The burden of HIV on Tuberculosis patients in the Volta region of Ghana from 2012 to 2015: implication for Tuberculosis control

We conducted a retrospective study of all TB cases registered from 2012 to 2015 in five districts of Volta Region of Ghana. The districts were Ho, Hohoe and Kpando in the Middle zone; Kadjebi in the Northern zone and Keta in the Southern zone of the Volta region. Three districts were selected from the middle zone due to high population density compared with the other zones. The Volta region is the longest region in Ghana, and stretches from the Gulf of Guinea through nearly all the vegetational zones found in the country. The Region is divided into 25 administrative districts/municipalities with Ho as the Regional capital. Volta Region has a total of 377 health facilities serving a population of 2,789,211 with a growth rate of 2.5%. The region is divided into three natural geographical belts namely the southern, middle and the northern belts. There are 44 DOTS centres and 41 diagnostic centres in the Region that provide TB diagnosis and treatment services to suspected clients. TB diagnosis, treatment, and monitoring are done as per the national tuberculosis control program (NTBCP) guidelines (Volta Regional Health Directorate: 2015 annual report, unpublished). All patients diagnosed with TB are also supposed to undergo HIV counselling and testing. Fig. 1 represents the map of the Volta region showing the study districts.

Data were extracted from the district TB register (TB 07). The register is a standardized document used by all district tuberculosis control programmes in Ghana. It is kept by the district TB focal person who goes round all treatment centres within the catchment area from time to time to update it by serially transferring patients’ information from the facility TB registers into the district register. These information include patients’ demographics, identifiers, type and category of TB, initial and follow up sputum smear examination results, HIV test results, and treatment outcomes.

Smear positive PTB refers to a patient with at least one sputum smear positive for acid fast bacilli (AFB), or one sputum smear positive for AFB plus radiographic abnormalities consistent with active pulmonary tuberculosis; or one sputum specimen positive for AFB plus culture specimen positive for Mycobacterium tuberculosis.

This study utilized routine service delivery data for the purposes of programme monitoring and evaluation. The data analysed did not include identifiers of the patients and was exempted from ethical approval. The University of Health and Allied Sciences, School of Public Health’s scientific review committee ruled that this study do not require formal ethical approval.

Of the 1772 TB cases registered during the study period, 1633 (92.2%) were tested for HIV. The proportion of TB cases tested for HIV was more than 90% for all districts except Ho and Kadjebi where 85% and 81.8% of cases registered during the period were tested respectively. Of the 1633 cases tested for HIV, 297 (18.2%; 95% CI: 16.4–20.1) were HIV positive. The prevalence was highest in Kpando municipal (26.0%; 95% CI: 21.5–31.2) followed by Kadjebi district (24.9%; 95% CI: 19.7–30.9) and lowest in Keta municipal (10.8%; 95% CI: 7.9–14.7) as shown in Table 2 and Fig. 2.

The overall prevalence of TB/HIV co-infection was significantly higher (24.1%; 95% CI: 20.8–27.7) among females compared to males (15.1%; 95% CI: 13.1–17.4) (p < 0.001). With regards to age, the prevalence was highest (27.0%; 95% CI: 18.2–38.1) among patients <15 years of age and lowest (3.5%; 95% CI: 1.6–7.4) among patients ≥70 years (p < 0.001). Fig. 3 shows the trend of prevalence of TB/HIV co-infection stratified by sex whereas Fig. 4 represents the prevalence of TB/HIV by age groups.

Treatment outcomes significantly differed among TB cases and TB/HIV co-infected patients. Nearly 90% (95% CI: 88.1–91.5) of only TB cases evaluated were successfully treated, compared to 77% (95% CI: 71.7–81.7) among TB/HIV co-infected patients (p < 0.001). TB/HIV co-infected patients were about 3 times more likely to die before completing treatment compared to TB only patients. Defaulter rate was also highest (9; 3.3%) among co-infected patients compared to 21 (1.7%) among patients with TB only. However, treatment failure rate was about 2 times more among patients with TB only compared to TB/HIV co-infected patients as shown in Table 3.

In the adjusted analysis, patients who were ≥70 years old had 91% lower odds of being infected with HIV (AOR: 0.09; 95% CI: 0.04–0.26; P < 0.001) than patients who were less than 15 years old. Additionally, female TB patients were about 2 times more likely to be HIV positive compared to male patients (AOR: 1.89; 95% CI: 1.44–2.49; P < 0.001). With regards to TB classification, smear negative pulmonary TB patients were 84% more likely to be HIV positive (AOR: 1.84; 95% CI: 1.37–2.47; P < 0.001) than smear positive pulmonary TB patients. However, the odds of HIV infection was not significantly different among extra-pulmonary TB patients compared to the reference group. TB Patients registered in Keta municipality had 62% lower odds of being HIV positive (AOR: 0.62; 95% CI: 0.38–0.99; P = 0.047), compared to those registered in Ho municipality. Conversely, patients registered in Hohoe, Kadjebi, and Kpando were more likely to be HIV positive (AOR: 1.69; 95% CI: 1.13–2.54; P = 0.01), (AOR: 2.29; 95%CI: 1.46–3.57; P < 0.001), (AOR: 2.15; 95% CI: 1.44–3.21; P < 0.001) respectively compared to the reference district (Table 4).

Systematic screening for HIV among TB patients is recommended by WHO as an essential component of the TB care package. This study established that more than 9 in 10 TB patients notified during the period had documented HIV test result, higher than the WHO’s global estimate of 55% in 2015 and that of the African Regions (81%) [1]. This shows that HIV screening practices among TB patients is good in this part of the world and should be sustained. Similar finding was reported in a study in Ethiopia [10].

Regional and countries prevalence studies on TB/HIV co-infection showed varied values ranging between 2.9 and 72.3%, with pooled prevalence of 23.5% [11]. The overall HIV seroprevalence in TB patients in this study is higher than the current global estimate of 15% but much lower than the estimate from the African Region (36%) [1] and the national average of 24% [12] but is comparable to findings from studies done in India (18.9%) and Brazil (19%) [13, 14].

Overall, the global prevalence of TB/HIV co-infection has been falling since 2008 [1]. Conversely, this study identified a stable TB/HIV co-infection in the study districts during the years 2012 to 2015. This suggests that additional efforts to strengthen TB/HIV collaborative activities are required in order to reduce the burden of HIV in TB patients. However, given that we used only 4 years in our analysis, we recommend further studies which incorporate data of several years before a firm conclusion can be drawn.

In this study, TB/HIV coinfection rate was significantly higher in female patients than in males. This finding is consistent with a number of studies that showed that females bear a disproportionate burden of HIV infections in sub-Saharan Africa [15‐18]. The factors contributing to this could include lower socioeconomic position of women [18] as well as biology, sexual behaviour and socially constructed gender differences between men and women in roles and responsibilities, access to resources and decision-making power [18, 19]. Our finding is however contrary to findings from a study in Northwest Ethiopia [10] but similar to report from Northeastern Ethiopia [20].

A high rate of TB/HIV co-infection was also observed in patients <15 years of age. This is in contrast to several studies that have shown TB/HIV coinfection rates to be higher in persons aged 25–45 years [10, 21, 22] representing the sexually active age group. The high prevalence in persons <15 years could imply early indulgence in sexual activities by this age group in the study districts but this needs to be thoroughly investigated.

Among patients with pulmonary TB, those with sputum smear negative were about 2 times more likely to be co-infected with HIV. This finding concords with that of a previous report, which showed that, in patients with HIV/AIDS, especially in the late stage of HIV infection, TB is often atypical in presentation and has low sputum smear positivity in pulmonary TB, which could result in delayed diagnosis of TB [23].

TB/HIV co-infected patients in this study had more unsuccessful treatment outcomes than patients with TB only and were more likely to die before completing treatment. Unsuccessful treatment outcomes associated with TB/HIV coinfection have been shown by several studies [21‐24]. The reason for the poor outcomes in this group could be due to drug interactions between the rifamycins (rifampin or rifabutin) and some antiretroviral agents [25] as well as malabsorption of anti-TB drugs among patients with advanced HIV [26], leading to low serum concentrations of drugs and therefore to unsuccessful treatment outcomes [27]. In addition, the high death rate among TB/HIV co-infected patients could be due to alternation of the clinical manifestation of TB and lack of a rapid and sensitive TB diagnostic test for diagnosing TB in HIV patients leading to delayed diagnosis and treatment [28‐30] that could eventually lead to death. The clinical alteration of TB in HIV-positive patients could also explain they were more likely to be smear negative as seen in this study. In contrast, treatment failure rate was twice more higher in patients with only TB compared to TB/HIV co-infected patients. Several reasons could account for this; it could be that some TB patients resort to traditional/herbal treatment, poor adherence to treatment and some could even have drug resistant TB [31, 32] and therefore will not respond to first line anti-TB drugs but this needs to be evaluated further in another study.

This study was retrospective in design and based only on data that was available in public health records. We could not independently corroborate the accuracy of these records, nor could we collect additional data needed to confirm or refute our findings. In particular we could not differentiate between TB/HIV co-infected patients on ART and those not on ART, and therefore, we could not assess its effect on our findings. Though a limitation, it calls for linkage of databases between TB and HIV control programs to ensure completeness of data for TB/HIV co-infected patients at all levels of the health care system. This will improve analysis of data that can provide accurate information for effective planning of targeted interventions. Despite this limitation, the study did provide useful information on the burden of HIV among TB patients in five districts of the Volta region. Findings may be useful to TB program managers and policy makers in implementing interventions to improve control of these infections.