HIV care among patients with presumptive tuberculosis in Masvingo district of Zimbabwe, 2017: how well are we doing?

Introduction While HIV care among tuberculosis (TB) patients is successfully implemented and monitored, it is not routinely reported among “presumptive TB patients without TB”. The present study describes the ascertainment of HIV status and receipt of antiretroviral therapy (ART) and the associated factors among presumptive TB patients (with and without TB) in 35 public health facilities of Masvingo district of Zimbabwe from January to June 2017. Methods This was an analysis of secondary programme data. We performed log binomial regression to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). Results Of 1369 presumptive TB patients, 1181 (86%) were ascertained for HIV status (98% among those subsequently diagnosed with TB, 83% among non-TB). Of them, 748 (63%) were HIV positive, more among TB patients (69%) than those without TB (61%). Among HIV-positive patients, 475 (64%) received ART, significantly higher among TB patients (78%) compared to those without TB (57%). Patients without TB were significantly more likely to have non-ascertained for HIV status (aRR=2.4, 95% CI=1.4-5.0) and not receiving ART (aRR=1.8, 95% CI=1.6-2.0), compared to those with TB. Conclusion We found high rates of HIV status ascertainment among presumptive TB patients. But, ART uptake was poor among “presumptive TB patients without TB”, despite implementation of “test and treat” strategy in Zimbabwe. The programme should step up the monitoring of HIV status and ART receipt among presumptive TB patients, by introducing an indicator in the quarterly reports of the national TB programme.


Introduction
Despite great progress in the response to Tuberculosis-Human Immunodeficiency Virus (TB/HIV) syndemic globally, the morbidity and mortality remains high. According to the World Health Organization (WHO) Global TB Report 2017, an estimated 1.0 million people globally had HIV-associated TB, and 374, 000 died from it in 2016 [1]. Because HIV is treatable with highly effective antiretroviral therapy (ART) and most of the TB is curable, such high mortality is unacceptable. The WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have both embraced a new vision to end epidemics of HIV and TB, in line with the sustainable development goals by 2030 [2]. To achieve this, the WHO's Global TB Programme has formulated an 'End TB strategy' with an overall vision of a TB-free world (zero deaths, zero disease and zero suffering due to TB) and a goal of ending the TB epidemic (annual incidence of TB to 10 new cases or less per 100,000 population) [3]. Similarly, UNAIDS has provisionally defined ending the AIDS epidemic as reducing the number of new HIV infections and AIDS-related deaths by 90% compared to 2010 levels [2]. Both the TB and HIV worlds have set themselves ambitious 90-90-90 targets to achieve by 2020.
With respect to HIV, it means diagnosing 90% of estimated PLHIV, treating 90% of those diagnosed with HIV and achieving viral suppression in 90% of those treated with ART [2]. In the case of TB, this means diagnosing and treating 90% of all people with TB, including 90% of the key populations at risk of TB and achieving 90% treatment success for all people diagnosed with TB [4]. In 2012, WHO launched its updated policy on collaborative TB/HIV activities, which recommended HIV testing for not only patients diagnosed with TB, but also to all those being investigated for possible TB (hereafter referred to as "presumptive TB"). This recommendation was based on high HIV prevalence among patients with presumptive TB [5][6][7][8][9][10][11][12] and high mortality among HIV-infected presumptive TB patients without active TB [13] [16]. Since that study, several programmatic interventions have been implemented by the national HIV programme in Zimbabwe including decentralized availability of HIV testing and ART services at all health facilities and the adoption of "test and treat" policy, meaning all PLHIV be started on ART irrespective of CD4 count or clinical staging [17]. However, whether these measures have resulted in improved HIV care among presumptive TB patients is not known.
Thus, the present study was carried out to describe the ascertainment of HIV status and uptake of ART services and the associated factors among presumptive TB patients (with and without TB) attending the public health facilities of Masvingo district, Zimbabwe during January-June 2017.

Methods
Study design: this was an analysis of secondary data collected routinely by the National AIDS and TB programme in Zimbabwe.

Setting
General setting: Zimbabwe is a country situated in Southern Africa with a population of ~13 million [18]. Zimbabwe has 10 provinces of which eight are rural and two are city provinces. The country's Gross Domestic Product (GDP) is 113.9 billion US dollars which places it in the group of low income countries [19]. Masvingo Province is one of the country's eight rural provinces, located in the southern part of the country and has a population of 1.5 million. The province has seven districts out of which Masvingo is the study district [2]. Masvingo is predominantly a rural district with a population of 0.3 million.
Zimbabwe NTP: all patients presenting at health facilities are screened for signs and symptoms of TB using the TB screening questionnaire. Anyone who has cough for more than two weeks, fever, weight loss, night sweats or household contact of active TB is considered to be "presumptive TB patient" and recorded in a "Presumptive TB Register" which is placed at each health facility.
Then s/he is evaluated for TB in accordance with the standard TB diagnostic algorithm using sputum smear microscopy and/or Xpert MTB/RIF assay [20]. Of the health facilities in the district, five have TB diagnostic facilities-all of these have sputum microscopy while two of these have Xpert MTB/RIF. Those who are negative bacteriologically are assessed clinically using chest radiography and other appropriate investigations and a diagnosis of clinical TB is made by the treating physicians [21]. All diagnosed TB patients are treated free of charge with daily DOTS regimen under direct supervision as per national guidelines [20]. TB treatment is available at all health facilities [20]. As part of the TB-HIV collaborative activities, HIV status is routinely ascertained among presumptive TB patients. For patients who know their status, HIV test result is documented in presumptive TB register. Patients with unknown HIV status are offered HIV testing and those found to be HIV-positive are initiated on ART free of cost [22]. HIV testing and ART services are available at all health facilities of the study district.  Receiving ART: this includes HIV-infected presumptive TB patients who were receiving ART during the study period (includes those previously on ART and those newly started on ART). The key predictor variables included age, gender, entry point and type of TB. Chi-square test was used to study the association of demographic and clinical variables with non-ascertainment for HIV and not receiving ART [17].
The strength of association was expressed using relative risk (RR) and adjusted RR with 95% confidence intervals (CI) using a log binomial

Results
There were a total of 1426 presumptive TB patients during the study period. Of them, 57 (4%) from the Zimbabwe Prison Service, Mutimurefu were excluded due to missing data. Of the remaining 1369 included in the analysis, more than half of the patients were adults in the age group of 15-44 years (780, 57%), females (690, 51%), belonged to the rural areas (842, 63%) and were referred from general outpatient department (710, 52%). Nearly a quarter of the presumptive TB patients were diagnosed with TB (330, 24%). Of them, 128 (9%) had bacteriologically confirmed pulmonary TB, 174 (13%) were diagnosed as "clinically confirmed pulmonary TB" and 28 (2%) had extra-pulmonary TB (Table 1).   [16]. Fourth, double data entry and validation was done to minimize data entry errors. There were a few limitations. Firstly, routine programme data were used in this study which was found to be incomplete in some places. We assumed that HIV-positive presumptive TB patients whose ART status was "not recorded" as having not initiated on ART. It is possible that the patients received ART at the clinic without getting recorded in the register (less likely in our view) or were initiated elsewhere (especially outside the district) without the information being communicated to the clinic. We also assumed that presumptive TB patients whose HIV status was "not recorded" as not tested for HIV.

Conclusion
The study found encouragingly high rates of HIV status ascertainment among presumptive TB patients. However, uptake of ART was poor among those without TB. The national TB and HIV programmes should step up the monitoring of HIV status and ART uptake among presumptive TB patients.

What is known about this topic
 HIV testing is routinely offered not only to TB patients but also to "presumptive TB patients without TB" but HIV care among the latter is not routinely reported and monitored;  A study carried out in a single health facility in Zimbabwe in 2009-13 reported high HIV ascertainment and low ART uptake (38%) among presumptive TB patients.

What this study adds
 HIV status ascertainment continues to be high among presumptive TB patients (86%), though marginally better among TB patients (98%) compared to non-TB (83%);  Even after implementation of "test and treat" approach, ART uptake (63%) remains poor: worse among patients without TB (57%) compared to those with TB (78%);  Compared to previous study, ART uptake has improved from 38% to 57%, though still far away from the globally recommended 90-90-90 target.

Competing interests
The authors declare no competing interests.