Prevalence of tuberculosis and HIV/AIDS co-infection among HIV clients at global fund supported comprehensive facilities in Nigeria

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1 International Research on Medical Sciences Vol.4(6), pp , August, 2016 Available online at ISSN Apex Journal International Full Length Research Prevalence of tuberculosis and HIV/AIDS co- among HIV clients at global fund supported comprehensive facilities in Nigeria Alau, K.K. 1*, Weaver, M.R 2, Ogungbemi, M. K. 1, Ashefor, G. 1, Anenih, J. 1, Adeyemi, A. 1, Alagi, M. 1, Anosike, A.O. 1 and Udemezue S. 1 1 Strategic Knowledge Management Department, National Agency for the Control of AIDS, Abuja, Nigeria. 2 Department of Global Health, University of Washington, Seattle, United States of America. Accepted 4 July, 2016; Published 29 August, 2016 Nigeria has one of the largest burdens of both HIV and tuberculosis (TB) in the world. The prevalence of HIV among TB patients in Nigeria has been established to be 22%. This study was designed to estimate the prevalence of TB among HIV clients in Nigeria. We analyzed secondary data from the HIV/TB programs in 241 Global Fund (GF) supported comprehensive facilities in Nigeria. From January 2013 to June 2015, 57,516 HIV clients were enrolled into care/treatment at the GF supported sites. Clients were screened symptomatically during clinic visit. Any clients that answered yes to at least one TB symptomatic questions was referred to the laboratory for TB test either by microscopy or genexpert. The TB co- among the HIV clients was the ratio of HIV clients with reactive tests to clients enrolled into HIV treatment/care. In 2013, 1,622 out of the 19,527 HIV clients were diagnosed with TB and the co- rate was 8.31%. In 2014, 1,595 out of the 23,906 HIV clients were diagnosed with TB and the co- rate was 6.67%. In 2015, 1,075 out of 14,083 clients were diagnosed with TB and the co rate was 7.6%. The overall co- rate 7.5% while the TB co- among HIV clients by the 6 geopolitical zones was North-West (5.1%), South-East (5.7%), North-East (5.9%), North-Central (6.8%), South-West (8.3%) and South-South (10.3). The overall co- rate of TB among HIV clients was 7.5%. Screening of TB among HIV clients is a public health priority to stop the spread of TB. There is the need to improve TB control at HIV setting to reduce TB co-. Key word: TB, HIV, TB/HIV, prevalence, co- List of abbreviations: DOTS: Directly Observed Treatment Strategy; HIV: Human Immuno-deficiency Virus; PAF: Population-Attributable-Fraction; PLHIV: People living with HIV; TB: Tuberculosis INTRODUCTION Tuberculosis (TB) remains the major cause of death in people living with HIV (PLHIV) worldwide (Badri et al., 2002). HIV-infected persons have an approximately 30 times increase in the incidence of active TB (Selwyn et al., 1989). While the use of highly active antiretroviral therapy (ART) reduces the risk of TB by 70% 90%, the incidence of TB remains two to four-fold higher than HIV- *Corresponding author. kennethalau@yahoo.com, Tel: negative populations (Suthar et al., 2012; Lawn et al., 2005; Girardi et al., 2005; Elzi et al., 2007; Gupta et al., 2012). Since the first case of AIDS reported in Nigeria in 1986, Nigeria s HIV prevalence increased steadily from 1.8% in 1991, to 4.5% in 1995, peaked at 5.8% in 2001 and started to decline to 5% in 2003 and 4.1% in 2010 (Federal Ministry of Health, 2010). According to National HIV and AIDS Reproductive Health Survey, 2012, the current HIV prevalence in the general population is 3.4% (Federal Ministry of Health, 2012); 3.46 million Nigerians have been estimated to be living with HIV in 2013 (Nigeria Global AIDS, 2014).

2 092 Int. Res. Med. Sci TB and HIV constitute major public health problems in Nigeria. The country has one of the largest burdens of both HIV and TB in Africa and the world. The Global AIDS Report of 2013 reported that there is an increase in the number of people with TB receiving antiretroviral therapy in 10 countries that represent more than 80% of the global number of HIV-positive people with TB of which Nigeria is inclusive (UNAIDS, 2013). The World Health Organization estimates that 13% of the 8.6 million new TB cases in 2012 were co-infected with HIV, causing almost a quarter of the 1.3 million TB related deaths (World Health Organization, 2013.). HIV accelerates progression of latent TB into active TB disease (Centers for Disease Control and Prevention, 2000). A recent modeling of the population-attributablefraction of different risk for TB quantified the relative contributions of determinants of TB disease burden in Nigeria (Lönnroth et al., 2010). This showed that the top population-attributable risk (PAF) for TB was HIV, accounting for 25% of all TB disease. Based on the Nigeria national TB prevalence survey, an incidence of 338/100,000 and 590,000 incident cases of all forms of TB were estimated (Report of First National TB Prevalence Survey in Nigeria, 2012). In 2013, the Nigerian National TB and Leprosy Control Program reported that 88% of people diagnosed with TB received an HIV test (Sharma et al., 2005). Also, 19,423 of the 88,317 TB cases tested were found to be HIV positive. This represents a TB/HIV co- rate of about 22%. The prevalence of HIV among TB patients in Nigeria increased from 2.1% in 1991 to 19.1% in 2001 and 22% in The prevalence of TB among HIV clients in Nigeria has not been determined even though studies in some part of the country have been conducted. The objective of the study is to determine the prevalence of TB among HIV clients at Global Fund supported comprehensives facilities in Nigeria from January 2013 to June 2015 (30 months). METHODS Study area and population Secondary analysis of data collected from on the HIV/TB program in 241 Global Fund supported comprehensive facilities in Nigeria was done. About 57,516 HIV clients were enrolled into care/treatment at the GF supported sites from January 2013 to June The 57,516 HIV clients were screened symptomatically (asked for TB symptoms: Night sweat, cough, weight loss and fever) during clinic visit. Any clients that answered yes to any of the TB symptomatic questions become TB presumptive and were referred to the laboratory for TB diagnosis (either by microscopy or Genxpert). The data set used for the analysis include; Number of HIV clients newly enrolled to care and treatment and number of HIV clients that are on care/treatment that tested TB positive. The TB co- among the HIV clients were calculated from the number of HIV clients enrolled into treatment/care that turn out to be TB positive during the period under consideration. Descriptive statistics were used to analyze the secondary data collected from the Global Fund supported comprehensive facilities. We also reported the 2012 HIV prevalence rate by state and calculated the correlation between 30-month TB/HIV prevalence. Inclusion and exclusion criteria Samples were taken from only HIV clients that are newly enrolled in care or treatment at Global Fund supported facilities. HIV clients that are already on Directly Observed Treatment Strategy (DOTS) were excluded. RESULTS AND DISCUSSION Table 1 reports the TB rate among HIV clients for three time periods: 2013, 2014, and the first six months of 2015, as well as the 2012 HIV prevalence rate by zone and state. Out of the 19,527 HIV clients enrolled in 2013, the TB co- was 8.31% (1,622). In 2014, 23,906 HIV clients were enrolled out of which 6.67% (1,595) had co-. In 2015, co- was 7.6% (1,075) among the HIV clients enrolled (14,083). The overall co- of tuberculosis among the 57,516 HIV clients enrolled within the 30 months period at the Global Fund supported comprehensive sites in Nigeria was 7.5%. The highest TB/HIV co- of 16.7% ( %) was recorded in Edo state though the HIV prevalence of the state is low (0.8%), this was followed by Rivers state with 15.6% ( ) with a high HIV prevalence of 15.2% and all are in the south south zone. The least TB/HIV co- was recorded in Ondo state 1.7% ( %) with a HIV prevalence of 4.3% followed closely by Abia state with 1.8% ( %) with HIV prevalence of 3.9%. Data in Table 1 were used to calculate the correlation coefficient between the 30-month TB/HIV prevalence and HIV prevalence. The correlation was positive and Figure 1 compared the HIV prevalence, TB prevalence and TB/HIV prevalence by zone. South-south had the highest HIV prevalence of 5.5% and the highest TB/HIV prevalence of 10.3%, this was followed by South-West with HIV prevalence of 2.8 and the highest TB prevalence of 28% and with a TB/HIV prevalence of 8.3% which is the second highest. South-East has the least HIV (1.8) and TB prevalence (9) and the least TB/HIV prevalence (5.7) after North-West (5.1). The results showed a positive correlation of 0.50, 0.86, 0.09 and 0.39 in south west, north west, north central and south south zone respectively in TB prevalence and

3 Kenneth et al 093 Table 1. TB prevalence among HIV clients at Global Fund Supported facilities by zone and state. State (2013) (2014) (Jan-Jun 2015) 30 month HIV Prevalence (NARHS 2012) Benue 5.26% 5.86% 5.4% 5.7% 5.6% FCT 9.52% 4.02% 8.3% 7.4% 7.5% Niger 2.28% 3.27% 10.6% 4.7% 1.2% Kwara 8.85% 7.39% 6.5% 7.5% 1.4% Plateau 11.40% 14.57% 9.3% 12.1% 2.3% Nasarawa 7.78% 7.11% 13.6% 8.8% 8.1% Kogi 5.88% 6.75% 9.1% 6.7% 1.4% Adamawa 2.41% 3.65% 3.2% 3.3% 1.9% Gombe 5.94% 5.03% 7.3% 5.7% 3.4% Taraba 7.35% 3.55% 7.0% 5.8% 10.5% Yobe 4.76% 6.27% 8.8% 6.8% 5.3% Borno 9.32% 12.65% 15.7% 12.3% 2.4% Bauchi 7.58% 10.27% 5.7% 8.3% 0.6% Bayelsa 6.41% 11.17% 4.1% 7.9% 2.7% Delta 7.71% 7.20% 5.4% 7.0% 0.7% C. Rivers 9.49% 6.28% 5.0% 6.9% 4.4% Edo 20.21% 11.39% 17.3% 16.7% 0.8% Akwaibom 8.02% 10.89% 8.7% 9.4% 6.5% Rivers 6.86% 17.63% 19.0% 15.6% 15.2% Jigawa 5.29% 2.97% 3.9% 3.8% 2.1% Kebbi 3.76% 3.37% 3.6% 3.6% 0.8% Kaduna 12.50% 7.67% 8.2% 8.2% 9.2% Sokoto 13.33% 7.41% 6.8% 8.8% 6.4% Katsina 7.14% 1.97% 6.0% 4.3% 0.7% Zamfara 2.17% 4.46% 2.1% 3.3% 0.4% Kano 5.92% 5.47% 8.4% 6.3% 1.3% Ogun 4.71% 2.77% 3.4% 3.7% 0.6% Osun 6.11% 2.23% 2.5% 3.6% 2.6% Oyo 15.47% 15.04% 15.4% 15.3% 5.6% Lagos 15.03% 7.67% 8.4% 10.8% 2.2% Ekiti 4.23% 5.48% 2.8% 4.2% 0.2% Ondo 2.22% 1.15% 2.1% 1.7% 4.3% Abia 0.92% 2.57% 1.4% 1.8% 3.3% Ebonyi 8.64% 2.51% 3.6% 5.0% 0.9% Enugu 8.37% 9.50% 4.1% 7.7% 1.3% Anambra 5.00% 7.80% 4.1% 6.1% 1.2% Imo 4.91% 4.45% 13.9% 7.4% 2.5% Nigeria 8.31% 6.67% 7.6% 7.5% 3.4% TB/HIV prelevalence while a negative correlation was observed in south east and north east zone. Study on prevalence of TB/HIV co- and relationship between TB and CD4/ESR in HIV patients in Niger Delta region (south south zone) of Nigeriawas recorded (Nwabuko et al., 2012). The results showed that of the 389 subjects that took part in the study 23 of them had TB/HIV co-. This gives an observed prevalence of 5.91% of TB/HIV co- which is similar to the result in Table 1 for Delta state which is 7.0% ( ). Also, a co- of 10.5% in Aminu Kano Teaching Hospital, North-West zone was observed (IIlyasu, 2009). The observed TB/HIV prevalence in Kano state as presented in Table 1 is 6.3% ( ). Study Limitation Only used the data that is available and the data was not

4 094 Int. Res. Med. Sci South West 2.8% 8.3% 28% South South 5.5% 10.3% 16% South East 1.8% 5.7% 9% TB/HIV Prevalence North West 5.1% 3.2% 19% HIV prevalence TB Prevalence North East 5.9% 3.5% 18% North Central 3.4% 6.8% 10% 0% 5% 10% 15% 20% 25% 30% Figure 1. Figure 1. Comparing HIV prevalence, TB TB prevalence prevalence and TB/HIV and prevalence TB/HIV by prevalence zone in Nigeria. by zone in Nigeria disaggregated by age and gender. There might be some data quality issues that are beyond our control. Conclusion The overall co- rate of TB among HIV clients was 7.5% while the TB co- among HIV clients by the 6 geopolitical zones was North-West (5.1%), South-East (5.7%), North-East (5.9%), North-Central (6.8%), South- West (8.3%) and South-South (10.3). The screening of TB among HIV clients is of public health priority toward mitigating the spread of TB. There is the urgent need to introduce or improve TB control at HIV setting to reduce TB co-. ACKNOWLEDGE The authors would like to acknowledge the Iorwa Apera and Modasola Bologun of the West Africa Infectious Diseases Institute and Susana Oguntoye for organizing the Data Analysis, Abstract and Manuscript Writing Workshop in September 2015.The authors also acknowledge the Global Fund, for their support to the Nigeria national response for HIV/AIDS, Tuberculosis and Malaria. The authors also thank all the Global Fund HIV and TB Principal Recipients and Sub-Recipients for their continuous efforts and not forgetting the health workers at the facilities. REFERENCES Badri, M., Wilson, D., and Wood, R. (2002). Effect of highly active antiretroviral therapy on incidence of tuberculosis in South Africa: a cohort study. Lancet. 2002; 359: PMID: Centers for Disease Control and Prevention (2000). Targeted tuberculin testing and treatment of latent tuberculosis. Am J Respir Crit Care Med. 2000; 161: S PMID: Elzi, L., Schlegel, M., Weber, R., Hirschel, B., Cavassini, M., and Schmid, P. (2007). Reducing tuberculosis incidence by tuberculin skin testing, preventive treatment, and antiretroviral therapy in an area of low tuberculosis transmission. Clin. Infect. Dis. 2007; 44: PMID: Federal Ministry of Health (2010,). National HIV Sero- Prevalence Sentinel Survey among Pregnant Women Attending Antenatal Clinics in Nigeria, Technical Report, 2010, pp Federal Ministry of Health (2012,). National HIV and AIDS Reproductive Health Survey in Nigeria. 2012, pp Girardi, E., Sabin, C.A., d'arminio Monforte, A., Hogg, B., Phillips, A.N. and, Gill, M.J. (2005). Incidence of Tuberculosis among HIV-infected patients receiving highly active antiretroviral therapy in Europe and North America. Clin. Infect. Dis. 2005; 41: PMID: Gupta, A., Wood, R., Kaplan, R., Bekker, L.G. and, Lawn,

5 Kenneth et al 095 S.D. (2012). Tuberculosis incidence rates during 8 years of follow-up of an antiretroviral treatment cohort in South Africa: comparison with rates in the community. PLoS One ; e doi: /journal.pone PMID: IIlyasu Z. (2009). Prevalence and predictors of tuberculosis co among HIV seropositive patients attending the Aminu Kano Teaching Hospital, Northern Nigeria. J. Epidemol. 19(2):81-87 Lawn, S.D., Badri, M. and, Wood, R. (2005). Tuberculosis among HIV-infected patients receiving HAART: long term incidence and risk factors in a South African cohort. AIDS 2005; 19: PMID: Lönnroth, K., Castro, K.G., Chakaya, J.M., Chauhan, L.S., Floyd, K., and Glaziou, P, et al. (2010). Tuberculosis control and elimination : cure, care, and social development. Lancet. 2010, ;375(9728): Nigeria Global AIDS Response Progress Report of Nwabuko, C.O., Ejele, O.A., Chuku, A., Nnoli, M.A., Chukwuonye, (2012). Prevalence of Tuberculosis-HIV Co and Relationship between Tuberculosis and CD4/ESR in HIV Patients in Niger Delta Region of Nigeria. IOSR J.ournal of Dental and Med.ical Sci.ences (JDMS). ISSN: , ISBN: Volume 2(, Issue 4):, PP Report of First National TB Prevalence Survey in Nigeria. 2012, pp. 61. Selwyn, P.A., Hartel, D., Lewis, V.A., Schoenbaum, E.E., Vermund, S.H. and, Klein, R.S., et al. (1989). A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus. N. Engl. J. Med. 1989; 320: PMID: Sharma, S. K., A. Mohan, A. and T. Kadhiravan, T. (2005). HIV-TB Co- Infection: Epidemiology, Diagnosis and Management, Indian J.ournal of Med.ical Res.earch, Vol. 121, No. (4, 2005, pp): Suthar, A.B., Lawn, S.D., del Amo, J., Getahun, H., Dye, C. and, Sculier, D., et al. (2012). Antiretroviral therapy for prevention of tuberculosis in adults with HIV: a systematic review and meta-analysis. PLoS Med 2012; 9: e doi: /journal.pmed PMID: The GAP Report, UNAIDS. 2013, pp World Health Organization. Global tuberculosis report 2013.

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