Prevalence and Factors Affecting the Development of Active-Tb among HIV-Positive Patients at Shashemene Referral Hospital, Shashemene, West Arsi, Ethiopia

AFB: Acid Fast Bacilli; AIDS: Acquired Immune Deficiency Syndrome; AOR: Adjusted Odds Ratio; ART: Anti-Retroviral Therapy; AU: Ambo University; AUERB: Ambo University Electoral Review Board; CD4: Cluster of Differentiation 4; COR: Crude Odds Ratio; EPTB: Extra Pulmonary Tuberculosis; FMOH: Federal minister of Health; HBC: High Burden Countries; HIV: Human Immunodeficiency Virus; MDRTB: Multi Drug Resistance Tuberculosis; OPD: Outpatient Department; PTB: Pulmonary Tuberculosis; PLWHIV: People Living with Human Immune-deficiency Virus; RVI: Retro Viral Illness; SPSS: Statistical Package of Social Science; SRH: Shashemene Referral Hospital; TB: Tuberculosis; WHO: World Health Organization.


Introduction
Tuberculosis (TB) is an infectious bacterial disease commonly caused by Mycobacterium tuberculosis, which mainly affects the lung parenchyma [1].It is spread from one person to another person via droplets of nuclei from the throat and lungs of people with the active TB infection.In immune competent people, infection with Mycobacterium TB often has no symptoms, since the person's immune system acts to suppress the bacteria [2].
TB is among the leading causes of mortality for people living with HIV (PLWHIV) which comprises 25% of all causes of deaths [3].HIV and TB respectively, are the first and second leading causes of death worldwide due to a single infectious agent [1,4].HIV increases the progression of latent Mycobacterium tuberculosis to active disease and also raises the frequency of occurrence of TB [5].PLWHIV may also be more vulnerable to TB infection [3,6].Both TB and HIV lead to the main problem of infectious disease in impoverished countries [7].trend in TB incidence, prevalence and mortality has been reported over the 10 years, eradication of the disease worldwide is still out of reach, and huge resource investment is still required.TB is a povertyrelated disease which disproportionately upsets the poorest, the most susceptible and disregarded population groups wherever it happens [11].Increasing access to diagnosis and care, the basic requirements in the fight against TB, are mainly challenging in these population groups [12].Information is limited on the proportion of TB, HIV and TB/HIV co-infection in the study area in Ethiopia [13].
Based on the 2014 WHO report, the prevalence of TB is 211 per 100,000 of the population.About 13% of all new TB cases are also HIV co-infected.Moreover, Ethiopia is one of the high TB/HIV and multidrug resistant TB (MDR TB) countries.Among TB patients with known HIV status, about 11% were HIV co-infected [6,14].
TB-HIV co-infections pose particular diagnostic and therapeutic challenges and put forth enormous burden on health care systems.Information is limited on the proportion of TB, HIV and TB/HIV co-infection in the study area in Ethiopia.Also, various studies done nationally could not reflect the real TB/HIV situation in Shashemene area due to methodological variation [13,14].Therefore the aim of this study was to estimate the prevalence and factors associated with active-TB infection among HIV positive patients at Shashemene referral Hospital West Arsi, Ethiopia.

Study area
This study was conducted at Shashemene referral Hospital HIV clinic.Shashemene Referral Hospital is found in Kuyera town about 238 km south of the capital city, Addis Ababa.It is one of the most experienced hospitals of the region with more than 50 y of service for the population of the area which is currently estimated to be 2.1 million people.It was built by missionaries in 1942 and in 1968 upgraded to governmental general hospital.In 1999 the hospital upgraded to referral hospital.Nowadays the hospital encompasses 12.2 hectares of land with a total of 242 employees with the bed number of 167 .The hospital on average serves 254 patients per day.Study was conducted from February to March 2017 by using data from September 2013 to March 2017.

Study design
Retrospective cross-sectional study design was used to conduct the research at HIV clinic of Shashemene referral hospital.

Target population
• All adult HIV positive patients.

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All patients those attended HIV clinic at SRH from September 2013 to March 2017

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A systematic sampling method was adopted for selecting a representative sample.

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Patients' cards were selected randomly using their ART unique identification number.

Eligibility criteria
Inclusion criteria: All adult Human Immunodeficiency Virus (HIV) sero-positive patients.
Exclusion criteria: 1) Cards of the Patients those develop active TB before HIV infection is confirmed.2) Patients with age of less than 18-years-old.

Data collection procedure
Separated data collection forms were designed on which data from the patient cards were collected.The forms were filled by data collectors recruited from nurses working in the HIV clinic.

Data processing and analysis
Descriptive statistics such as frequencies and percentage were summarized and presented in the form of tables and graphs.Odds ratio and 95% confidence interval was used to check significant association between dependent and independent variables using Bivariate and Multivariate analysis by logistic regression model.In all cases, P-value <0.05 was considered to be significant.All analyses were done using statistical package for social sciences (SPSS) version 16.

Ethical consideration
Ethical clearance was obtained from Ambo University, College of Medicine and Health Sciences, Department of pharmacy.Then, letter of permission was presented to AUERB.Verbal informed consent was obtained from medical director and health professional working in this clinic prior to patients card review after the purpose of the study was explained to them.Confidentiality of the information was assured by using medical record numbers.

Results
A total of 317 HIV infected patient medical records were selected by systematic random sampling.However only 309 HIV positive patients had complete information and were reviewed.Out of 309 HIV infected patients 48.5% were males.Majority of them were in the age group of 18-54 years (86.1%)(Table 1).Out of 309 HIV infected patients 77 (24.9%) developed active TB (Figure 1) and 218 (70.6%) and 55 (17.8%) were at WHO HIV clinical stage III and IV respectively.Other clinical profiles of the study participants were displayed in Table 2.

Discussion
HIV infection is the single most important fueling agent for everincreasing prevalence of tuberculosis.Moreover, TB is a well-recognized opportunistic infection in patients with HIV/AIDS.The prevalence of TB among study participants was 77 (24.9%) (Figure 1).The result of this study is slightly higher than study done in south Ethiopia, Hawassa University, from a total of 499 HIV/AIDS positive patients 91 (18.2) of the study participants were found to have tuberculosis [15] and lower than study done at Jimma University, Southwest Ethiopia [16].This variation may be due to difference in study area, study period and incidence of the diseases.Pediatrics was not included due to different pharmaceutical preparation, pharmacokinetics and difficulty of adherence in this age group.
The most important associated factor for development of TB in HIV/ AIDS patients is the immunological state of the person.Maintaining the CD4 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 bacilli.In this study, In multivariate logistic regression analysis, married was 0.058 times less likely to develop TB than the Divorced (AOR=0.058,95% CI (0.015, 0.221), P=0.000) and 0.172 times less  likely to develop TB than Widow (AOR=0.172,95% CI (0.054, 0.172), P=0.003) displayed (Table 3).Farmers were 0.152 times less likely to develop TB than Unemployment (AOR=0.152,95% CI: 0.032, 0.182, P=0.017) and those who had CD4 cell count less than 200 cells/mm 3 at HIV diagnosed were 5.803 times (AOR=5.803,95% CI: 1.778, 18.972, P=0.004) more likely to develop TB than those who had CD4 count between 200 and 350 cells/mm 3 while having CD4 cell count less than 200 cells/mm 3 at HIV diagnosed were 40.381 times more likely to develop TB than those who had CD4 count between 351 and 500 cells/ mm 3 .Study participants with secondary School educational level were 3.64 times (AOR=3.64,CI: 1.187, 11.129, P=0.024) and tertiary School educational level 4.01 times (AOR=4.01,CL: 1.144, 14.072, P=0.030) more likely to develop TB than illiterate as shown in Table 3.
This finding is similar with study conducted in Southwest Ethiopia that shows factors independently associated with active TB: After adjustment for potential confounders were a low level of education (OR=2.8;95% CI: 1.1, 7.1) [17] and study done in China shows from significant variables low CD4 count were risk factor for active TB in people living with HIV/AIDS [18].The study conducted in Burkina Faso indicates that the TB risk factors among PLWHAs were from a rural area (p<0.001) and not educated (p =0.047) which is similar to the current study, But being male is not associated with HIV related TB in the current study unlike that of study done in Burkina Faso [19].

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.In this study there may be some risk factors that were not taken into account, such as duration of HIV, living environment, smoking and contact with tuberculosis in family.

Conclusion and Recommendation
There was high prevalence of TB infection among HIV patients in

Table 3 :
Ayeno HD, Liche TN (2018) Prevalence and Factors Affecting the Development of Active-Tb among HIV-Positive Patients at Shashemene Referral Hospital, Shashemene, West Arsi, Ethiopia.J Bioanal Biomed 10:100-104.doi:10.4172/1948-593X.1000215Factorsassociated with tuberculosis among HIV/AIDS positive patients at Shashemene Referral Hospital, (n=309), September 2013-March 2017.*=statisticallysignificant the study area.The prevalence of TB among study participants was 77 (24.9%).The most important factors independently associated with active TB in this hospital were unemployment; divorce and widow, CD4 level less than 200 cells/mm 3 are HIV diagnosed and illiteracy of study participants.Health information about risk factors for TB infection and early diagnosis and treatment of TB infection are very important for HIV patients in the study area.Furthermore, the health office should open for TB/HIV co-infection units in the hospitals. Citation: