Operational research on tuberculosis control in Malawi - 3. HIV testing and tuberculosis treatment outcome in a rural district in Malawi

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Operational research on tuberculosis control in Malawi

Banerjee, A.

Publication date

2003

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Citation for published version (APA):

Banerjee, A. (2003). Operational research on tuberculosis control in Malawi.

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3.. HIV testing and tuberculosis treatment outcome in a rural

districtt in Malawi

AA Banerjee

S Moyo

, F Salaniponi

, A Harries

11

_{Ntcheu District Hospital, Ntcheu, Central Region, Malawi}

National Tuberculosis Control Programme, Lilongwe, Malawi

Publishedd in:

Transactionss of the Royal Society of Tropical Medicine and Hygiene 1997;

Vol.. 91: pp. 707-708

Infectionn with the human immunodeficiency virus (HIV) is strongly associated with tuberculosiss (TB) in sub-Saharan Africa. Although TB in HIV-positive patients responds welll to treatment, cohort studies in urban areas of East, Central and West Africa [1-5] havee documented high mortality rates at 6 months and 12 months after the start of anti-tuberculosiss treatment. This adversely affects cure rates, and prevents the 85% cure ratee target set by the World Health Organization [6] from being reached. There is little informationn from rural areas of sub-Saharan Africa about acceptability of HIV testing amongstt TB patients or about treatment outcome in relation to HIV serostatus. We reportt from a rural district in Malawi.

Ntcheuu District Hospital is situated in Ntcheu, in the Central Region of Malawi, and servess a rural population of approximately 500,000. All patients diagnosed with TB in Ntcheuu district are registered in the hospital and are treated according to the Malawi Nationall TB Programme. At the end of eight months of anti-TB chemotherapy, the treatmentt outcome of all smear-positive pulmonary TB patients is evaluated by the districtt TB Officer in accordance with guidelines from the International Union Against Tuberculosiss and Lung Disease (IUATLD) [7], and results are entered in the district TB register.. In 1995, new smear-positive pulmonary TB patients in Ntcheu received two monthss of daily supervised streptomycin, rifampicin, isoniazid and pyrazinamide in hospitall followed by six months of isoniazid and thiacetazone at home.

Att the beginning of 1995, HIV counselling and testing were started in the hospital, and HIVV serostatus was assessed with a Serodia® particle agglutination test. On the TB wards,, patients were initially approached on an individual basis by a counsellor about counsellingg and HIV testing. This procedure was unpopular with patients, and by the endd of the first 3 months was changed to a general health talk on HIV infection and acquiredd immune deficiency syndrome (AIDS), after which patients were informed that thosee who wished to know more and who wanted individual counselling and HIV testing couldd approach the counsellors later in private. In August, it became apparent that male patientss believed that blood which was taken for HIV testing was being used for blood transfusionss and they were therefore unwilling to be tested. This misconception was resolvedd in the same month.

Treatmentt outcome of all new, smear-positive pulmonary TB patients who were diagnosedd and registered between 1 January and 31 December 1995 was obtained fromm the district TB register. Results of acceptance of HIV testing and HlV-serology weree obtained from case files and the TB register. Treatment outcomes between differentt groups of patients in relation to HIV-results were analysed by t h e /2 test.

Twoo hundred and five patients (97 men and 108 women, mean age 37 years) with new, smear-positivee pulmonary TB were diagnosed and treated at Ntcheu District Hospital in 1995.. HIV counselling and testing was accepted by 110 (54%) patients, 31 men (32% off men) and 79 women (73% of women). In the first six months of the year, HIV testing wass accepted by 30 (33%) of 91 patients; this included 2 (4%) men and 28 women (64%% of women). In the last six months HIV testing was accepted by 80 (70%) of 114 patients;; this included 29 men (58% of men) and 51 women (80% of women). Of patientss who were tested, 73 (66%) were HIV seropositive: 18 men (58% of men) and 555 women (70% of women). At the end of treatment, 126 (61%) patients were cured andd 56 (27%) had died. Treatment outcomes at the end of chemotherapy in relation to HIVV testing and HIV results are shown in the Table. Significantly fewer HIV positive patientss and fewer patients with no HIV test result were cured, compared with HIV negativee patients, and significantly more HIV positive patients and patients with no HIV testt result died, compared with HIV negative patients (P<0.05 in both cases).

Thee high HIV seropositivity rate amongst patients with new, smear-positive pulmonary TBB in a rural district revealed by this study was comparable to that observed in urban hospitalss in Malawi [8]. The overall acceptance rate for HIV testing was low (less than 55%),, although it improved considerably in the latter half of the year with different counsellingg procedures and when misconceptions had been addressed and resolved. Nott surprisingly, HIV positive patients had a worse outcome than HIV-negative patients inn terms of cure rate and death, as has been documented elsewhere. Treatment outcomess were also poor in patients who did not accept counselling. Many of these patientss may also have been HIV seropositive, and if very ill may not have seen the pointt in undergoing HIV testing. These results show that, even in a rural area of Malawi, thee cure rate of 85% cannot be achieved, largely because of high HIV-related mortality. Inn areas where HIV is prevalent, we believe that the WHO cure rate target should be sett at a lower level.

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References References

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2.. Okwera A, Whalen C, Byekwaso F, et al. Randomised trial of thiacetazone and rifampidn-containingg regimens for pulmonary tuberculosis in HIV-infected Ugandans. Lancett 1994; 344:1323 - 8

3.. Ackah AN, Coulibary D, Digbeu H, et al. Response to treatment, mortality, and CD4 lymphocytee counts in HIV-infected persons with tuberculosis in Abidjan, Ivory Coast. Lancett 1995; 345:607 - 1 0

4.. Elliott AM, Halwiindi B, Hayes RJ, et al. The impact of human immunodeficiency viruss on mortality of patients treated for tuberculosis in a cohort study in Zambia. Transs R Soc Trap Med Hyg 1995; 89:78-82

5.. Perriens JH, St Louis ME, Mukadi YB, et al. Pulmonary tuberculosis in HIV-infected patientss in Zaire. A controlled trial of treatment for either 6 or 12 months. N Engl J Medd 1995; 332:779-84

6.. World Health Organization. Treatment of tuberculosis : guidelines for national programmes.. 2nd edition. WHO/TB/97.220:1-66. Geneva: WHO, 1997

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8.. Harries AD, Maher D, Mvula B, Nyangulu D. An audit of HIV testing and HIV serostatuss in tuberculosis patients, Blantyre, Malawi. Tuber Lung Dis 1995; 76:413-7 76:413-7