PREVALENCE AND PATTERN OF DIAGNOSED CO-MOBIDITIES AMONG HIV PATIENTS IN UPTH

ABSTRACT

Malaria and HIV represent the two most important public health problems of sub-Saharan Africa due to geographical overlap. Together, they are responsible for more than 4 million deaths a year. However, when HIV and malaria co-infect an individual, they drastically worsen the morbidity outcome for the person, increasing the odds of mortality than as single infections. In Nigeria, there is paucity of data on the prevalence of this co-infection.

This study determined the prevalence of HIV-Malaria co-morbidity and its associated factors among adult persons living with HIV attending UPTH.

This is a cross sectional study design involving 200 participants drawn from the ART clinic of UPTH. Closed-ended interview questionnaire was used to obtain information from participants. The interview data were analysed using various statistical methods including cross tabulations and simple and multiple logistic regression.

There were 200 participants in the study. Forty-four (22%) of them were males and 156 (78%) were females. Two (1.00%) of the participants were pregnant at the time of the study. Ages of participants ranged between 20 to 65 years. Seventeen (8.50%) participants were between 20 to 30 years of age. Sixty-five (32.50%) participants were between 31 to 40 years of age. Eighty-one (40.50%) were between 41 to 50 years and 37 (18.50%) were above 50 years. The mean age of participants was 42.725 (SD= + 9.01).

Thirty-one (15.50%) participants were single while 67 (33.50%) were married. Fiftynine (29.50%), 26 (13.00%) and 17 (8.50%) participants were divorced, separated or widowed respectively.

Forty-seven (23.50%) participants had no formal education. One hundred and twentyfour (62.00%) of participants attained primary level education while 23 (11.50%) had secondary level education. Only 6 (3.00%) of participants had tertiary level education.

Twenty-four (12.00%) of participants were either unemployed or housewives. Fortyseven (23.50%) were employed in various positions in the public service. One hundred and twenty-seven (63.50%) of participants were self-employed whiles only 2 (1.00%) were employed in the private sector.

Participants resided in various localities in the Kpando Municipality of the Volta region of Nigeria with the highest number of 51 (25.50%) resident in Nkonya. Others were resident in Ho, Hohoe, Trevi among others.

The prevalence of HIV-Malaria co-morbidities at UPTH was found to be 41.00%. person living with HIV who visit hospital more often, with intervals less than a month, have statistically significant lower odds (OR= 0.29, 95% CI= 0.14-0.59, p=0.001) of the co-morbidity compared to person living with HIV who visit hospital less often with intervals longer than one month.

There is a high prevalence of 41.00% HIV-malaria co-morbidity among person living with HIV attending UPTH. The findings suggest that there is reduced odds of malaria infection among person living with HIV who visit hospital regularly. Thus, person living with HIV must visit hospital regularly so as to be educated on preventing the co-infection.

 

 

CHAPTER ONE

INTRODUCTION

Background

The Human Immuno-Deficiency Virus (HIV) is a disease-causing retrovirus that infects cells which are responsible for immunity in humans (primarily CD4⁺ T cells, but also macrophages, monocytes, thymocytes and dendritic cells), and leaves its host susceptible to opportunistic infections (Fanales-Belasio, Raimondo, Suligoi, & Buttò, (2010); Nizet & Esko, (2009)). This condition of decreased immunity is known as acquired immune deficiency syndrome (AIDS), a condition as yet without cure.

Although there are two sub-types of HIV – HIV 1 and HIV 2, HIV-1 has higher infectivity and global relevance (Butler, Pandrea, Marx, & Apetrei, 2007). HIV-1, apart from decimating an individual’s immunity also activates immune cells and elevates inflammatory-triggering cytokines and chemokines in the plasma and lymph nodes (Appay & Sauce, 2008). These actions of immune suppression and activation are responsible for the observable effects of its infection.

HIV is transmitted primarily through sexual contact (including vaginal, oral and anal sex), sharing of blood fluids (through contaminated blood transfusions, hypodermic needles), and from mother to child (during pregnancy, delivery, and/or breastfeeding) (De Cock, Jaffe, & Curran, 2012). The infection is often accompanied by typical presentations such as significant weight loss, recurrent unexplained diarrhoea, carcinomas, opportunistic infections such as tuberculosis and several other conditions.

Despite the global health significance of HIV, it is especially important in sub-Saharan Africa (SSA) because it is the region that has been hardest hit by the HIV pandemic (Mosam & Dlova, 2006). Also, HIV in SSA is associated with critical co-morbidities (i.e. occurrence of combination of disease conditions in the same person at the same time) of which some are due to the presence of endemic infectious diseases (Alemu, Shiferaw, Addis, Mathewos, & Birhan, 2013; Mutevedzi & Newell, 2011; Narayan et al., 2014).  One of such parasitic co-morbidities is malaria.

Malaria, is one of the leading causes of morbidity and mortality globally especially in tropical and sub-tropical regions of the world where about 3.2 billion people are at risk (World Health Organisation [WHO] , 2015). Malaria is a disease caused by protozoa of theplasmodium spp. (P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi) (Zambrano-Villa, Rosales-Borjas, Carrero, & Ortiz-Ortiz, 2002).

Although 6.2 million deaths due to malaria have been prevented around the world between 2000 to 2015, in 2014, 584,000 deaths were caused by malaria, and 90% of those deaths occurred in sub-Saharan Africa most of which were due to P. falciparuminfection –the most virulent and infective plasmodium species (Nadjm & Behrens, 2012); World Health Organisation [WHO] , 2015). This has been credited to the fact that climatic conditions favour transmission, the long lifespan and strong human-biting habit of the African vector species and the large number of people with low immunity including pregnant women, children and people living with HIV/AIDS (Alemu et al., 2013; De Silva & Marshall, 2012).

As a co-morbidity of HIV, malaria represents a substantial danger to those living with HIV as malaria not only enables the transmission of HIV, it also hastens progression from asymptomatic HIV infection to full-blown AIDS (Uneke & Ogbonna, 2009). In sub-Saharan Africa, this is significant as increased HIV transmission due to malaria, as well as its worsening of HIV condition ensures that HIV mortality remains high. Considering their infectiousness, it is not surprising to find that Malaria and HIV are the two most prevalent infections in sub-Saharan Africa (Uneke & Ogbonna, 2009).

In Nigeria, recent estimates show that HIV prevalence stands at 1.8% of the total population (National AIDS/STI Control Programme, 2015), while there were about 11.3 million hospital-treated cases of Malaria in 2013 (National Malaria Control Programme -Nigeria [NMCP] , 2014; Tay, Badu, Mensah, & Gbedema, 2015). This high prevalence of malaria has resulted in economic losses as well as significant disability adjusted life years (DALYs) and mortalities (Asante & Asenso-Okyere, 2003). Research has shown that between 2002 and 2005, at least 0.40% of the country’s GDP was eroded by malaria morbidity (Okorosobo, Okorosobo, Mwabu, Orem, & Kirigia, 2011).

When malaria infects people living with HIV, it increases the risk of concurrent HIV infection at the population level (Sanyaolu et al., 2013). There is evidence that the mean malaria parasite density in malaria-infected person living with HIV is 12 times that found in HIV-negative patients (Birku, Mekonnen, Björkman, & Wolday, 2002). Furthermore, it increases HIV replication in vitro and in vivo, increases the risk of severe malaria in adults, increases risk of congenital infection and helps propagate the spread of both disease (Sanyaolu et al., 2013).  In SSA, the burden of HIV/AIDS and malaria may be as high as 30 percent among HIV-positive populations (Ezeamama et al, 2012).

The risk of different groups of opportunistic infections typically increases at different stages of HIV infection in relation to CD4⁺ count. In children, it was found that HIV infection especially at low CD4 counts, increased children’s risk of developing malaria, and amplifies the frequency of the disease (Ezeamama et al., 2012). Also, a study has shown that there is a higher risk of malaria mortality among HIV-infected compared to

HIV-uninfected children with severe malaria (Malamba et al., 2007).

In HIV-infected pregnant women, there was higher incidence of peripheral and placental malaria, higher parasite densities, and more febrile illnesses, severe anaemia, and adverse birth outcomes than HIV-uninfected women, particularly in multi-gravidae (Ter Kuile et al., 2004). There was also an increase of malaria during pregnancy attributable to HIV.

In adult populations generally, the HIV and Malaria co-morbidity causes more frequent episodes of symptomatic malaria, increases HIV plasma viral load and decreases CD4+ T cells; together, they synergistically dysregulate production of cytokines and antibodies (Hochman & Kim, 2009).

Considering the effects of this co-infection, there is a need to investigate how prevalent it is in Nigeria and what risk factors predispose adults to it.

Problem statement

The threat that co-morbidity of HIV and Malaria poses is a substantial one considering how it disproportionately affects socially vulnerable populations including women, children, and HIV MARPS (most at risk population including female sex workers, men having sex with men, people who inject drugs and prisoners ) (Blair, 2015).

Statistics show that in sub-Saharan Africa, the co-morbidity of malaria and HIV occurs among 9% of those with HIV (amounting to more than 2 million people) (World Health Organization – WHO, 2005). In Nigeria currently, there is limited studies that have assessed this prevalence in the adult person living with HIV population. A facility based study in Nigeria by Tay et al. (2015) represents an exception, as it pegs the prevalence of HIV-Malaria co-morbidity among the adult sero-positive attendants of a private hospital at 11.75%.

However, among pregnant women several studies on the co-morbidity have been done.  This co-morbidity has been said to be responsible for a significant proportion of the  more than 300,000 HIV/AIDS related deaths in 2013, and adds to the 12 billion cost due to lost productivity, that sub-Saharan Africa experiences every year (WHO, 2005; 2015).

HIV-malaria co-morbidity in Nigeria therefore needs great attention. HIV and malaria are both generally treated as separate diseases, with any interactions between them often seen as coincidental. Also, previous population-based studies did not show the existence of any significant difference in clinical outcomes between HIV-positive and HIV- negative individuals with malaria. As such there is paucity of data on the prevalence and risk factors of malaria infection in HIV-positive patients in Nigeria.

Conceptual Framework

 

Figure 1:  Conceptual Framework (Author’s model)

The conceptual framework for this study is demonstrated in Figure 1. According to the framework, the prevalence of HIV-Malaria co-mobidities is determined by different factors. These factors include human related factors which encompasses socio-demographic characteristics such as age, gender and education, as well as knowledge of HIV and malaria and the health seeking behaviour adopted by the individual –whether they seek medical help or not, use drugs as prescribed, engage in risky behaviours that increase the likelihood of the co-infections. The physical environment also matters – this includes where the person resides, the housing condition of such a place, its climates, the season (considering there is a seasonal pattern to malaria infection) and whether it has vector breeding sites in proximity that increases the chances of getting co-infected.

Socio-economic factors also influence the prevalence of HIV-Malaria co-infection, as the sleeping patterns (which is predicted by occupation), household size (with larger households being more susceptible to co-infection), access to health care (to both prevent and manage co-infection), control activities engaged in (such as ITN use, IRS which is more prevalent in wealthy homes/communities) and migration (due to economic desires, such as rural-urban migration). The health providers also have a role in determining the prevalence of the HIV-Malaria co-infection, as their blood maintenance practices might cause infections, their screening might be flawed and fail to detect co-mobidities early. Their management of co-mobidities also matters in the prevalence levels in the general population.

 

Justification of the problem

Despite the availability of the measures and intervention to control both HIV and malaria separately, the enhanced risk of mortality due to HIV-malaria co-morbidity among the general adult population has not been thoroughly investigated in Nigeria. This study is thus, designed to provide epidemiological data of malaria among persons living with HIV.

The collected data will provide an understanding of the factors that influence the prevalence of HIV-malaria co-morbidity among the adult attendants of UPTH. The information that will be collected will be an essential component in the assessment of the effectiveness of both malaria and HIV control and elimination interventions, and encourage synergised efforts between these programs; and in so doing, recalibrate their efficiency in effectively reducing HIV-malaria co-morbidity burden. Furthermore, as malaria is not the only tropical infection that interacts with HIV, information obtained from this study may be useful for understanding how HIV interacts with other co-mobidities be it parasitic, bacterial or viral.

 

Objectives of the study

General Objective 

The general objective of this study is to determine the prevalence of HIV-malaria co- infection and its associated factors among adult person living with HIV attending UPTH.

 

Specific Objectives

1.      To assess the prevalence of HIV-malaria co-morbidity among the adult person living with HIV attendants of UPTH.

2.      To determine factors associated with HIV-malaria co-morbidity in the participants.

 

 

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