Article Text
PDF
Abstract
Objective To assess the prevalence, treatment outcomes and determinants of tuberculosis (TB)–HIV coinfection in Ghana.
Study design A retrospective review of TB case register for Kwabre East Municipality was conducted for the period 2010–2020 to identify TB–HIV coinfections.
Setting 462 patients with TB from four sub-municipal treatment centres were included in the study.
Primary outcome measure A logistic regression model was used to investigate the relationship between clinico-demographic factors (age, sex, type of patient, disease classification, treatment category and sputum smear microscopy) and TB–HIV coinfection.
Results Of the 462 individual TB cases found in the TB register from 2010 to 2020, 286 (61.9%) were screened for HIV and the results showed that 18% had TB–HIV coinfection. TB–HIV coinfection was highest in 2015 with a prevalence of 40% among all registered TB cases. The likelihood of TB–HIV coinfection was highest among patients with TB aged 40–49 years (AOR=3.99, CI=1.3, 12.7). Those who tested negative for TB at the end of their treatment period had lower odds of HIV coinfection (AOR=0.27, CI=0.10, 0.72).
Conclusion Nearly one out of every five (18%) patients with TB in the municipality were found to be coinfected with HIV. TB–HIV coinfection was significantly associated with patients' age and their TB treatment outcomes. Urgent interventions are needed to address these risk factors to promote optimal health for patients with TB in the municipality.
- public health
- epidemiology
- HIV & AIDS
- tuberculosis
Data availability statement
Data are available upon reasonable request. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
STRENGTH AND LIMITATION OF THIS STUDY
To the best of our knowledge, this is the first study on tuberculosis (TB)–HIV coinfection in the Kwabre East Municipality of Ghana and involves all the treatment centres for TB and HIV.
The data used in this study were retrieved from facility-based TB registers which are the only available sources for relevant information on patients with TB in the area.
The pooled data span a decade, and therefore, some of the reported experiences may have changed with time.
The study involved only patients with TB who sought treatment at the treatment centres, hence the overall prevalence could be underestimated.
Background
Coinfection of tuberculosis (TB) and HIV is a huge public health burden to many resource-limited countries, especially, in sub-Saharan Africa (SSA).1 TB, which is an airborne bacterial disease caused by Mycobacterium tuberculosis, is widely known as one of the most common causes of ailments and death among HIV-positive patients,2 and both diseases influence each other’s progression.3 4
In 2019, an estimated 10 million people had TB worldwide, with about 208 000 deaths among those coinfected with HIV.5 Moreover, 7.1 million (71%) out of the 10 million people who lived with TB in 2019 reported to national TB programmes leaving about 2.9 million (29%) people with unknown disease trajectories.5
TB–HIV coinfection is known as one of the major causes of severe ailments and mortality in SSA.6 Out of the estimated 400 000 annual deaths recorded for patients with TB coinfected with HIV worldwide, approximately 51% of the mortalities are known to occur in SSA.7 Ghana, a country in West Africa is classified by the WHO as a high-risk country for TB–HIV coinfection.8 In 2015, approximately 9900 new TB cases among HIV-positive individuals were reported in the country representing 36 per 100 000 population.8 Studies in Ghana indicate that the coinfection of patients with TB and HIV is an emerging challenge as more than 14% of TB cases in Ghana are now linked to HIV.8 9
Given that TB–HIV coinfection is a newly emerging challenge in the history of TB control in Ghana, it is important to understand the prevalence, treatment outcomes and risk factors associated with TB–HIV coinfection in order to develop evidence-based interventions for patients and at-risk populations. However, studies on the prevalence, treatment outcomes and risk factors associated with TB–HIV coinfection in Ghana are limited. In view of this significant research gap, this study aimed to assess the prevalence, treatment outcomes and determinants of TB–HIV coinfection using the Kwabre East Municipality in Ghana as a case study. Findings from this study provide an understanding of TB–HIV coinfection in the country and will inform health workers, advocates and policymakers working in the area of TB–HIV control to develop evidence-based interventions for addressing this significant public health challenge in the country.
Methods
Study site
The study was conducted in the Kwabre East Municipality of Ghana in West Africa. Kwabre East Municipality is 1 of the 36 administrative districts in the Ashanti region of Ghana. It is a peri-urban municipality that was originally part of the Afigya-Sekyere district and was divided into the Afigya Kwabre and Kwabre East Municipality in 2008. It is bordered on the South by Kumasi Metro, on the North by Sekyere-South District, on the East by Ejisu-Juaben Municipality and Afigya Kwabre on the West. The municipal capital is Mamponteng which is situated about 14.4 km away from Kumasi on the Kumasi-Mampong road (Kwabre East District profile, 2021).
Kwabre East Municipality has four districts: Kenyasi, Mamponteng, Aboaso and Asonomaso, with a population of 147 046 and a population growth rate of 2.7%. Each district has a health facility with a Directly Observed Therapy centre, where TB diagnosis and treatment are conducted. All patients positive for TB undergo counselling before checking for their HIV status. Kwabre East Municipal was selected because anecdotal information indicates that it is one of the hotspot areas for TB cases in the Ashanti region of Ghana. Also, the major occupation of the Indigenes in the district is sand winning which is assumed to also increase their exposure to silica and TB infection. A map showing the study site is displayed in figure 1 (Kwabre East District profile, 2021).
A map of Kwabre East Municipality. Source: Kwabre East Municipal Assembly.
Study design
This study was based on a review of all TB cases registered from 2010 to 2020 in the Kwabre East municipal healthcare facilities. Patients with TB undergoing treatment in all the health facilities in the municipality from 2010 to 2020 were included as shown in table 1.
Locations in the Kwabre East Municipality where TB registers were reviewed
Source of data
Data were extracted from a facility-based TB register which is a standard document stored by the healthcare facilities. Data from the register were entered into Microsoft Office Excel and encrypted with a password. To promote data validity, ambiguous and unclear information in the register were excluded from the analysis. For instance, data that failed to show evidence of diagnosis were excluded. The TB register entails sensitive clinical information on patient demographics, disease classification, sputum microscopy, treatment results, treatment outcomes, HIV status, treatment start date, and the date treatment ended.
Data coding, processing and analysis
Data extracted from the TB register were entered into Microsoft Office Excel for cleaning to promote the accuracy of the findings. The cleaned data were exported into STATA V.14 software for analysis. The outcome variable was TB–HIV coinfection whereas the predictor variables were age, sex, type of patient, disease classification, treatment category and sputum smear microscopy. Tables and graphs were used to display the univariable descriptive statistics: mean, SD, percentages and frequencies. Next, associations between the outcome and predictor variables were examined using logistic regression at 95% Confidence Interval. Variance inflation factor was used to assess multicollinearity or the strength of correlation. It was predetermined that variables having a variance inflation factor greater than 10 would be excluded from the final model. Diagnostics tests, particularly, Hosmer-Lemeshow and the Likelihood test were conducted to establish how well the data fits the model.
Operational definitions
As displayed in table 2, a number of key terms were defined prior to the review to promote consistency of the findings.
Operational definitions for the review
Patient and public involvement
This study used only secondary data from the TB registry. No patient was involved in the data extraction or analysis.
Ethical consideration
The study was reviewed and approved by the Ethical Review Committee of the Kwame Nkrumah University of Science and Technology (KNUST) with an approval number of CHRPE/AP/209/21. An introductory letter was also sent to the Kwabre East Health directorate for permission to access the TB register. The study did not include any patient identifiers and the review was conducted in line with the ethical standards of KNUST.
Results
Characteristics of patients with TB
A total of 462 TB cases were found in the TB register for the years 2010 to 2020. Of these, the majority (65.8%) were males and the average age was 41 years. Most of them (25.3%) were aged between 30 and 39 years and the least proportion (7.6%) were those aged 19 years or younger. Most of the TB cases (66.2%) were pulmonary positive, less than half (32.6%) were pulmonary negative and the rest (2.2%) were identified as extrapulmonary after smear microscopy tests. In terms of patient type, the vast majority of 93.5% were new TB cases, 4.6% were TB case relapse, 1% were defaulters, 0.7% relocated to unidentified places for treatments and the rest (0.2%) had treatment failure. Regarding the end-of-treatment results, 96.9% became negative, 2.2% were still positive and the remaining 0.9% had unknown treatment results (table 3).
Characteristics of patients with TB, 2010–2020
Prevalence of TB–HIV coinfection by patient characteristics
The overall prevalence of TB–HIV coinfection within the study period was approximately 18%. This result did not take into account patients with TB who were not tested for HIV. Among coinfected patients in the study, more than half (66.7%) were males and the remaining were females (33.3%). Approximately, 41% of the TB–HIV coinfection cases were people aged between 40 and 49 years and the least (5.9%) was among those aged 50–59 years. Concerning disease classification, more than half (56.9%) were pulmonary positive, more than a quarter (35.3%) were pulmonary negative and about 1 in every 12 cases (7.8%) were extrapulmonary. Although more than three-quarters (82.4%) of the TB–HIV coinfected patients tested negative at the end of their treatment cycle, this was significantly less than the proportion of patients with TB who tested positive at the end of their treatment period (table 4).
Prevalence of TB–HIV coinfection by patient characteristics
Trends in TB–HIV coinfection from 2010 to 2020
Figure 2 provides a pictorial view of the patterns of TB–HIV coinfection in the Kwabre East municipal assembly. Figure 2 shows that the prevalence of TB–HIV coinfection between 2010 and 2020 was undulating. Prevalence declined between 2010 and 2011 but increased and reached its peak in 2015 before declining gradually to 2020.
Trends in TB–HIV coinfection from 2010 to 2020. TB, tuberculosis.
Treatment Outcome of TB patients who tested positive and negative for HIV
Table 5 shows that patients with TB who tested negative for HIV had higher odds of cure (85.7%) than those coinfected with HIV (14.3%). The majority (84.5%) of the patients with TB who were HIV-negative completed their treatment successfully, whereas only 15.5% of those with TB–HIV coinfection were able to complete their treatments.
Treatment Outcome of TB patients who tested positive and negative for HIV
Whereas three-quarters (75%) of the participants with TB–HIV coinfection defaulted treatment, a quarter (25%) of the patients with TB defaulted from their treatments. Nineteen (65%) of the patients with TB died before completing their treatments, whereas 10 (35%) patients coinfected with HIV died before treatment completion. None of the patients with TB-HIV coinfection had treatment failure but one patient with TB had treatment failure and experienced multidrug resistance (table 5).
Associations of TB–HIV coinfection by patient characteristics
As displayed in table 6, there were significant associations between TB–HIV coinfection and patients aged between 40 and 49 years (OR=3.73, CI=1.47, 8.17), patients diagnosed with X-ray (OR=1.88, CI=0.10, 3.55), patients who were pulmonary positive (OR=0.23, CI=0.08, 0.68), patients who tested negative at end of their treatment period (OR=0.20, CI=0.09, 0.43) and patients with unsuccessful treatment outcomes (OR=2.77, CI=1.4, 5.24). However, when the data were adjusted, only patients aged 40–49 years (AOR=3.99, CI=1.3, 12.7) and those who tested negative at the end of their treatment period (AOR=0.27, CI=0.10, 0.72) showed maintenance of significant associations with TB–HIV coinfection. The treatment result with an AOR of 0.27 indicates that those who tested negative for TB were more likely to be protected from HIV coinfection compared to those who tested positive for TB. Also, age and the ability to complete treatment regimen were key factors associated with TB-HIV coinfections. The final model had a likelihood test that produced a p value of 0.001 indicating the fit of the model. Additionally, the goodness of fit test using Hosmer-Lemeshow also showed a p value of 0.20 which is greater than 0.05 confirming the model fit.
Associations of TB–HIV coinfections by patient characteristics
Discussion
This study aimed to assess the prevalence, treatment outcomes and determinants of TB–HIV coinfection in the Kwabre East Municipality of Ghana. The number of patients with TB registered from 2010 to 2020 in the TB register was 462. HIV screening for every patient with TB is recommended by the WHO as an important ingredient in TB care; however, in the Kwabre East Municipality of Ghana, approximately 62% of the patients with TB were screened for HIV. This figure is quite higher than WHO’s global estimate of 55% in 2015. However, our figure is lower than several studies conducted in Africa. For instance, a study involving many African countries found that 81% of patients with TB were screened for HIV.10 Similarly, other previous studies found that 96% of patients with TB were screened for HIV infection.11 12 These findings demonstrate the growing interest in the need to screen for HIV after testing positive for TB in Africa.
The overall prevalence figure of 18% for TB–HIV coinfection in the municipality is above the estimated national prevalence of 14%.8 9 Though high, it is important to draw attention to the fact that these figures may be underestimated given the possibility of unreported TB cases in both the municipality and the country at large. The high prevalence can be attributed to the growing population size of the municipality over time, and also the main occupation of the Indigenes which is sand winning. This finding indicates that the community needs serious attention in terms of interventions for TB–HIV coinfection.
Our finding that the prevalence of TB–HIV coinfection between 2010 and 2020 was undulating is a concern. Notably, TB–HIV coinfection declined between 2010 and 2011 but increased and reached its peak in 2015 before starting to decline again. Consistent with,12 the overall trend in TB and HIV coinfections from 2012 to 2018 in this present study shows an overall decline in the number of cases reported. This finding also corroborates with observations from8 who found declines in TB–HIV coinfection from 2012 to 2018. A possible explanation for this result might be the improvement of TB–HIV combined programmes in 2015 aimed at increasing screening and treatment for all patients suffering from these diseases.11 A possible explanation for the undulating trend could be associated with inconsistent testing for HIV post-TB infection and changing rates of TB infection in the municipality. We recommend that public health advocates should continue to encourage patients with TB to provide consent to tests for HIV by showcasing the benefits of the tests.
In terms of the sociodemographic differences, we found that most of the patients with TB were men, and they were almost twice the number of women. This may be because more men compared with women usually engage in risky behaviours that affect the lungs, such as alcohol consumption and smoking and therefore making them prone to contracting TB.13 Also, most men in the Municipality who are likely to be breadwinners for their families engage in sand winning as their main occupation which also increases their chances of TB infection. This finding is not surprising and aligns with a study by Osei et al and Otiende et al.8 12 TB infection was also high among those aged 30–39 years. This is also not surprising as Ghana and Africa in general have a very youthful population.10 The youth are also likely to be breadwinners and hence many of them might have been predisposed to the sand winning occupation which in turn increases their exposure to silicon and TB.
Regarding treatment outcomes, patients with TB who tested negative for HIV had higher odds of being cured than the coinfected patients. This is reasonably in line with the literature on reported treatment complications associated with TB–HIV coinfection.6 The study findings suggest patients with TB who are coinfected with HIV had higher odds of defaulting their treatment regimen, probably due to complexities associated with treatment. This suggests a need for extra attention in the provision of treatment support for patients with TB coinfected with HIV.
One complicated finding was that 19 out of 462 patients with TB reportedly died before completing their treatment regimen compared with 10 out of 51 patients with TB coinfected with HIV. Although the frequency of death among the patients with TB was higher than those coinfected with HIV, the proportional or percentage differences clearly show that those coinfected with HIV had a higher risk of mortality than those infected with only TB. A surprising finding, however, was the discovery that none of the patients with TB-HIV coinfection had treatment failure compared with the one patient with TB whose treatment failed. This unexpected finding may however be due to the relatively high number of patients with TB compared with the small number of patients who tested positive for both TB and HIV.
One of the key objectives of this study was to assess the associations between clinicodemographic factors and TB–HIV coinfection. The finding that patients aged 40–49 years were significantly associated with TB–HIV coinfection differs from other reported studies. For instance, a previous study in Ghana has shown that TB–HIV coinfection is significantly associated with patients aged 25–45 years.8 Another study by Davy-Mendez et al1 noted associations between TB–HIV coinfection and patients aged less than 15 years. These differences may however be due to the differences in patient characteristics in the locations where the studies were conducted. Another possible reason is the differences in the age classifications across studies. It was also revealed in this study that patients with TB who tested negative for TB at the end of their treatment regimen were significantly associated with a lower risk of HIV coinfection. This result is consistent with previous studies1 2 8 14 which found that patients with TB who receive negative test results post-treatment have lower risks of HIV coinfection.
Limitations of the study
Caution should be taken in interpreting the findings in this study, particularly, regarding the reported associations as the sample of 51 TB–HIV coinfections was too small to establish causality. This weakness of the small sample size was particularly evident in the logistic regression analysis as outlier figures distorted the reported CIs. Additionally, only patients with TB who reported and registered at a health facility in the municipality were included in the study and this may have influenced an underestimation of the actual prevalence of TB–HIV coinfection in the area as some people may have avoided hospital attendance due to factors such as fear of stigmatisation. Moreover, TB–HIV coinfections in private hospitals were not captured in this study. However, it is a common rule of thumb in the Ghanaian healthcare system for clinicians to refer TB–HIV cases to referral health centres. Furthermore, the use of secondary data to examine the factors associated with TB–HIV coinfection is a further limitation considering that other possible explanatory variables were unavailable in the TB register. In other words, the analysis was limited to only variables recorded in the register and that is a constraint in the establishment of associations. Furthermore, the pooled data spans a decade and some of the experiences reported in this study may have changed with time.
Implications for policy and research
The findings in this study have important implications for policy and further research. First, the high prevalence of TB–HIV coinfections in the register indicates the need for urgent measures to reduce such coinfections. This is particularly serious for the municipality considering that the reported prevalence was higher than the estimated national figure. The district health management team and health promoters can develop or intensify public education messages on TB–HIV coinfections in the municipality to encourage voluntary testing. Given that those who tested negative for TB at the end of their treatment regimen were also at lower risk of HIV coinfection, preventive health messages on the importance of adhering to TB treatment can be advocated across the community to promote awareness and also sensitise community members to the importance of seeking for early treatment.
In terms of research, the findings provide a preliminary basis for further research on TB–HIV coinfection in the municipality. Importantly, more work is needed to establish causal inferences in the associations between risk factors and TB–HIV coinfection. A more in-depth understanding of the individual, community and contextual factors associated with TB–HIV coinfection is an important ingredient needed to support the development of interventions against TB–HIV coinfections. Future studies can consider using prospective study designs, such as tracking methods or qualitative interviews to draw experiences from patients to help improve understanding of what is happening on the ground. Such an approach will also help address the missing gaps and information observed in this present study.
Conclusions
There are emerging concerns about a potential upsurge in TB–HIV coinfections in many resource-limited settings, such as Ghana. This study examined the prevalence, outcomes and correlates of factors associated with TB–HIV coinfections in the Kwabre East Municipality of Ghana. This important preliminary study has established that the prevalence of TB–HIV coinfection is about 18% in the municipality. Most patients with TB who tested negative for HIV had ‘completed’ treatment outcomes and higher cure rates compared with patients with TB-HIV coinfections. The study also found that age and treatment results are two key factors associated with TB–HIV coinfections. To contribute to reaching the goal set in the global Sustainable Development Goal 3 which is to promote healthy lives and well-being for all by 2030, there is a need for serious investments into combating TB–HIV coinfections in the municipality and even beyond.
Data availability statement
Data are available upon reasonable request. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study was reviewed and approved by the Ethical Review Committee of the Kwame Nkrumah University of Science and Technology (KNUST) with an approval number of CHRPE/AP/209/21. An introductory letter was also sent to the Kwabre East Health directorate for permission to access the TB register. The study did not include any patient identifiers and the review was conducted in line with the ethical standards of KNUST.
Acknowledgments
I wish to acknowledge the research assistants and the focal person for TB in Kwabre East Municipality for their contribution in this study.
Footnotes
Contributors EOB devised the project and the main conceptual ideas. IYA and EKN provided high-level technical advice. EOB and EKN performed and supervised the analysis, respectively. EOB drafted the research methods, whereas EKN supervised the fieldwork. EKN, IYA, BNA and AMM provided feedback on the analytical framework. IYA and EOB drafted the manuscript. EKN, BNA and AMM reviewed the manuscript and provided feedback. All authors discussed the results and contributed to the final manuscript. EOB is responsible for the overall content as the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.