WOLAITA SODO UNIVERSITY

COLLEGE OF HEALTH SCIENCE AND MEDICINE

SCHOOL OF PHARMACY

ASSESSMENT OF PREVALENCE AND FACTORS AFFECTING THE

DEVELOPMENT OF ACTIVE-TB INFECTION AMONG HIV/AIDS PATIENTS IN
ART CLINIC AT WOLAITA SODO UNIVERSTY COMPREHENSIVE SPECILIZED
HOSPITAL, SOUTHERN ETHIOPIA,2022

A RESEARCH PAPER SUBMITTED TO SCHOOL OF PHARMACY, COLLEGE

OFMEDICINE AND HEALTH SCIENCE, WOLAITA SODO UNIVERSTY.

BY:-

MEKDELAWIT GIZAW …….027/11

BIRTUKAN ABEBE ………058/10

MELKAMU TEKALEGN ….034/10

FIRAOL MEKONNEN……158/10

BEREKET MATIWOS…….090/10

Under the supervision of

MrAmsaluGulla(MSc. Pharmaceutics)

Sep, 2022

WolaitaSodo, Ethiopa
ACKNOWLEDGEMENT

Firstly, We would like to thanks School of Pharmacy College of Health science and Medicine for
providing such a chance of study and offering technical support and assigning advisor timely.
We would also like to express our gratitude to our advisor MR AmsaluGulla for his desirable
effort in giving us a guidance, comments, suggestion and correction on our research
Finally, Our gratitude also goes to all the people helped us in the preparation of this research.

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 TABLE OF CONTENTS

List of Tables................................................................................................................................................v
Acronyms & Abbreviation...........................................................................................................................vi
ABSTRACT..................................................................................................................................................vii
Introduction:..........................................................................................................................................vii
Objective:...............................................................................................................................................vii
Methodology:........................................................................................................................................vii
Work Plan & Budget...............................................................................................................................vii
Results....................................................................................................................................................vii
Conclusion.............................................................................................................................................viii
CHAPTER ONE: INTRODUCTION...................................................................................................................1
1.1GeneralBackground............................................................................................................................1
1.2 Statement of the problem.................................................................................................................2
1.3 Significance of the study....................................................................................................................3
CHAPTER TWO: LITERATURE REVIEW..........................................................................................................4
2.1 Prevalence of active tuberculosis among ART patients.....................................................................4
2.2 Factors affecting the development of active TB on ART patients......................................................5
CHAPTER THREE: OBJECTIVE.......................................................................................................................8
3.1General Objective:..............................................................................................................................8
3.2Specific objective:...............................................................................................................................8
CHAPTER FOUR: METHODOLOGY................................................................................................................9
4.1. Study setting and study period.........................................................................................................9
4.2 Study design......................................................................................................................................9
4.3 Population.........................................................................................................................................9
4.3.1 Source population.......................................................................................................................9
4.3.2Study population.........................................................................................................................9
4.4 Inclusion and exclusion criteria..........................................................................................................9
4.4.1 Inclusion criteria.........................................................................................................................9
4.4.2 Exclusion criteria.......................................................................................................................10
4.5 Sample size determination and Sampling technique.......................................................................10
4.5.1 Sample size determination.......................................................................................................10
4.5.2 Sampling technique..................................................................................................................11

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 4.6 Data Collection Method...................................................................................................................11
4.6.1 Data collecting instrument and procedure...............................................................................11
4.7Study Variables.................................................................................................................................11
4.7.1 Dependent Variables:...............................................................................................................11
4.7.2 Independent Variables..............................................................................................................11
4.8 Operational definitions....................................................................................................................11
4.9 Data quality control.........................................................................................................................12
4.10 Data collection process& analysis..................................................................................................12
4.11Dissemination of the results...........................................................................................................12
CHAPTER FIVE: RESULT..............................................................................................................................12
5.1 Socio-demographic characteristics of the study participants..........................................................12
5.2. Clinical and laboratory characteristics............................................................................................14
5.3 Factors affecting the development of active TB on ART..................................................................16
CHAPTER SIX: DISCUSSION........................................................................................................................17
CHAPTER SEVEN: CONCLUSION AND LIMITATION.....................................................................................18
7.1 CONCLUSION...................................................................................................................................18
6.2 Limitations of the study...................................................................................................................19
REFERENCE................................................................................................................................................20

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iv
List of Tables

Table 5. 1 Summary result of TB/HIV co-infection vs. socio-demographic variable...................................13

Table 5. 2: Summary result of TB/HIV co-infection vs. clinical and laboratory profiles of the study
participants................................................................................................................................................15

v
Acronyms & Abbreviation

AFB……………. Acid Fast Bacilli

AIDS…………… Acquired Immune Deficiency Syndrome

ART……………. Anti -Retroviral Therapy

EPTB…………… Extra Pulmonary Tuberculosis

FMOH…………. Federal minister of Health

HAART………….Highly active anti- retroviral therapy

HIV………………Human Immunodeficiency virus

WSUCSH………. WolaitaSodo university comprehensive specialized hospital

MTB……………… Mycobacterium Tuberculosis

PLWHIV…………. People Living with Human Immune- deficiency Virus.

PTB………………. Pulmonary Tuberculosis

RVI………………. Retro viral Illness

TB………………… Tuberculosis

WHO………………World Health Organization

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ABSTRACT
Introduction: Tuberculosis is the most common presenting opportunistic infection among
HIV-infected patients, who remain at high risk for TB throughout the course of their disease.
Tuberculosis and HIV have been closely linked since the emergence of AIDS. HIV infection has
contributed to a significant increase in the worldwide incidence of tuberculosis. Due to the
shared immune defense mechanisms between the two diseases, TB is a leading preventable cause
of death among people living with HIV. The aim of this study is undertaken to assess the
prevalence and factors affecting the development of active-TB infection among HIV positive
patients in ART clinic at WolaitaSodo university comprehensive specialized hospital.

Objective: The aimed of this study was conducted to assess the prevalence and factors
affecting the development of active-TB infection among HIV positive patients in ART clinic at
WolaitaSodo university comprehensive specialized hospital from September 2019 to August
2022.

Methodology: Hospital based retrospective cross-sectional study design was conducted to

determine the prevalence and factors affecting the development of active- TB infection among
HIV positive patients in ART clinic at WolaitaSodo university comprehensive specialized
hospital on 163 patients September 2019 to August 2022. Data was collected by using structured
checklist which contains patient's socio-demographics characteristics and clinical and laboratory
profile. Simple random sampling technique was employed to enroll the aforementioned sample
size during the study period.

Results: A total of 163 patients medical records containing required information were reviewed
Of these 23(14.1%) had TB/HIV co-infection. The proportion of male medical record who had
TB/HIV-co infection accounted for a larger proportion in the sample 13(56.5%) compared to
female respondents 10(43.5%). Most of them were in the age range 16-54 years 21(91.3%).

Conclusion: The prevalence of tuberculosis in this study was 14.1%. Tuberculosis was
associated with low CD4 count, poor drug adherence, co morbidity and family history of TB . In
conclusions, the prevalence of tuberculosis in this study was found to be high among divorced,
widowed, unmarried, secondary education, CD4<200 cells/mm3. Therefore Health information

vii
about risk factors for TB infection and early diagnosis and treatment of TB infection are very
important for HIV patients in the study area.

Key word: prevalence, factor

viii
 CHAPTER ONE: INTRODUCTION

1.1GeneralBackground
HIV and TB are the first and second leading causes, respectively of death globally due to a
single infectious agent[1, 2]. Due to the shared immune defense mechanisms between the two
diseases, TB is a leading preventable cause of death among people living with HIV and vice
versa[1, 3].

Tuberculosis is the most common presenting opportunistic infection among HIV-infected

patients, who remain at high risk for TB throughout the course of their disease. TB and HIV have
been closely linked since the emergence of AIDS. HIV infection has contributed to a significant
increase in the worldwide incidence of tuberculosis. By producing a progressive decline in cell-
mediated immunity, HIV alters the pathogenesis of tuberculosis, greatly increasing the risk of
developing disease and leads to more frequent extra pulmonary (EPTB) involvement and
atypical radiographic manifestations[4].

TB/HIV co-infection causes aserious bidirectional and synergistic combination of illness in

which HIV promotes the progression of latent TB infection to disease, and TB accelerates the
progression of HIV disease to poor prognosis including death[5].

In healthy people, infection with MTB often causes no symptoms, since the person's immune
system acts to wall off the bacteria[1, 6].

It is among the leading causes of death for PLWHIV which shares about 25% of all causes of
deaths[7].

[24]
Around 14 million individuals worldwide are estimated to be co- infected . According to
World Health Organization report Ethiopia remain to among the 30 high burden countries with
TB and HIV infection in the world. Likewise, TB has been reported to exacerbate HIV
infection[4, 8, 9].

Most of these deaths occur in resource-limited settings like Ethiopia. TB and HIV/AIDS
constitute the main burden of infectious disease in resource-limited countries[10].

1
1.2 Statement of the problem
TB is an infectious disease and it is the most frequently diagnosed opportunistic infection and
disease in HIV infected patients world-wide[4, 11].

Despite being preventable, it is still a leading killer of people living with HIV. At least one in
four deaths among PLWHIV can be attributed to TB, and many of these deaths occur in
developing countries[3].

Worldwide about 11.1 million adults are co-infected with TB and HIV. Seventy percent of co-
infected people are living in sub-Saharan Africa. Tuberculosis becoming a major public Health
problem, especially in area where HIV infection rates is higher[12].

Globally, over one in ten of the 9 million people who develop TB each year are HIV-positive; Of
the 8.8 million incident cases of TB in 2010, 1.1 million (1.0 million– 1.2 million) were among
people living with HIV. The proportion of TB cases co infected with HIV is highest in countries
of the African region; overall, accounted for 82% of TB cases among people living with HIV.
Tuberculosis has been recognized as a major public health problem for more than five decades in
Ethiopia. According to the 2014 WHO TB report, the prevalence of all forms of TB, TB
mortality, and TB/HIV co-infected patients’ mortality were 211, 32 and 5.9 per 100,000
populations, respectively[9].

In Ethiopia, TB/HIV co-infected patients had greater risk of common mental disorders, lower
quality of life, low family income and poor physical health than HIV infected patients without
active TB[13].

The management of TB and HIV co-infected individual is challenging because of: pill burden,
increase adverse effect, drug to drug interaction and immune reconstitution inflammatory
syndrome (IRIS)[14].

Moreover, there are only few of studies done in the TB/HIV co-infection in the other area of
Ethiopia, which do not represent our study setting (WSUCSH). So the study will be conduct to
assess the exact factors and prevalence of TB among HIVAIDS patient.

2
1.3 Significance of the study
Determining the prevalence and factors affecting the development of active TB among HIV
patients have a great importance for the healthcare professional in WolaitaSodoin making
appropriate adjustments as a solution and to improve TB/HIV co-infected patients’ co-
management.

The knowledge of the prevalence and factors affecting the development of active TB disease
among HIV infected population in a local context also help to reduce the burden of the disease
by facilitating the early detection of at-risk patients and urging the responsible authority for
devising surveillance and proper follow-up activities in the area of TB/HIV collaborative.

It is anticipated that findings from this study contribute to the body of knowledge that informs
TB/HIV program planners, decision makers, and project implementers by providing factors
affecting the development of active TB on ART population.

This study view of the need to accelerate efforts and reach the international targets set in the
context of TB/HIV co-infection, the result of this study also plays significant role by increasing
awareness toward early detection and prevention of the diseases.

Identifying the potential risk factors for development of TB on ART patients, may help the anti
TB treatment not to takes a long time unlike other OI’s treatment which create pill burden for
those who are on HAART.

This study help to design regular surveillance techniques of TB infection in HIV patients. Thus,
assisting physicians to identifying factors affecting the development of the active - TB infection
in HIV patients and expect these infectious disease trends ahead of time to manage them.

3
 CHAPTER TWO: LITERATURE REVIEW

2.1 Prevalence of active tuberculosis among ART patients

Tuberculosis (TB) remains one of the world’s deadliest communicable diseases. In 2020, an
estimated 10 million people (140/100,000) were ill of TB, and 1.3 million TB deaths occurred
among HIV- negative people. About 7.5% of all incident cases of TB worldwide occur among
people living with HIV(PLHIV), where AFRICA stands the highest[15].

In 2014, WHO estimates 9.6 million individuals who developed incident tuberculosis, of which,
1.3 million or 12%, were co-infected with HIV. Almost three-quarter of these cases were in the
African region[15].

In 2013, an estimated 9.0 mil-lion people developed TB and 1.5 million died from the disease.
An estimated 1.1 million (13%) of the 9 million people who developed TB in 2013 were HIV-
positive.

The prevalence of TB was estimated to be 394 per 100, 000 populations including those co-
infected with HIV and there were 152, 030 new cases of which 3,190 were below 15 years of
age[16].

It was estimated that 36.9 million people are living with HIV (PLHIV) in the world. In some part
of the world, the prevalence of PLHIV continues to increase as result of availability of anti-
retroviral drugs. The statistics showed that nearly 2 million people were newly infected with HIV
and 1.2 million people died due to AIDS-related diseases annually[10].

The African Region accounts for about four out of every five HIV-positive TB cases and TB
deaths among people who are HIV positive and the majority of victims live in sub Saharan
Africa, which accounts seventy percent (70%) [17]. Some Africa countries have reported
continuing rises in tuberculosis case rates despite declining HIV prevalence, while others show
stable or declining tuberculosis incidence among HIV-negative individuals[7].

The case fatality ratio (the global proportion of people with TB who die from the disease) varied
from under 5% in a few countries to more than 20% in most countries in the WHO African

4
Region. This shows considerable inequalities among countries in access to TB diagnosis and
treatment that need to be addressed[18].

According toKhazaei et al., (2016), the prevalence of TB patients was 21.9% among HIV
patients. About 57.4% of the patients were below 35 years of age and most of them (85.5%) were
male.The result of the study done in Tanzania showed that, from a total of 67,686 patients
assessed7,602 patients were diagnosed with active TB[6].

According toa study conducted in Ethiopiareported that a TB/HIV co-infection prevalence of 18

% ranging from 8.3 % (in Silte zone) to 35.3 % (in South Omo zone)[19].

Study from Hawassa University Referral Hospital, south of Ethiopia found that, from a total of
499 HIV/AIDS positive patients, ninety-one (18.2%) of the study participants were found to
have tuberculosis of which, 20 (22%), 58(64%) and 13 (14%) were smear positive, smear
negative and extra-pulmonary tuberculosis cases, respectively[14].

Tuberculosis threatens the poorest and most marginalized populations [30]. The current increasing
HIV associated tuberculosis shifted the clinical pattern TB towards smears negative pulmonary
PTB and extra pulmonary TB EPTB(9, 20). The prevalence of TB among HIV positive clients in
Ethiopia was 7.8%[1, 9-11, 21].

From a total of 571 HIV positive study participants enrolled, 158 (27.7%) were found to have
pulmonary tuberculosis[22].

Another study done in Dilla Hospital, south of Ethiopia explored that, from 1391 ART patients,
178 (12.8%) had active TB, of which 143(80.3%) patients with pulmonary TB and 19.7% with
extra pulmonary TB[23].

2.2 Factors affecting the development of active TB on ART patients

A cross-sectional study conducted in Abadan and Khorramshahr, the south west of Iran on a total
of 366 HIV/AIDS positive patients with medical recordsfound that co-infection with hepatitis B
and drug abuse can dramatically increases the risk of TB in HIV/AIDS patients.This study also
reveals thatmale gender, history of imprisonment, co-morbidity with hepatitis C, stage of disease,
and CD4 cell count were statistically significant and associated with the incident of TB [24].

5
The cross-sectional record review on 1320 HIV/AIDS patients in Aminu Kano Teaching
Hospital, Northern Nigeria,TB/HIV co-infection was significantly associated with marital status,
WHO clinical stage and CD4 count[6].

Evidence from prospective observational study in Mulago Hospital, Uganda; showed that female
sex and baseline BMI ≤ 20 predicted incidents of TB in TB-HIV co-infections among patients
with ART[25].

As the cross-sectional study carried out at the HIV clinic of Jos University Teaching Hospital,
Nigeria on 218 consecutive adult patients over a 7-month period shows, being WHO clinical
stage 3 or 4,having HBV co-infection,oropharyngeal candidiasis, chronic diarrhea and Kaposi’s
sarcoma were the risk factors[26].

The retrospective review analysis of patient medical records in Hawassa University Referral
Hospital, found that, froma total of 499 HIV/AIDS positive patient medical records reviewed;
being female, WHO clinical stage 3, WHO clinical stage 4, functional status being ambulatory
and poor INH prophylactic management were independently associated with TB-HIV co-
infection[14].

According to the retrospective follow-up study conducted at the government owned General
Hospital located in Arba Minch town, Southern Ethiopia;496 records of HIV Infected patients
analyzed and determined that family size, history of cigarettes smoking, WHO baseline clinical
stage, hemoglobin level, age in group, addiction, sex of respondent, CD4 count, ART
intervention, type of initial regimen and past history of TB treatment were significant risk factors
for development of tuberculosis among HIV infected patients[27].

The hospital based retrospective studies conducted among 571 adult HIV-positive patients
attending HIV clinicin Amhara region explored that lower baseline CD4 count<200cell/μl,
patients who drunk alcohol, patients who were ambulatory at the initiation of ART, patients
whose marital status was single were significant predictors for increased risk of tuberculosis in
PLWHIV. Nonsmoker patients, patients in WHO clinical stage I, patients in WHO clinical stage
II and ownership of the house had significant protective benefit against risk of TB[22].

The institutional based cross-sectional study conducted among a total of 385 HIV cases to assess
magnitude of tuberculosis and its associated factors among HIV patients at FelegeHiwot Referral

6
Hospital in Bahirdarcity declared thatbody mass index (BMI)less than 18.5, CD4 count less than
200 and functional status bed redden and ambulatory were significant predictors of TB[28].

A case control study conducted in 2 public hospitals and 13 health centers in Addis Ababa found
that the presence of isoniazid and cotrimoxazole prophylaxis had protective benefit against risk
of TB. In contrary, bedridden, having WHO clinical stage III/IV and hemoglobin level, 10 mg/dl
at enrollment to ART care were predictors for increased risk of tuberculosis in PLWH after ART
initiation[29].

According to the case-control study conducted among 123 TB infected HIV positives in
Nekemte, western Ethiopia.Being divorced/widowed, not attending formal education, being
underweight (BMI < 18.5 kg/m2), having history of diabetic mellitus, and being in advanced
WHO HIV/AIDS clinical staging were determinant factors associated with TB/HIV co-
infection[30].

7
 CHAPTER THREE: OBJECTIVE

3.1General Objective:

To determine the prevalence and factors affecting the development of the active - TB infection
among HIV positive patients in ART clinic at WSUCSH from September 2019 to August 2022.

3.2Specific objective:

 To determine the prevalence of active TB among HIV/AIDS patients.

 To assess factors affecting the development of active TB among HIV/AIDS patients

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 CHAPTER FOUR: METHODOLOGY

4.1. Study setting and study period

The study was conducted at WSUCSH, which is located in Wolaita town,Wolaita zone southern
Nations, Nationalities and people Region (SNNPR).Wolaita is 328 km far from capital city of
Ethiopia(Addis Ababa). WSUCSH is serving the people in catchment area of 3 million people
including neighboring Dwuro, Gamo, Gofa and KambataTambaro zones and other. The
Hospitalserving over 100,000 outpatient visitors in a year. The hospital has 7 pharmacies which
renders service for Inpatient,Emergency,Outpatient,Gynecology,Ophthalmology, OR and Anti-
retroviral (ART)pharmacy.

The study was conducted to determine the prevalence and factors affecting the development of
active-TB infection among HIV/AIDS patient in ART clinicfrom September 2019 to August
2022. on patient medical records of HIV/AIDS (HIV sero-positive) patients.

4.2 Study design

Retrospective cross-sectional study design was conducted in ART clinic of WSUCSHto
determine the prevalence and factors affecting the development of active-TB infection among
HIV/AIDS patient by reviewing patient medical records of all HIV/AIDS patients during the
study period.

4.3 Population
4.3.1 Source population
HIV/AIDS (all HIV sero-positive) patients

4.3.2Study population
HIV/AIDS patients who were registered on the ART clinic from September 2019 to August
2022

4.4 Inclusion and exclusion criteria

4.4.1 Inclusion criteria
 All HIV/AIDS patients card registered on ART during study period.

9
4.4.2 Exclusion criteria
 Cards of the Patients those develop active TB before HIV infection is confirmed because
it is categorized as HIV among TB, not TB among HIV.
 Unreadable patient cards.
 Patient cards with incomplete information.

4.5 Sample size determination and Sampling technique

4.5.1 Sample size determination
Using a single mean formula, the sample size was determined as follows

Z ² XP(1− p)
ni =
d²

Where,

n is the required sample size;

d is the marginal error that is 5% (d=0.05);

p is the proportion of prevalence of active-TB among patients living with HIV/AIDS who came
to WSUCSH (0.5 [50%]);

z is the required degree of accuracy at 95% confidence level =1.96. Using the above formula:

(1.96)² X 0.5(1−0.5)
¿= =384
0.05²

Since the sample was taken from the total population of 398 PLWHA who have been taking
ART, since it is < 10,000, the final sample size was determined after using the correction factor.
So that,

niX N
nf= ¿+(N −1)

384 X 262
nf= 384+(262−1) =155

When 5% contingency is added, the total sample size was 163. Accordingly,163 samples was
taken from WSUCSH.
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4.5.2 Sampling technique
A simple random sampling method was adopted for selecting a representative sample.

4.6 Data Collection Method

4.6.1 Data collecting instrument and procedure
Data collection format which contain patient’s socio-demographic characteristics and clinical
and laboratory profile of study participants was utilized for the study. The data was collected by
using structured questionnaires and data was collected by reviewing patients’ medical records.
The questionnaire was prepared in English language including all relevant variables based on the
objectives of the study. The collected data was checked for completeness. Data collection
questionnaire papers, pen and pencil was used during data collection.

4.7Study Variables
4.7.1 Dependent Variables:
 The occurrences of TB in HIV infected patients.
4.7.2 Independent Variables
 Patient demographics (age, sex, education status, religion, residence, ethnic).
 Patient’s clinical conditions (including WHO clinical stages and co-morbidities)
 Laboratory profiles (including CD4 counts).

4.8 Operational definitions

Active tuberculosis: Active tuberculosis refers to disease that occurs in someone infected with
Mycobacterium tuberculosis that is characterized by signs or symptoms of active disease, or
both, and is distinct from latent tuberculosis infection, which occurs without signs or symptoms
of active disease.

HIV (Human Immunodeficiency Virus): is a virus that attacks the immune system, the body's
natural defense system.A retrovirus, human immunodeficiency virus type 1
(HIV-1), is the major cause of AIDS. A second retrovirus, HIV-2, also is recognized to cause
AIDS, although it is less virulent, transmissible, and prevalent than HIV-1.

 retroviruses are transmitted primarily by:

 sexual contact and by contact with infected blood or blood products as well as
from childbearing women to their offspring.

11
Tuberculosis (TB): is a chronic bacterial an infectious disease caused by the bacterium
Mycobacterium tuberculosis (MTB).
 Less frequently, it can be caused by M. bovis and M. africanum.
 TB usually affects the lungs (pulmonary TB) and All parts of the body can be infected
(EPTB). extra-pulmonary sites affected the lymph nodes, pleura, spine, urinary tract, the
brain, joints, bone and abdomen

4.9 Data quality control

The data was collected by the principal investigator. Before starting the data collection, data
collecting format was cross matched with available information on records; then the study
questions rearranged as necessary. Incomplete chart will be discarded. The data was cleared and
checked every day for completeness and consistency before data processing and analysis

4.10 Data collection process& analysis

After data collection, the data was coded, edited and cleaned to ensure accuracy, consistency and
completeness before entering into computer statistics program. After that categorized and
analyzed by using SPSS 26 computer software package. Quantitative data was completed and
interpretation was done according to the finding of the study data was presented in tables and
figures.

4.11Dissemination of the results

After the completion of the study, the result was compiled and given to School of Pharmacy
College of Health and Medical Science of WolaitaSodo University and other concerned bodies

CHAPTER FIVE: RESULT

5.1 Socio-demographic characteristics of the study participants

A total of 163 patient’s medical records containing required information were reviewed. Of
these 140(85.9) were not found to have TB/HIV-co infection while 23(14.1%) had TB/HIV co
12
infection. The proportion of female medical records had TB/HIV-co infection accounted for a
larger proportion in the sample 12(52.2%) compared to female medical records 11(47,8%). Most
of them were in the age range 16-54years 21(91.3%) and majority of TB/HIV patients 15(65.2%)
were urban residents while 8(34.8%) were residing in rural areas. Among TB/HIV co-infected
patients 17(73.9%) were nonsmokers and 15(65.2%) TB/HIV co-infected patients were
nonalcoholic

Table 5. 1 Summary result of TB/HIV co-infection vs. socio-demographic

variable

Variable TB/HIV co-infected Chi-square

p.value
YES n(%) NO n(%) Total(%)
1 Gender Male 11(47.8) 67(47.9) 80(47.9) 0.998
Female 12(52.2) 73(52.1) 83(52.1)
Total (100%) 23 140 163
2 Age ˂5yr 0(0.0) 2(1.4) 2(1.2) 0.282
6yr-15yr 2(8.7) 4(2.9) 6(3.7)
16yr-54yr 21(91.3) 124(88.6) 145(89.0)
55yr-64yr 0(0.0) 10(7.1) 10(6.1)
Total (100%) 23 140 163
3 Religion Muslim 2(8.7) 15(10) 17(10.4) 0.429
Orthodox 8(34.8) 38(27.1) 46(28.2)
Protestant 11(47.8) 83(59.3) 94(57.7)
Catholic 2(8.7) 4(2.9) 6(3.7)
Total (100) 23 140 163
4 Occupation Government 1(4.3) 16(11.4) 17(10.4) 0.117
employee
Farmer 3(13.0) 17(12.1) 20(!2.3)

13
 Merchant 6(26.1) 31(22.1) 37(22.7)
Student 2(8.7) 14(10.0) 16(9.8)
House wife 4(17.4) 33(23.6) 37(22.7)
Soldier 3(13.0) 2(1.4) 5(3.1)
Other 4(17.4) 27(19.3) 31(19.0)
Total (100%)
23 140 163
5 Educational status Illiterate 2(8.7 13(9.3) 15(9.2) 0.721
Primary school 8(34.8) 63(45.0) 71(43.6)
Secondary school 9(39.1) 39(27.9) 48(29.4)
Higher education 4(17.4) 25(17.9) 29(17.8)
Total (100%) 23 140 163
6 Marital status Unmarried 5(21.7) 32(22.9) 37(22.7) 0.047
Married 9(39.1) 85(60.7) 94(57.7)
Divorced 5(21.7) 9(6.4) 14(8.6)
Widow 4(17.4) 14(10.0) 18(11.0)
Total (100%) 23 140 163
7 Residence Urban 15(65.2) 97(69.3) 112(68.7) 0.697
Rural 8(34.8) 43(30.7) 51(31.3)
Total (100%) 23 140 163
8 Family size ˂2 14(60.9) 91(65.0) 105(64.4)
3-4 8(34.8) 38(27.1) 46(28.2)
˃5 1(4.3) 11(7.9) 12(7.4)
Total (100%) 23 140 163
9 Smoking Status Yes 6(26.1) 16(11.4) 22(13.5) 0.057
No 17(73.9) 124(88.6) 141(86..5)
Total (100%) 23 140 163
10 Alcohol Intake Yes 8(34.8) 33(23.6) 41(25.2) 0.251
No 15(65.2) 107(76.4) 122(74.8)
Total (100%) 23 140 163

14
5.2. Clinical and laboratory characteristics
Out of23 TB/HIV patients 23(14.1%) developed TB, 20(87.0%) had PTB and 3(13.0%) had
Extra pulmonary TB. The majority of patients who had TB/HIV co-infection, 16(69.6%) were in
WHO clinical stage of III followed by WHO clinical stage I, II 4(17.4%). 17 (73.9%) of the
participants were on working status.

Table 5. 2: Summary result of TB/HIV co-infection vs. clinical and laboratory

profiles of the study participants.

Chi-
No Variable TB/HIV co-infected
square
p.value
Total
YES n(%) NO n(%)
13(8.0) 0.333
1 Viral load D 3 (13.0) 10(7.1)
150(92.0)
ND 20(87.0) 130(92.9)
163
Total (100%) 23 140
2 CD4 level when TB ˃500 15(65.2)
developed
350-500 2(8.7)
200-350 5(21.7)
˂200 1(4.3)
Total (100%) 23(100)
3 WHO HIV/AIDS stage I and II 4(17.4)
of diseases
III 16(69.6)
IV 3(13.0)
Total (100%) 23
3 TB Diagnosis Sputum direct 11(47.8)
microscopy
Chest x ray 5(21.7)
Gene xpert 7(30.4)
Total (100%)
4 TB category Pulmonary TB 20(87.0)
Extra pulmonary TB 3(13.0)
Total (100%) 23
5 ART status On HAAT 23(100) 138(98.6) 161(98.8) 0.564
Not on HAAT 0(0.00) 2(1.4) 2(1.2)

15
 Total (100%) 23 140 163
6 CD4 level at ART ˃500 15(65.2) 15(10.7) 30(18.4) 0.000
initiation
350-500 2(8.7) 48(34.3) 50(30.7)
200-350 5(21.7) 70(50.0) 75(46.0)
˂200 1(4.3) 7(5.0) 8(4.9)
Total (100%) 23 140 163
7 Prophylaxis for TB INH 21(91.3) 135(96.4) 156 0.207
R 0(0.0) 2(1.4) 2(1.2)
No 2(8.7) 3(2.1) 5(3.1)
Total (100%) 23 140 163
8 Functional status of Working 17(73.9) 86(61.4) 103(63.2) 0.250
the patients
Ambulatory 6(26.1) 54(38.6) 60(36.8)
Bedridden 0(0.0) 0(0.0) 0(0.0)
Total (100%) 23 140 163
9 Family history of Yes 7(30.4) 12(8.6) 19(11.7) 0.02
TB
No 16(69.6) 128(91.4) 144(8.3)
Total 23 140 163
10 CD4 level when anti ˃500 11(47.8)
TB initiated
350-500 4(17.4)
200-350 6(26.1)
˂200 2(8.7)
Total (100%) 23
11 Anti-TB discontinue Yes 3(13.0)
No 20(87.0)
Total (100%) 23
12 co morbidity Yes 8(34.8) 12(8.6) 20(12.3) 0.000
No 15(65.2) 128(91.4) 143(87.7)
Total (100%) 23 140 163
13 Drug adherence Good 10(43.5) 110(78.6) 120(73.6) 0.000
Poor 13(56.5) 30(21.4) 43(26.4)
Total (100%) 23 140 163

5.3 Factors affecting the development of active TB on ART

Patients attending WSUCSH hospital Multivariate logistic regression analysis revealed that
patients. A patient whose marital status of TB/HIV coinfected was unmarrried, divorce, window
(21.7%,21.7%,17.4) more likely to develop TB than those patients whose married (39.1%).
Patients whose CD4 count ˃ 500 (65.2). Poor drug adherence in patients with TB/ HIV positive
patients was (56.5% ). Family history of TB and co morbidity also highly afected Multi-

16
Covariate and Bivariate Analysis result for different socio- demographic, clinical and risk
variables that affect TB/HIV Co-infection

CHAPTER SIX: DISCUSSION

The aim of this study was to determine the prevalence of TB development among adult HIV-
Positive patients, who receiving ART at WSUCSH. Out of 163 HIV positive patients, who
attended the ART clinic, 23(14.1%) had TB developed HIV infection is the single most
important fueling agent for ever-increasing prevalence of tuberculosis in Ethiopia. Moreover, TB
is a well-recognized opportunistic infection in patients with HIV/AIDS. The prevalence rate of
TB while receiving ART in the index study is similar to a previous prevalence rate of 37.4%
reported from Bahir Dare in 2021 [30], and it is also similar to rate reported in india from 2013,
where a total of 1012 were enrolled 172(17%) were found to develop active TB[31]. Similarly
study done in Arbaminch, among 496 HIV positive patients, showed that 21.4% patients had
HIV/TB co-infection[27], and another study done in Northwestern Tanzania, among 391 patients
43(11%) participants were developed TB[32]. Smaller TB rate of 4.69% was reported from the
North America[33]. The difference in TB rates could partly be explained by the overall
prevalence of TB and HIV which is lower in most of the developed countries as compared to
resource-restricted countries. However, even with these differences, it is important to note that
though ART has significant effect on the overall occurrence of TB among HIV patients [34,35] ,
the occurrence of TB while receiving ART is still higher as compared to the general population
as reported previously [36,37]. This variation may be due to difference in study area, study
period and incidence of the diseases. The HIV epidemic has influenced the epidemiology of TB
significantly. HIV is a well-known risk factor for progression to active TB among those infected
with Mycobacterium tuberculosis. Studies reported the prevalence of HIV infection among TB
patients. A number of factors were investigated for their potential association with the
occurrence of TB while receiving ART. In the index study, male patients were found to have an
increased risk of developing TB. Several studies have had similar findings including a study
from South Africa by Gupta and colleagues [36]. Low CD4 cells in HIV-infected persons
indicates severely depressed immunity that makes them susceptible to fresh or active TB
infection or reactivation of latent infection and rapid degradation of clinical condition. It has
already been established that TB attributed to a six-fold to seven-fold increase of viral load in
HIV positive population [37]. According to an estimate of World Health Organization, TB has
become one of the leading causes of death among HIV-infected persons . All HIV-infected
individuals should be tested for tuberculosis prior to the initiation of ART in countries like India
where tuberculosis is endemic. Several tests including chest x-ray and sputum cultures should be
done to all individuals. This will result in early detection and treatment, and thus reduction of
spread of disease.

17
The prevalence of TB/HIV co-infection patient on ART in our study was moderate at 14.1%. Th
This study found that, out of 23 active TB-HIV co-infected patients, 12(52.2%) were females
and 11(47.8%) were male. This study result is lower than studies conducted in Amhara region,
Ethiopia that were found the proportion of female respondents who had TB/HIV-co infection
accounted for a larger proportion in the sample 107 (69%) compared to male respondents 48
(31%) . This variation is due to difference in study area, study period and prevalence of the
diseases. The highest proportion of the study participants were in age group of 16–54 years,
21(91.3%) followed by 6-15year, 2(8.7%). Patients with no education and those with secondary
education accounted for the larger proportion 9(39.1%) of having TB/HIV coinfection compared
to those with illiterate 2(8.7), primary education 8(34.8%) and higher education 4(17.4%). In
addition, majority of TB/HIV patients 15(65.2%) were urban residents while 8(34.8%) were
residing in rural areas. This finding was in line with study conducted in Amhara region, Ethiopia
in which majority of TB/HIV patients 130(82.8%) were urban residents while 27(17.2%) were
residing in rural areas. Majority of study participants were merchant 6(26.1%),compared with
House wife 4(17.4)government employee 1(4.3%), students 2(8.7%), farmer 3(13.0%) , soldier
3 (13.0) and other 4 (17.4). Highest prevalence were found in married 9 (39.1%), followed by
unmarried 5 (21.7),divorced 5(65.2) and widow 4 (17.4%),. Of 23 active TB/HIV patients,
11(47.8%) were diagnosed by sputum directed microscopy and 7 (30.4%)gene xpert and
5(21.7%) were diagnosed by chest X-ray. Regarding socio–demographic and clinical
characteristic of the study participants, the proportion of tuberculosis was high among working
17(73.9%) followed by ambulatory 6(26.1%) and bedridden 0(0.0%). WHO stage III clinical
disease 16(69.6%), followed by clinical disease, stage II and I 4(17.4) and stage IV 3(13.0%),
having CD4 level less than 200 cells/mm3 blood at ART initiation 1(4.3%), CD4 level between
200_350 cell/ml 5(21.7%), CD4 level between 350_500 cell/ml 2(8.7%) and CD4 level ≥ 500
cell/ml 15(65.2%). Maintaining the CD4 positive cell level as high as possible in patients with
advanced disease helps the person to have low risk of infection or re-activation of tubercle bacill.
Similarly, low level of CD4 count was reported as risk factor for development of tuberculosis in
HIV/AIDS patients from Tanzania [6]. our study also revealed a poor adherence of participants
to the ART drug, indicating higher proportion of tuberculosis 13(56.5%) among the participants
compared with patients having good adherence 10(43.5%) and this result is in line with studies
conducted in Addis Ababa. [20] This study also revealed that there is significant association
between TB/HIV co infection.

CHAPTER SEVEN: CONCLUSION AND LIMITATION

7.1 CONCLUSION
According to this study the prevalence of active TB among study participants was 23(14.1%).
These findings suggest that active TB is still a common problem among patients receiving ART
in our settings. Patients who are at increased risk of developing active TB while receiving ART ,

18
those who are diagnosed with advanced HIV disease .There were a differences on the prevalence
of tuberculosis between males and females, females being more affected. In addition, being
house wife was also positively associated. TB was found to be high among patients on ART with
low drug adherence and CD4 cell count

6.2 Limitations of the study

The obtained data was based on recorded information in the medical records of patients. So
accuracy of the findings of this study depends on the accuracy of the registered information.
Therefore, information bias may be occurred in the registered data And also this study was a
hospital-based analysis of the HIV/TB co-infected patients and the findings might not be
generalizable.

19
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