration of a short course of nevirapine to mothers during labor and to

newborns post-partum reduces the risk of mother-to-child transmission (MTCT) by as much as

47 percent (Guay and others 1999). However, recent data suggest that such short-term successes

may be at the expense of resistance and viral failure once treatment is introduced after delivery

(Waller et al., 2022).

Treatment as prevention (TasP) refers to taking HIV medication to prevent the sexual

transmission of HIV. It is one of the highly effective options for preventing HIV transmission.

People living with HIV who take HIV medication daily as prescribed and get and keep an

undetectable viral load have effectively no risk of sexually transmitting HIV to their HIV-

negative partners (HIV.gov, 2020).

Taking post-exposure prophylaxis when person have been exposure to HIV (HIV.gov, 2020).

Taking pre-exposure prophylaxis (HIV.gov, 2020).

Taking HIV Medication to Stay Healthy and Prevent Transmission. If you have HIV, it is

important to start treatment with HIV medication (called antiretroviral therapy or ART) as soon

as possible after your diagnosis. If taken every day, exactly as prescribed, HIV medication can

14
reduce the amount of HIV in your blood (also called the viral load) to a very low level. This is

called viral suppression. It is called viral suppression because HIV medication prevents the virus

from growing in your body and keeps the virus very low or “suppressed.” Viral suppression

helps keep you healthy and prevents illness (HIV.gov, 2020).

15
 CHAPTER THREE

MATERIALS AND METHODS

3.1 Study Area

The study was carried out in Kiambu County at Thika Level 5 hospital, located at Thika town.

This hospital has many departments including laboratories, surgery, nursing casualty,

comprehensive care center, mortuary, physiotherapy and many others hence it is also a center for

learning and research for many students and staffs. It is thus best suitable place for conducting

this study.

3.2 Study design

This research employed a cross-sectional descriptive study design and it was the most

appropriate because of the short time frame of the study and to estimate a population parameter

like prevalence of HIV/AIDS and tuberculosis.

3.3 Study population

The study targeted adults living with HIV/AIDS, seeking laboratory investigation for

mycobacterium tuberculosis bacteria at Thika Level 5 hospital laboratories during the study

period of three months

3.4 Inclusion and Exclusion Criteria

3.4.1 Inclusion criteria

The study included adults living with HIV/AIDS, seeking laboratory investigation for MTB

bacteria at Thika Level 5 hospital laboratories, who consented to take part in the study

16
3.4.2 Exclusion Criteria

Adults living with HIV/AIDS who failed to consent were excluded.

3.5 Sample size determination

The sample size was calculated using the Fischer’s formula of the year 2004 (Fischer etal.2004)

since the size of the target population is larger than 10000.

n= z2pq/d2

Where;

N = Minimal sample size required.

p = Estimated prevalence of TB among HIV patients= 26.7%.

Zα/2 = Standard normal deviate at 95% confidence interval corresponding to 1.96

δ = Absolute error between the estimated and true population prevalence of TB of 5%.

The calculated sample size

N = 1.962α/2 0.267(1-0.276)

0.052

=35 patients.

Adjusted for 20% incomplete data, the sample size was 40.

3.5 Sampling Technique

A convenience sampling technique will be used where by researcher simply picks those who

happen to be available until the desired size is attained.

3.6 Data collection

Physical examination for HIV/AIDS and TB was performed. Interviews were conducted to

adults living with HIV/AIDS so as to obtain information about the background characteristics of

17
their past and present illness. The interview were also conducted to reveal any history of chronic

illnesses, any opportunistic infections, whether they are on medication (ARVs) or not, and their

occupation.

3.7 Specimens

Persons suspected of having TB of the lungs or larynx should have at least three sputum

specimens examined by AFB smears and culture. If extrapulmonary TB is suspected, specimen

from the suspected site should be examined.

Persons suspected of having HIV, serological assays for venous/capillary whole blood and oral

fluid specimens have now have been developed and make POC HIV testing feasible using rapid

test devices. Serological testing by the EIA format is designed for use on serum or plasma

specimens, which requires preparation of the specimen from whole blood and use of reagents

that often require refrigeration.

3.8 Specimen processing and Laboratory investigation

3.8.1 HIV diagnosis

Antibodies to HIV proteins may be detected by various methodologies; the current standards are

enzyme-linked immunosorbent assays (ELISAs) for screening and Western blot (WB) for

confirmation. Other acceptable methodologies are particle cell agglutination for screening, and

immunofluorescence and radioimmunoblot assay for confirmation (Stanford healthcare, 2023).

HIV p24 antigen assay-The p24 protein is a product of the gag gene and resides in the viral core.

Prior to the availability of viral load testing, p24 will be used for monitoring disease activity as

well as diagnosis. It is specific as a diagnostic test but falls short on sensitivity, as a negative test

is not uncommon in genuine HIV infection (Stanford healthcare, 2023).

18
Saliva Tests A cotton pad is used to obtain saliva from the inside of your cheek. The pad is

placed in a vial and submitted to a laboratory for testing (Stanford healthcare, 2023).

Viral Load Test This test measures the amount of HIV in your blood. Generally, it's used to

monitor treatment progress or detect early HIV infection

3.8.2 Tuberculosis diagnosis

The Mantoux tuberculin skin test (TST) or the TB blood test can be used to test for M.

tuberculosis infection. Additional tests are required to confirm TB disease. The Mantoux

tuberculin skin test is performed by injecting a small amount of fluid called tuberculin into the

skin in the lower part of the arm. The test is read within 48 to 72 hours by a trained health care

worker, who looks for a reaction (induration) on the arm.

Blood tests may be used to confirm or rule out latent or active tuberculosis. These tests use

sophisticated technology to measure your immune system's reaction to TB bacteria

A posterior-anterior chest radiograph is used to detect chest abnormalities. Lesions may appear

anywhere in the lungs and may differ in size, shape, density, and cavitation. These abnormalities

may suggest TB, but cannot be used to definitively diagnose TB.

The presence of acid-fast-bacilli (AFB) on a sputum smear or other specimen often indicates TB

disease. Acid-fast microscopy is easy and quick, but it does not confirm a diagnosis of TB

because some acid-fast-bacilli are not M. tuberculosis.

Culture is done on all initial samples to confirm the TB diagnosis. A positive culture for M.

tuberculosis confirms the diagnosis of TB disease.

For all patients, the initial M. tuberculosis isolate should be tested for drug resistance

19
3.9 Data analysis and storage

The data obtained was analyzed using computer Microsoft excel and the results stored in flash

cards, computer and memory cards.

3.10 Data presentation

The data was analyzed in percentages and presented in tables, pie charts and bar graphs.

3.11 Ethical consideration

Authorization for the study was sought from Mount Kenya University review board and

permission to conduct the study obtained from Thika Level 5 hospital authorities.

The study and interviews were conducted on the adults living with HIV/AIDS who consented to

the study. The confidentiality, comfort and safety of the patient was highly maintained and the

study conducted in accordance with professional ethics.

20
 CHAPTER FOUR: RESULTS

4.1 Bio Data

4.1.1 Gender of the Respondent

Table 1: Gender of the Respondents

Gender No. of Respondents Percentage

Male 16 40%

Female 24 60%

Total 40 100%

Figure 1: Gender of the Respondents

Gender of the Respondents

40%
Male
Female
60%

Majority of the respondents interviewed were females (60%) with the males accounting for 40%.

21
4.1.2 Residence

Table 2: Residence of the Respondent

Residence No. of Respondents Percentage

Rural 10 25%

Urban 16 40%

Peri-urban 14 35%

Total 40 100%

Figure 2: Residence of the Respondent

Residence of the Respondents

16
14
12
10
8
6
4
2
0
Rural Urban Peri-urban

Majority of the respondent resided in an urban setting (40%), followed by those from a peri-

urban setting (35%), with the least being those from the rural setting at 25%.

22
4.1.3 Education Level

Table 3: Education Level

Education Level No. of Respondents Percentage

Primary 12 30%

Secondary 10 25%

Tertiary 7 17%

No Formal Education 11 28%

Total 40 100%

Figure 3: Education Level

Education Level

28% 30% Primary

Secondary
Tertiary
No Formal Education
18%
25%

Majority of the respondents had attained primary education (30%), 28% had no formal

education, 25% of the respondents had attained secondary education with only 17% having

attained tertiary education level.

23
4.1.4 Family History of TB

Table 4: Family History of TB infection

Family History of TB infection No. of Respondents Percentage

Yes 22 55%

No 18 45%

Total 40 100%

Figure 4: Family History of TB

Family History of TB infection

25

20

15

10

0
Yes No

Majority of the respondents indicated that there was a family history of TB at 55%, with 45%

stating that there was no family history of TB.

24
4.2 Prevalence of TB

4.2.1 Cases of TB & HIV/AIDS

Table 5: Prevalence of TB

Prevalence of TB No. of Respondents Percentage

Positive Case of TB 10 25%

Negative Case of TB 30 75%

Total 40 100%

Figure 5: Prevalence of TB

Prevalence of TB

25%

Positive Case of TB
Negative Case of TB

75%

The prevalence of TB was found to be 25% with positive cases of TB with negative cases

accounting for 75% of study respondents.

25
4.2.2 Type of Tests Done

Table 6: Types of Tests

Types of Tests No. of Respondents Percentage

Smear AFB Microscopy 26 65%

Direct Nucleic Acid Amplification 2 5%

Serology 4 10%

I don’t Know 8 20%

Total 40 100%

Figure 6: Types of Tests

Types of Tests

30

25

20

15

10

0
Smear AFB Direct Nucleic Acid Serology I don’t Know
Microscopy Amplification

Majority of the respondents indicated that the TB test done was Smear AFB Microscopy (65%),

20% did not know the type of test done, 10% indicated that a serology was done with 5%

indicating that Direct Nucleic Acid Amplification was the test done.

26
4.3 Risk Factors contributing to TB and HIV/AIDS

4.3.1 Previously History of TB

Table 7: Do you have a previous history of TB

Do you have a previous history of TB No. of Respondents Percentage

Yes 16 40%

No 24 60%

Total 40 100%

Figure 7: Previously History of TB

Previously History of TB

40%
Yes
No
60%

Majority of the respondents indicated that they did not have previous history of TB (60%), while

40% indicating that they had a previous history of TB.

27
4.3.2 House Ventilation

Table 8: Status of the House Ventilation

Status of the House Ventilation No. of Respondents Percentage

Poorly Ventilated 18 45%

Moderately Ventilated 16 40%

Excellently Ventilated 6 15%

Total 40 100%

Figure 8: Status of House Ventilation

Status of House Ventilation

18
16
14
12
10
8
6
4
2
0
Poorly Ventilated Moderately Ventilated Excellently Ventilated

Majority of the respondents indicated that the house was poorly ventilated (45%), 40% indicated

that house they were living in was moderately ventilated with the least (15%) indicating that

their houses were excellently ventilated.

28
4.4.3 Individual Factors of TB among HIV/AIDS Patients

Table 9: Risk Factors of TB

Risk Factors of TB No. of Respondents Percentage

Smoking 6 15%

Lack of Antiretroviral Therapy 14 35%

Weak Immune System 12 30%

Malnutrition 8 20%

Total 40 100%

Figure 9: Risk Factors of TB

Risk Factors of TB

20% 15%
Smoking
Lack of Antiretroviral
Therapy
Weak Immune System
35% Malnutrition
30%

Majority of the respondents indicated that Lack of Antiretroviral Therapy was the leading risk

factor of contracting TB at 35%, 30% cited a weak immune system as a risk factor of TB, with

20% arguing that malnutrition was a risk factor of TB with least indicating that smoking was a

risk factor of contracting TB at 15%.

29
4.5 Ways of Creating Awareness on TB & HIV/AIDS

4.5.1 Education on TB & HIV/AIDS

Table 10: Whether one has ever received education on TB & HIV/AIDS

Whether one has ever received education on No. of Respondents Percentage

TB & HIV/AIDS

Yes 18 45%

No 22 55%

Total 40 100%

Figure 10: Whether one has ever received education on TB & HIV/AIDS

Whether one has ever received education on TB &

HIV/AIDS

25

20

15

10

0
Yes No

Majority of the respondents indicated that they had never received education on TB &

HIV/AIDS (55%) with 45% indicated that they had received education on TB & HIV/AIDS.

4.5.2 Source of Information

Table 11: Source of Information

Source of Information No. of Respondents Percentage

30
 Community Health Volunteer 6 33%

Social Media 8 45%

Hospital Clinic 2 11%

From Friends 2 11%

Total 18 100%

Figure 11: Source of Information

Source of Information

11%
11% 33% Community Health Volunteer
Social Media
Hospital Clinic
From Friends

44%

Majority of the respondents indicated that they learnt of TB & HIV/AIDS through social media

(45%), 33% learnt from the Community health volunteers, 11% indicated they learnt from the

hospital clinic and friends respectively.

4.5.3 Possible avenues that may improve education

Table 12: Possible avenues that may improve education

Possible avenues that may improve education No. of Respondents Percentage

31
 Workshops 6 15%

Seminars 6 15%

Medical Camps 4 10%

Chamas 24 60%

Total 40 100%

Figure 12: Possible avenues that may improve education

Possible avenues that may improve education

25

20

15

10

0
Workshops Seminars Medical Camps Chamas

Majority of the respondents indicated that Chamas would be good avenues to provide education

on TB & HIV/AIDS (60%), 15% indicated that workshops and seminars would provide more

education with 10% indicating that medical camps create more awareness on the comorbidity of

TB & HIV/AIDS.

32
 CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 Discussion

The study found out that females had more incidences of TB among HIV patients than the male

gender. Although some studies have postulated men to be more vulnerable to TB than women

due to their behavioral characteristics such as smoking tobacco they agree that there have been

recorded more TB cases among females than males. These studies have documented that women

with pulmonary TB have different symptoms from men and may not test positive on microscopic

examination of the sputum, or that TB lung lesions might not be as severe in women as in men,

resulting in women not being accurately diagnosed. The findings of this study are also consistent

with the findings of another study which found out that women co-infected with TB and HIV are

significantly more likely to die of TB than are co-infected men. This is particularly the case for

women in Africa, where some studies have found that HIV-associated TB deaths among HIV/TB

co-infected women exceed those among co-infected men by 20 percent.

The study found a positive correlation between the residence and education level with the TB &

HIV/AIDS among the residents. Urban areas often have higher population density and can be

more susceptible to the rapid spread of infectious diseases like TB due to close living quarters,

limited access to healthcare in certain urban pockets, and higher rates of migration. However,

urban areas usually have better healthcare facilities and a higher level of awareness, which can

lead to early diagnosis and treatment. Urban areas, especially in developing countries, may have

higher rates of HIV/AIDS due to factors such as a higher prevalence of risky behaviors, limited

access to education and healthcare among vulnerable populations, and challenges in

implementing effective prevention programs. Research indicates that peri-urban areas often face

limited access to healthcare facilities, poor sanitation, and overcrowded living conditions

33
contribute to the prevalence of TB. Lack of awareness and education further worsens the issue.

This is consistent to the findings of another study which revealed that low education levels have

been consistently associated with higher rates of tuberculosis (TB) and HIV/AIDS (Tok et al.,

2020).

The study also found that for the positive cases identified there was a family history of TB. This

holds that a family member with a history of TB does increase the risk of exposure to the

bacteria, especially in households where there is close and prolonged contact with the infected

individual. In such cases, family members might have a higher likelihood of contracting TB, but

this is due to exposure rather than a genetic link causing reinfection. The study found a

comorbidity prevalence of 25% which is consistent to the findings of Kimenye (2020) who found

a prevalence of 26% among adults in Kenya. The most common TB test done in the facility was

Smear Test. With regards to the risk factors the study found out that the ventilation status of the

houses which contributed to higher incidences of TB among the patients.

This is consistent to the findings Lee et al., (2022) Improper ventilation, resulting from no

windows, kaccha housing, living on the lower floors of high-rise buildings, and overcrowding, is

associated with disease transmission and increases the incidence of TB by prolonging the time

that TB bacilli droplets remain suspended in indoor air. In addition lack of Antiretroviral

Therapy, a weak immune system, smoking and malnutrition were also found to be risk factors of

TB. The study also sought whether enough awareness was created among patients living with TB

and HIV/AIDS where majority of the patients argued that they had not received education on

HIV/AIDS with some indicating that they had learnt through social media, community health

workers and hospital clinics. This implies that there is a need to create more awareness on TB

34
and HIV/AIDS on the symptoms, prevention and treatment. The main avenues where this

information may be availed to the public included workshops, seminars and Chamas.

5.2 Conclusion

TB/HIV is the most common comorbidity which still carries high mortality and morbidity

worldwide. Although most of the studies focused on the causes of HIV/AIDS and TB separately

few studies have focused on the co-existence of both ailments. There is therefore a need to

address the causes of the comorbidity, prevention strategies and measures that may help reduce

the incidences of their co-existence before they get out of hand.

5.3 Recommendations

The study recommends that;

The study recommends use of programs aimed at strengthening the gender capacity of health

care providers, HIV testing counselors and community health workers through avenues such as

occupational training materials. This would provide workers with TB prevention, screening and

treatment literacy as a routine part of their work with women, particularly in areas with high HIV

prevalence.

The study recommends development of targeted interventions to address behavioral risk factors

such as smoking, which increases vulnerability to TB. They may implement anti-smoking

campaigns and provide resources for smoking cessation.

35
 REFFERENCES

CDC (2015) Centre for Disease Control.

Hamada, Y., Getahun, H., Tadesse, B. T., & Ford, N. (2021). HIV-associated tuberculosis.
International journal of STD & AIDS, 32(9), 780-790.
Kimani, E., Muhula, S., Kiptai, T., Orwa, J., Odero, T., & Gachuno, O. (2021). Factors
influencing TB treatment interruption and treatment outcomes among patients in Kiambu
County, 2016-2019. PloS one, 16(4), e0248820.
Kimenye, M. K. (2020). Association between Delay to Treatment Initiation and Treatment
Outcomes among Rifampicin Resistant Tuberculosis Patients in Selected Sites in Kenya
(Doctoral dissertation).
Lee, J. Y., Kwon, N., Goo, G. Y., & Cho, S. I. (2022). Inadequate housing and pulmonary
tuberculosis: a systematic review. BMC Public Health, 22(1), 1-12.
Nyasulu, P. S., Ngasama, E., Tamuzi, J. L., Sigwadhi, L. N., Ozougwu, L. U., Nhandara, R.
B., ... & Ncayiyana, J. (2022). Effect of HIV status and antiretroviral treatment on
treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South
Africa. Plos one, 17(10), e0274549.
Olarewaju, S. O., Akande, R. O., Abu, C., & Adeyemo, C. (2023). Factors influencing
tuberculosis preventive practices among people living with HIV/AIDS enrolled in
secondary health facilities in Lagos, Nigeria. African Health Sciences, 23(2), 97-108.
Röltgen, K., Cruz, I., Ndung’u, J. M., & Pluschke, G. (2019). Laboratory diagnosis of Buruli
ulcer: challenges and future perspectives. Buruli ulcer: Mycobacterium ulcerans disease,
183-202.
Santos, L. F. S., Carneiro, P. H. V., de Oliveira Serra, M. A. A., Dos Santos, L. H., de Andrade,
H. L. P., Pascoal, L. M., ... & Neto, M. S. (2022). Tuberculosis/HIV co-infection in
Northeastern Brazil: Prevalence trends, spatial distribution, and associated factors. The
Journal of Infection in Developing Countries, 16(09), 1490-1499.
Shah, H. D., Nazli Khatib, M., Syed, Z. Q., Gaidhane, A. M., Yasobant, S., Narkhede, K., ... &
Saxena, D. (2022). Gaps and interventions across the diagnostic care cascade of TB
patients at the level of patient, community and health system: a qualitative review of the
literature. Tropical Medicine and Infectious Disease, 7(7), 136.
Singh, A., Prasad, R., Balasubramanian, V., & Gupta, N. (2020). Drug-resistant tuberculosis and
HIV infection: current perspectives. HIV/AIDS-Research and Palliative Care, 9-31.
Ticha, V., Bimerew, M., & Phetlhu, D. R. (2022). Perceptions of nurses on TB with HIV
adherence counselling skills in a health sub-district, Cape Town: A qualitative study.
Health SA Gesondheid, 27(1).

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Tok, P. S. K., Liew, S. M., Wong, L. P., Razali, A., Loganathan, T., Chinna, K., ... & Kadir, N.
A. (2020). Determinants of unsuccessful treatment outcomes and mortality among
tuberculosis patients in Malaysia: A registry-based cohort study. PloS one, 15(4),
e0231986.
Waller, K. M., Leong, R. W., & Paramsothy, S. (2022). An update on fecal microbiota
transplantation for the treatment of gastrointestinal diseases. Journal of gastroenterology
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37
 APPENDICES

Appendix I: Questionnaire

Bio Data
1. Gender?
Male ( ) Female ( )
2. Where do you live
Rural ( )
Peri-urban ( )
Urban ( )
3. What is your education Level
Primary ( )
Secondary ( )
Tertiary ( )
No formal Education ( )
Prevalence of TB among HIV/AIDS patients
4. Is there a family history of TB?
Yes ( ) No ( )
5. Infected with TB & HIV/AIDS?
Yes ( ) No ( )
6. What type of tests were done for TB?
Smear AFB Microscopy ( )
Direct Nucleic Acid Amplification ( )
Serology ( )
Risk Factors of TB among patients with HIV/AIDS
7. Did you have a previous TB infection?
Yes ( ) No ( )
8. What is the ventilation status of your house?

38
Poorly Ventilated ( )
Moderately Ventilated ( )
Well Ventilated ( )
9. Which of the following do you believe are the risk factors of TB among HIV/AIDS
patients?
Smoking ( )
Lack of Antiretroviral Therapy ( )
Weak Immune System ( )
Malnutrition ( )
Creating Awareness
10. Have you ever received any education on TB infection among H/V/AIDS Patients?
Yes ( ) No ( )
Community Health Volunteers ( )
Social Media ( )
Hospital Clinics ( )
From a friend ( )
11. Which avenues do you believe can create more awareness on TB and HIV/AIDs
education?
Workshops ( )
Seminars ( )
Medical Camps ( )
Chamas ( )

39
Appendix II: Work plan

MONTH ACTIVITY

June to July 2023 Topic selection and proposal writing

September 2023 Presentation of proposal

October 2023 Data collection and laboratory analysis

October to November Compiling results , data analysis and project writing

November 2023 Presenting the project and submitting the project print out

40
Appendix III: Budget

ITEM UNIT UNIT COST ( KSH ) TOTAL COST (KSH)

Printing and binding - - 2,500

Ball pens 3 @ 25 75

Recording book 1 A4 200 pages @ 250 250

HB pencils 2 @15 30

Browsing - - 400

miscellaneous - - 325

TOTAL 3550

41