SEROPREVALENCE OF HUMAN IMMUNODEFICIENCY VIRUS IN ANTENATAL PATIENTS IN FEDERAL MEDICAL CENTRE, OWERRI

SUMMARY

There has been a resurgence of cases of tuberculosis (TB) in recent years globally.

This resurgence is overwhelming the capacity of the tuberculosis unit of the Federal Medical Centre Owerri, Imo State. This has been attributed to the emergence of the global epidemic of Human Immunodeficiency Virus (HIV). This is despite the numerous efforts aimed at reducing the scourge by the National tuberculosis control unit in conjunction with donor agencies. This study was undertaken to determine the prevalence of HIV among tuberculosis patients in the Federal Medical Centre Owerri, Imo State and the extent and effect of HIV on the epidemiology of TB.

 

This was cross-sectional study of patients seen at the TB unit of our hospital. A total of 160 subjects with tuberculosis confirmed by a Ziehl-Nielsen test were consecutively recruited until the required sample size was obtained between July and December 2005. They comprise 86 males and 74 females aged 15-64 years. They were screened for HIV 1 and 2 antibodies using the World Health Organization approved Immunocomb HIV 1 and 2 test kit. All initially reactive samples were confirmed using the HIV 1 and 2 CombiFirm ELISA test.

 

The seroprevalence of HIV antibodies in TB patients was 30.6%. The age group 2029 and 30-39 years were mostly affected (p=0.043). A higher proportion of females

(32.4%) with tuberculosis were found to be infected with TB compared to the males (25%). There was a higher incidence of mid and lower lobe infiltrates in the X-rays of the HIV positive patients (79%) compared with the HIV negative patients (60%).

 

Mandatory HIV screening for TB patients and equally, screening TB patients for HIV is advocated. Furthermore, there is an urgent need for a more aggressive health education targeted at the youths on preventive measures aimed at arresting the spread of HIV and TB.

CHAPTER ONE

INTRODUCTION

 

In 1680, John Bunyan described tuberculosis (TB) as “the captain of all these men of death”. Tuberculosis, one of the oldest diseases known to affect humans is caused by the bacteria mycobacteriumtuberculosis.

The disease mainly affects the lungs, although in up to one third of cases, other organs are involved. It is an important opportunistic infection among Human Immunodeficiency Virus (HIV) – infected persons worldwide ¹, and unlike other opportunistic infections in HIV infected persons, TB is also infectious to healthy individuals ². It is the world’s leading curable infectious killer with about twenty thousand people developing TB daily and five thousand people dying from the disease ³.

 

The World Health Organization (WHO) has estimated that about two billion people are infected with tuberculosis worldwide, which is about one third of the world population. About eight to ten million of these individuals develop the clinical disease and three million of them die annually, with over three quarters of these occurring in the tropics ⁴. Hence, the World Health Organization declared TB a global emergency in 1993 ^5,6, . In Nigeria, few studies have been carried out to determine the prevalence of tuberculosis. In a clinical study by Wokoma⁷ in Port Harcourt, a rate of 7.7% was reported, while Brisibi⁸ reported a rate of 5% in Maiduguri.  Akisete⁹ reported a rate of 15% in Lagos.

 

Presently, Nigeria ranks fourth among the world’s twenty-two countries with a high tuberculosis burden of all African countries. Nigeria had nearly 386,000 new T.B cases in 2002; of these, 159,000 were pulmonary sputum smear-positive (ss+) cases. The estimated TB incidence (all cases per 100,000 population) was 307 in 2004 ¹⁰.

 

These figures indicate an upsurge in the prevalence of tuberculosis in the country. The poor socio-economic factors, poverty, malnutrition, inadequate housing and poor hygiene definitely contributed to this increase. The problem of inadequate and inequitable distribution of health facilities and health workers further compounded the situation. The recent upsurge in the prevalence of tuberculosis globally and especially in Nigeria has been attributed to the pandemic of the human immunodeficiency virus (HIV) infection and the adverse economic condition in the country ¹¹.

 

The Acquired Immune Deficiency Syndrome (AIDS) is a relatively new disease entity first described in Los Angeles in the United States of America in a group of homosexuals in 1981¹² who presented with Kaposi sarcoma and pneumocystic carinii pneumonia, while the causative virus, human immunodeficiency virus  (HIV)

was identified in 1983 ^13,14. It was formerly called the Human T Lymphocyte virus type III (HTLV  III) and Lymphadenopathy  Associated Virus (LAV) .

 

The first case of HIV/AIDS was reported in Nigeria in 1986 ¹⁵. Nigeria has the third highest number of people estimated to be living with HIV/AIDS in the world (5 million as at the end of 2OO3) after South Africa and India ¹⁶. She has the second highest number of people with it in sub-Saharan Africa, and the highest number in West Africa. The prevalence rate in Nigeria is 5.4%, compared with 7.5% in sub-Saharan Africa and 1.1% globally. In Nigeria, the national seroprevalence rate of HIV infection based on sentinel groups has been on the increase; 1.8% in 1991, 3.8% in 1993, 4.3% in 1995 and 5.4% in 1999 ¹⁷ .The sentinel population used included pregnant women, patients with sexually transmitted diseases, patients with tuberculosis and commercial sex workers. In the 2003 survey, the national prevalence rates varied from as low 1.2% in Osun state to as high as 12% in Cross River state. Overall, thirteen of Nigeria’s thirty six states had prevalence rates of over 5%, these figures give support that there are explosive, localized epidemics in some states. At 5.4% HIV/AIDS prevalence rate are highest for young people between the ages of 20-24 compared with other age groups and it is estimated that 60% of new infections are in the 15 – 25  age group¹⁸.

 

The September 2002 National Intelligence Council Report identified Nigeria as one of the five countries where HIV/AIDS is expected to spread rapidly by 2010 with immense social and economic consequences predicted for Nigeria in particular. The other countries were Ethiopia, Russia, India and China. Despite the grim nature of HIV / AIDS statistics in Nigeria as illustrated in Table 1^15,19,20, very few Nigerians have access to basic HIV/ AIDS prevention, care, support or treatment services.

 

Around 500,000 people are estimated to require antiretroviral therapy (ART) and only 28,000 to 48,000 people are receiving ART (4 – 8% of those in need) ²⁰. This makes Nigeria to have the third highest level of unmet need for ART in the world.

 

WHO estimates that more than ten million people worldwide live co-infected with TB and HIV, more than two-thirds of whom are in sub-Saharan Africa. An epidemic of HIV and TB is sweeping across Africa. Twenty three million people in Africa are infected with HIV, a third of whom are infected with TB ²¹. HIV infection has contributed very significantly to the rising global incidence and mortality from TB, and WHO estimated that, of nearly five million people worldwide who are co-infected with TB and HIV, three quarters live in Africa ²².

 

TB was considered on the brink of elimination in the developed world until the late

1980s when new HIV-related TB cases and multi-drug-resistance tuberculosis (MDR TB) resurfaced. In the developing countries however, TB has remained an important public health problem exacerbated in the last decade by poverty, demographic changes and the rapid spread of HIV. Most TB patients in high HIV-prevalent countries are HIV infected.

Table 1.1: HIV/AIDS in Nigeria ^{15 19 20}

INDICATOR	NIGERIA	SUBSAHARAN AFRICAN	GLOBAL
Estimated number of people living with HIV/AIDS, 2003.	3.6million	25 million	37.8 million
Percent of adult population estimated to be living with HIV/AIDS, 2003.	5.4%	7.5%	1.1%
Estimated number of deaths due to HIV/AIDS, 2003.	310,000	2.2 million	2.9 million
Women as percent of adult estimated to be living with HIV/AIDS, 2003.	58%	57%	48%
Percent of young women, ages 15-24, estimated to be living with HIV/AIDS, 2001.	4.7-7.0%	8.9%	1.4%
Percent of young men, ages 15-24, estimated living with HIV/AIDS, 2001.	2.4-3.6%	4.4%	0.8%
Estimated number of AIDS orphans, 2003.	1.8 million	12.1 million	15 million
Number of people estimated to be receiving antiretroviral therapy (ART), JUNE 2005.	28,000- 48,000	500.000	970,000
Number of people estimated to be in need of ART, June 2005.	598,000	4.7 million	6.5 million

 

Many high HIV-prevalent African countries are scaling up Highly Active Anti-

Retroviral Therapy (HAART), in line with WHO’s `3 by 5’ initiative. Progress is being made as 500,000 patients in Africa had been started on HAART by June 2005 which is a threefold increase in numbers when compared with 12 months previously²³.

 

The implication of the co-infection of HIV and TB is more than just the presence of two diseases. The presence of HIV contributes to the reactivation of dormant TB and unless treated, leads to a more rapid disease progression of TB and death.  The HIV epidemic has greatly worsened tuberculosis control in Africa. Tuberculosis is one of the commonest and most frequent causes of death in HIV positive Africans. The interaction between TB and HIV is also characterized by a high mortality rate in individuals co-infected with HIV and Mycobacterium tuberculosis.   In the year 2000, of an estimated 1.8 million deaths from TB, 12% was attributed to HIV, while TB was the cause of 11% of all HIV-related mortality²⁴. HIV-positive individuals are at high risk of TB. Even for HIV-infected persons on HAART, the risk of TB is higher than individuals who are HIV negative. It has been reported that HIV-positive patients who have completed a course of anti-TB treatment are at increased risk of recurrent TB, particularly where the continuation phase contains a non-rifampicin-containing

combination²⁵.   

 

The HIV/AIDS pandemic in sub-Sahara Africa poses a massive threat to development. UNAIDS has estimated that in nine countries with an adult HIV prevalence of 10% or more, AIDS will on the average cost them 17 years of life expectancy. This decline in life expectancy is due not only to death of adults, but also to deaths among children where AIDS is wiping out the gains made by other public health programmes in reducing infant mortality rate²⁶. The limited resources in many countries including Nigeria, are best chanelled into providing the infrastructure of the existing health services, strengthening community services and home-based care for TB and AIDS patients. Since about 30-40% of all AIDS deaths result directly from tuberculosis, a stronger TB case finding and treatment has the potential to make a significant reduction in HIV related mortality ²⁷.

 

The upsurge in HIV/AIDS, TB and malaria has led to a renewed global attention. In recent years, infectious diseases have been recast as both a threat to the health and security of wealthier developed nations and an obstacle to the development of the poor countries. The idea of health as a public good has gained prominence, leading to a new conscience and altered donor climate among the wealthy nations. One of the eight Millennium Development Goals (MDGs) adopted by the United Nations in 2002 specifically addresses the issue of communicable diseases such as tuberculosis and HIV by 2015. Other goals, such as the reduction of maternal and child mortality, are also directly affected by the prevalence of tuberculosis and human immunodeficiency virus.

 

 

JUSTIFICATION OF STUDY

 

Recently there has been a large increase in the number of tuberculosis patients overwhelming the capacity of the TB unit of the Federal Medical Center Owerri. This made the unit to stop admitting tuberculosis patients with HIV infection during the intensive phase of directly observed treatment short course (DOTS). This is because of pressure on the existing facilities, and the fact that often the relatives end up abandoning such patients once they discover the HIV result, due to stigmatization. However, those that were severely ill are admitted for resuscitation and possible blood transfusion.

 

This new development gives great cause for concern, considering the fact that in some African countries like Malawi²⁸, not only is seventy-five percent of TB patients

HIV seropositive in a reported study, seventy percent of all medical inpatients are HIV seropositive and this is similar to a study in Abidjan ²⁹.

 

Because of the diverse sociocultural differences that exist between various parts of the country, it is desirable to carry out seroprevalence studies in various zones of the country. Most of the published data on the prevalence of HIV in TB patients are from other parts of the country, while none has been carried out in Owerri. This study was therefore carried out to establish the prevalence of HIV among tuberculosis patients at the Federal Medical Center, Owerri thus highlighting the magnitude of the problem in our environment. It is hoped that this study would encourage regular screening of tuberculosis patients for HIV infection and equally, screening HIV patients for tuberculosis as it is the commonest opportunistic infection they are predisposed to. Such knowledge of the epidemiology of HIV in TB patients will help to prevent further spread of the virus in the community.

 

Finally, this study is expected to generate more interest among doctors and policy makers on the dual menace of HIV and TB co-infection and the need to have a joint HIV/TB control unit as it is impossible to plan and effectively control any of the diseases without considering the other.

 

 

 AIM AND OBJECTIVES OF THE STUDY

AIM

To determine the current prevalence of HIV in tuberculosis patients in Federal

Medical Center Owerri, in order to reduce the incidence of tuberculosis and HIV.

 

OBJECTIVES

1. To estimate the frequency of HIV seropositivity in patients with pulmonary tuberculosis.
2. To determine the sex distribution of tuberculosis patients with HIV.To determine the age distribution of tuberculosis patients with HIV. iv.   To determine the sex distribution of patients with tuberculosis.
3. To determine the age distribution of patients with tuberculosis.
4. To determine epidemiological characteristics of HIV in TB patients.

SEROPREVALENCE OF HUMAN IMMUNODEFICIENCY VIRUS IN ANTENATAL PATIENTS IN FEDERAL MEDICAL CENTRE, OWERRI

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