Tuberculosis is one of the respiratory diseases that affect all ages and sexes worldwide. It affects mostly the lungs (pulmonary TB) but also can be found in other parts of the body (extra pulmonary TB) [1]. The most important source of infection is an untreated pulmonary tuberculosis patient. When such a person coughs, sneezes or spits, tiny droplets nuclei containing the bacilli are released. Transmission is through inhaling these droplet nuclei. Human Immune Deficiency Virus (HIV) the causative agent of Acquired Immune Deficiency Syndrome (AIDS) is found in pandemic proportions globally. The virus attacks and damages the body’s immune system, thereby impairing the capacity of the body to fight infectious organisms. As the disease progresses and immunity declines, patients become more susceptible to infections such as tuberculosis, pneumonia, recurrent fungal infections and many more which accounts for most of the ill health associated with the disease [2].

Demographic Factors are characteristics assigned to age, sex, education, income, marital status, job, location, religion, birth rate, death rate, family size and marriage [3]. Nowadays the most prevalent diseases may be linked to the individual’s lifestyle – bad habits and unhealthy diet increase the risk of chronic diseases. World Health Organization (WHO), recognizes that the person’s health is affected by genetic, environmental, social and economic factors which are related to the person’s well-being, living conditions, income, family life, education, quality of life and to a lesser extent – medical help [4]. The occurrence of Tuberculosis among individuals with HIV forms a grave public health hazard. The prevalence of tuberculosis infection is higher in persons who are HIV positive than those who are HIV negative. This could be attributed to the reduction in their immune level by the HIV virus. Also, persons co-infected with TB and HIV have an increased risk of developing opportunistic infections, as a result of the double blow dealt to the immune system of the person by both diseases [5,6].

Tuberculosis (TB) and Human Immune-deficiency Virus (HIV) have been closely linked since the emergence of AIDS as TB is the most common opportunistic infection affecting HIV-seropositive individuals. It remains the most common cause of death in patients with AIDS with HIV infection contributing to a significant increase in the worldwide incidence of TB by producing a progressive decline in cell-mediated immunity [7]. HIV alters the pathogenesis of TB, greatly increasing the risk of disease from TB in HIV co- infected individuals and leading to more frequent extra pulmonary involvement [7]. There is evidence that immune responses in tuberculosis and in other infection induce cytokines that enhance the replication of HIV and this drives the patient into a full picture of AIDS. If the individual host the two pathogens, M. tuberculosis and HIV, potentiate one another, accelerating the deterioration of immunological functions and resulting in premature death if untreated. Although HIV-related TB is both treatable and preventable, incidence continues to climb in developing nations wherein HIV infection and TB are endemic and resources are limited [7]. The disease threatens the poorest and most marginalized, disrupts the social fabric of society and slows or undermines gains in economic development. 

According to the National HIV & AIDS and Reproductive Health Survey (NARHS Plus) in 2012, the national HIV prevalence rate was 3.4%. Also, in 2015, there were an estimated 10.4 million new TB cases worldwide with about 1.2 million (accounting for 11%) of these being among people also living with HIV [8]. Tuberculosis remains the leading killer of people living with HIV globally, with about a third of all HIV deaths attributed to it. There were about 1.4 million TB deaths and an additional 0.4 million deaths resulting from TB among people living with HIV in 2015 [8]. Whereas individuals with healthy immune systems may not fall ill from TB infection, people living with HIV with a low CD4 count are at greater risk of TB infection. 

The burden of TB/HIV co-infection in the life of an individual diminishes the quality of life. Millions of people living with TB/HIV co-infection is causing a growing demand for health services, thereby increasing the workload of health providers. Compared to other developed and developing countries, TB/HIV co-infection is on the increase in Nigeria. Almost one in four deaths among people with HIV is due to TB. Tuberculosis and human immune deficiency virus co-infection has been associated with different age group, geographical location, gender and marital status. There is no recent data on TB/HIV co-infection in General Hospital Umuguma. Assessment of TB/HIV co-infection will be important for the planning, resource allocation, prevention and control activities. Hence, this study is aimed at ascertaining the demographic factors as determinants of TB/HIV co-infection among patients who used DOTS in General Hospital Umuguma, Imo State.

Study Area

This was the DOTS center in General Hospital Umuguma in Owerri. This health institution also conducts HIV test to determine the HIV status of TB patients and provide comprehensive services for prevention, care and treatment of HIV/AIDS. Umuguma Town is Owerri West Local Government Area's Headquarters. It is in Imo state, Nigeria.

Study Design

This study utilized descriptive, cross sectional epidemiological design to assess demographic factors as determinants of TB/HIV co-infection among patients in a DOTS center in Umuguma over the course of 5years (January 2013- December 2017).

Population of Study

The target population consisted of 2240 patients aged 2-80years that were treated in General hospital Umuguma DOTS center in Owerri –west LGA from 2013-2017. It involved the review of DOTS register for TB and HIV co-infection with respect to demographic information. All the 2,240 patients registered in the hospitals DOTS register from January 2013- December 2017 were studied.

 Instrument for Data Collection

The assessed hospital's DOTS register from January 2013- December 2017 provided the information for the period under review while the researcher developed a proforma which was used to collect the data. Section 1 of the proforma was designed to collect demographic data (such as age, gender, marital status and location) while section 2 was used to collect information on results of TB and HIV test conducted for the patients. 

Validity of the Instrument

The face and content validity were carried out and the ethics committee of the studied health facility also approved of the proforma. The proforma was examined together with the stated objectives, research questions and hypotheses. Modifications were made based on validators comments.

Reliability of the Instrument

The DOTS register used in Tuberculosis Control Programme is the same globally. Based on that, the researcher designed a proforma in such way to extract the information needed for the study in the DOTS register in line with the objectives of the study where information was extracted from records, the data was signed by the officer in charge of the register.

Informed Consent

This was obtained in written and verbal forms from the health institution study site before access to DOTS register was gained for the required information to be extracted.

Method of Data Collection

The data such as age, gender, marital status and location, as well as HIV and TB status were collected from the DOTS register using the proforma developed. The HIV status were determined in the study health institution following national HIV testing algorithm in Nigeria where Alere Determine was used for the first screening and positive samples were re-tested with Trinity Biotech Unigold. Those with discordant results were retested using the breaker Stat Pak (chembio HIV1/2 stat pak Assay USA). The study excluded TB patients having incomplete data on the DOTS register.

Method of Data Analysis

Data collected were analysed using descriptive statistics, bivariate and multivariate logistic regression models to identify the predictors of TB/HIV co-morbidity. Statistical significance was set at p-value≤0.05.

Table 1 shows that out of the 2240 patients who attended DOTS clinic of General Hospital Umuguma, 801 (36%) were males and 1439 (64%) were females. About half of the study participants were between 31-40 years old followed by 21-30 age group (23%). The age group of 41- 50 age group made up 18%, 51–60 years were 3.6%, proportion above 60 years were 2.1% while age group 11-20 years constituted 1.9% of participants. The married patients were 680 (30.4%) while the single made up 1560 (69.6%). The urban dwellers were 1433 (63.9%) while Rural dwellers were 807 (36.0%).

Out of the 2240 TB patients tested for HIV, 970 (43.3%) were positive giving an overall TB/HIV co-infection rate of 43.3% (Table 2). In 2013, TB/HIV co-infection was 46.1%, 34.7% in 2014, 32.8% in 2015, 48.4% in 2016 and 53.2% in year 2017. There was a statistically significant increase in prevalence of TB/HIV co-infection as the year progressed from 2013 to 2017 (c2 = 55.7, p<0.05). 

In Table 3, the highest TB/HIV co-infection of 49.5% was among TB patients of 31-40 years old followed by 21 to 30 years old (24.2%). Those 41 to 50 years, 51 to 60 years,11 to 20 years,61 and above and 1 to 10 years had 18.6%, 3.6%, 1.9%,1.8% and 0.5% co-infection respectively.

Table 1: Socio-Demographic Distribution of the Participants

Table 2: Prevalence of TB/HIV Co-Infection Among the DOTS Clinic Attendees 2013-2017

c2 = 55.7, df = 4: p<0.05

Table 3: Distribution of TB/HIV Co-Infection According to Socio-Demographics of Subjects

Table 4: Predictors of TB/HIV co-infection in among the subjects (Unadjusted and Adjusted)

COR = Crudes Odds Ratio, AOR = Adjusted odds ratio, *Statistically Significant

The difference between the various age groups was statistically significant (c2 = 21.62, p<0.05). Also, of the 970 TB/HIV co-infected patients, there was significantly higher proportion of males (46.6%) than females with TB/HIV co-infection (c2 = 5.38, p<0.05).

The highest prevalence of TB/HIV co-infection was in the 21-30 years’ age group (45.6%) closely followed by 31-40 years’ age group (43.2%) and 11-20 years’ age group (41.9%). The least co-infection rate was found in the 1-10 years’ age group (0.11%). Males (46.6%) had a higher TB/HIV co-infection rate than females (41.5%) and unmarried respondents having a co-infection rate of 52.6% compared to their married counterparts who recorded 22.1%. Furthermore, TB/HIV co-infection was higher in urban dwelling TB patients (46.3%) than rural dwelling patients (38%).

Table 4 shows that after adjusting for age group, gender, area of residence and marital status, the TB patients aged 31-40 years are 55 % more likely to have a TB co-infection than 1-10 years’ age group AOR = 1.55 (95% CI: 0.22-1.38) p = 0.009. Similarly, patients aged 21-30 years have an increased odd of TB/HIV co-infection by 41% compared to TB patients aged 1-10 years. AOR = 1.41 (95% CI: 0.51-2.89) p = 0.002. However, age groups 41-50 years and ≥60 years reduced the odds of TB/HIV co-infection among TB patients by 68% and 66% respectively compared to TB patients within the age group of 1-10 years. These were statistically significant AOR = 0.32 (95% CI: 0.01-0.26) p = 0.03 and AOR = 0.26 (95% CI 0.01-0.26) p = 0.05 respectively.

Female TB patients have a slightly reduced odds of TB/HIV co-infection at 0.9% compared to the male patients though this was not statistically significant AOR = 0.91 (95% CI: 2.15-4.66), p = 0.065. More so, residing in urban areas increased the odds of the TB/HIV co-morbidity by 35% of the odds of TB patients residing in rural areas and this association was statistically significant AOR = 1.65 (95% CI: 0.96-2.19), p = 0.05. Furthermore, unmarried TB patients have statistically significant more than thrice increased odds of HIV co-infection compared to their married counterparts AOR= 3.75 (95% CI: 0.96-3.19), p = 0.04).

In summary, overall TB/HIV co-infection among patients was 43.3%. TB and HIV co-infection was higher among males than among females. The highest co-infection was among TB patients of 31-40 years old. Also TB/HIV co-infection was markedly higher among the unmarried than the married; and urban dwellers recorded more TB/NIV co-infection than rural dwellers.

The result of this study shows that the TB/HIV co-infection was 43.3%. Daniel et al, [9], reported lower values than that found in this study. However, this study was similar to those reported in related studies by Smart et al. [10], Mukhtar [11], Christopher et al., [12] and Adjei et al., [13]. Different states in Nigeria have reported different prevalence of the co-morbidity, some of which conform with findings of this study. A more recent study in Kano State, Nigeria found the prevalence of the co-infection lower (11.2%) than the observations of this study [14]. Contrary to the findings of this study and other studies, a study in Abeokuta, Ogun State, Nigeria recorded no TB/HIV co-infection among the study participants [15]. Nonetheless, 42.7% HIV sero-prevalence rate among TB patients was noted in a study in a National Hospital in Abuja state, Nigeria [16], which is similar to that of this current study. Furthermore, the current results pointed to an overall increase in trend of the dual infection over the study period. This particularly high TB/HIV co-infection rate and the rising trend with each passing year could be explained by the good case detection capacity expected of a referral center such as the study site. It may also have been delimited by the participants’ self-selection. There is need for subjects suspected of TB to be tested for HIV as well.

HIV co-infection among TB patients in this study was higher in females than in males though not statistically significant. Other related studies that support this finding in terms of no significant difference between the sexes include that by Akinleye et al., [17], Houston et al., [18] and those by Mor et al., [19]. However, studies by Van [20], Chum et al., [21], Olanrewaju et al. [22] and others found significant higher HIV co-mobidity in females than males. Females have a higher susceptibility to HIV infection because they are usually exposed to sexual activities earlier than men mainly for economic reasons [23,24]. In addition, the biological composition of women usually increases their risk of HIV infection compared to men.

There was significant difference among HIV and TB patients of various ages who used DOTS in General Hospital Umuguma, from January 2013 –December 2017. This finding is in agreement with previous reports from similar studies of Sume et al. [25] and Christopher et al. [12]. This high HIV co-infection among TB patients probably reflects the age-specific prevalence of HIV in the community. This may be related to the patients’ in the age groups 21-40 years, as young adults, being sexually active and particularly at risk of HIV infection [26-28]. 

In this study, TB/HIV co-infection was significantly higher in the unmarried when compared to married patients. This finding is consistent with related studies that showed higher number of HIV infected TB cases in unmarried participants than married ones as in Erhabor et al., [29] and Mitku et al., [30]. This may be because unmarried TB patients, many of whom may be adolescents, are likely to have multiple sexual partners and be involved in high risk sexual behaviours (homosexuality, commercial sex work, alcohol use and intravenous drug abuse) hence, have an increased risk of acquiring HIV infection [27,31]. 

This study found that TB/HIV co-infection was significantly higher in urban dwelling patients than rural dwelling TB patients. This agrees with related studies by Daniel, GD. et al., [9] and Houston et al., [18], that showed higher number of HIV infected TB cases in urban than rural areas. The reason for this might be the presence of high prevalence of HIV infection among urban dwellers than rural dwellers [32]. Also, TB continues to cluster in disadvantaged groups including urban slum dwellers, who are more often than not the poor and hungry [33,34].

In conclusion, the demographic factors, age, sex, marital status and location, to varying degrees. predict HIV co-infection among the TB patients. Co-infection was significantly predicted by urban dwellers, 31 to 40 age groups, female gender and being unmarried. Thus, there is urgent need for programmatic revision of ongoing intervention strategies for TB, strengthening of health systems infrastructure, targeted capacity building for health personnel and intensified public awareness on TB/HIV co-infection. Thus, there should be targeted interventions for women, unmarried people, people of sexually active and reproductive age group and urban dwellers.

Recommendations

With the increasing rates of TB and HIV co-infection, we recommend that: The National and State TB and Leprosy Control programs should ensure increased surveillance, intensified case finding for TB and HIV testing services (HTS) for HIV and TB diagnosis and referral. There should be deployment of more TB microscopy, GeneXpert, DOTS and HIV counselling and testing centres and interventions for prevention and care of TB and HIV/ AIDS by use of antiretroviral therapy as well as use of Isoniazid preventive therapy to prevent reactivation of TB among people living with HIV. 

The Government through the Ministry of Health should make efforts to strengthening the Public-Private mix [35], health education and media awareness on these demographic factors that promote Tuberculosis and HIV co-infection. Health workers and organizations involved in tackling TB should support the general health service response to HIV/AIDS and vice versa, by taking on TB as a major killer of people living with HIV by ensuring that they are given Isoniazid Preventive Therapy (IPT). Tackling TB should include HIV as the most potent force driving the TB epidemic by ensuring they take Clotrimazole Preventive Therapy (CPT).

The Government should empower people with TB and foster community participation in TB care, prevention and health promotion. In consistent with principles of primary health care as stated by Alma Ata declaration and to achieve better disease outcomes, intervention frameworks by the National TB and Leprosy Control Program that address TB/HIV co-infection should not only focus on the medical interventions of diseases, but should also integrate and improve socio-demographic factors that fuel both diseases. DOTS centres in health facilities should ensure strict compliance with the Centres for Disease Control and Prevention recommendation that all newly diagnosed TB patients be tested for HIV after pre-test counselling by offering HIV testing to those using DOTS centres.

Limitations of the Study

These include: 

• The study was done in a particular location (General Hospital Umuguma) and so the results cannot be generalized beyond the study population

• The study was done only in a health facility with functional DOTS and AFB smear microscopy, services and high patient volume

• Non-availability of HIV test results for some patients

• Reduced sensitivity of smear microscopy in HIV positive individual leading to reduction in the number of individuals with TB that are HIV positive

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