The impact of HIV on resource utilization by patients with tuberculosis in a tertiary referral hospital, Nairobi, Kenya

HIV Prevalence Among Tuberculosis Patients in Sub-Saharan Africa: A Systematic Review and Meta-analysis

HIV associated tuberculosis (TB) morbidity and mortality is a major concern in sub-Saharan Africa. Understanding the level of HIV infection among TB patients is vital for adequate response. We conducted a systematic review and meta-analysis to estimate the prevalence of HIV in TB patients in sub-Saharan Africa. We searched PubMed, EMBASE, Web of Science and CINAHL databases. A meta-analysis with a random-effects model was performed. Potential sources of heterogeneity in the prevalence estimates were explored using meta-regression analysis. We identified 68 studies that collectively included 62,969 TB patients between 1990 and 2017. The overall estimate of HIV prevalence in TB patients was 31.8% (95% CI 27.8-36.1). There was substantial heterogeneity in the prevalence estimates in Southern, Central, Eastern, and Western sub-Saharan Africa regions (43.7, 41.3, 31.1 and 25.5%, respectively). We noted an apparent reduction in the estimate from 33.7% (95% CI 27.6-40.4) in the period before 2000 to 25.7% (95% CI 17.6-336.6) in the period after 2010. The Eastern and Southern sub-Saharan Africa region had higher prevalence [34.4% (95% CI 29.3-34.4)] than the Western and Central region [27.3% (95% CI 21.6-33.8)]. The prevalence of HIV in TB patients has declined over time in sub-Saharan Africa. We argue that this is due to strengthened HIV prevention and control response and enhanced TB/HIV collaborative activities. Countries and regions with high burdens of HIV and TB should strengthen and sustain efforts in order to achieve the goal of ending both HIV and TB epidemics in line with the Sustainable Development Goals.

Tuberculosis and HIV Infection: The Global Setting

Tuberculosis (TB) and human immunodeficiency virus (HIV) infection make each other's control significantly more difficult. Coordination in addressing this "cursed duet" is insufficient at both global and national levels. However, global policy for TB/HIV coordination has been set, and there is consensus around this policy from both the TB and HIV control communities. The policy aims to provide all necessary care for the prevention and management of HIV-associated TB, but its implementation is hindered by real technical difficulties and shortages of resources. All major global-level institutions involved in HIV care and prevention must include TB control as part of their corporate policy. Country-level decision makers need to work together to expand both TB and HIV services, and civil society and community representatives need to hold those responsible accountable for their delivery. The TB and HIV communities should join forces to address the health-sector weaknesses that confront them both.

Towards universal access to HIV prevention, treatment, care, and support: the role of tuberculosis/HIV collaboration

Tuberculosis is the oldest of the world's current pandemics and causes 8.9 million new cases and 1.7 million deaths annually. The disease is among the most common causes of morbidity and mortality in people living with HIV. However, tuberculosis is more than just part of the global HIV problem; well-resourced tuberculosis programmes are an important part of the solution to scaling-up towards universal access to comprehensive HIV prevention, diagnosis, care, and support. This article reviews the impact of the interactions between tuberculosis and HIV in resource-limited settings; outlines the recommended programmatic and clinical responses to the dual epidemics, highlighting the role of tuberculosis/HIV collaboration in increasing access to prevention, diagnostic, and treatment services; and reviews progress in the global response to the epidemic of HIV-related tuberculosis.

The cost to health services of human immunodeficiency virus (HIV) co-infection among tuberculosis patients in Sudan

OBJECTIVE

To compare the cost of managing HIV-positive and HIV-negative tuberculosis (TB) patients in Sudan.

METHODS

A prospective cohort of 1797 consecutive TB patients referred to the chest clinics within the general health services from March 1998 to March 2000 were included in this study. Patients were tested blindly for HIV; 1724 were HIV-negative and 73 were HIV-positive.

FINDINGS

The total cost associated with management of tuberculosis was significantly higher for HIV-positive, as compared with HIV-negative TB patients (105.08 US dollars versus 73.92, p=0.003). This difference was due mainly to greater costs for hospitalization of those HIV-positive, as compared with those HIV-negative (190.80 versus 141.00, p=0.001). The differences in cost for diagnostic tests, for drugs, for management of adverse reactions and for intercurrent symptoms were not significant (p>0.05) between HIV-positive TB patients and HIV-negative TB patients. Side effects of treatment were slightly more common among persons without HIV infection than among HIV-positive patients (14 and 9.6%, respectively). The total cost of management of HIV-positive patients in this series of patients was 6% of all costs for TB case management and the marginal cost attributable to HIV-positivity was 0.9% of the total cost.

CONCLUSION

The management of the HIV-positive TB case was more costly than that of the HIV-negative case in this stage of the HIV/AIDS epidemic in Sudan.

Cost-effectiveness of highly active antiretroviral therapy in South Africa

BACKGROUND

Little information exists on the impact of highly active antiretroviral therapy (HAART) on health-care provision in South Africa despite increasing scale-up of access to HAART and gradual reduction in HAART prices.

METHODS AND FINDINGS

Use and cost of services for 265 HIV-infected adults without AIDS (World Health Organization [WHO] stage 1, 2, or 3) and 27 with AIDS (WHO stage 4) receiving HAART between 1995 and 2000 in Cape Town were compared with HIV-infected controls matched for baseline WHO stage, CD4 count, age, and socioeconomic status, who did not receive antiretroviral therapy (ART; No-ART group). Costs of service provision (January 2004 prices, USD 1 = 7.6 Rand) included local unit costs, and two scenarios for HAART prices for WHO recommended first-line regimens: scenario 1 used current South African public-sector ART drug prices of $730 per patient-year (PPY), whereas scenario 2 was based on the anticipated public-sector price for locally manufactured drug of $181 PPY. All analyses are presented in terms of patients without AIDS and patients with AIDS. For patients without AIDS, the mean number of inpatient days PPY was 1.08 (95% confidence interval [CI]: 0.97-1.19) for the HAART group versus 3.73 (95% CI: 3.55-3.97) for the No-ART group, and 8.71 (95% CI: 8.40-9.03) versus 4.35 (95% CI: 4.12-5.61), respectively, for mean number of outpatient visits PPY. Average service provision PPY was $950 for the No-ART group versus $1,342 and $793 PPY for the HAART group for scenario 1 and 2, respectively, whereas the incremental cost per life-year gained (LYG) was $1,622 for scenario 1 and $675 for scenario 2. For patients with AIDS, mean inpatients days PPY was 2.04 (95% CI: 1.63-2.52) for the HAART versus 15.36 (95% CI: 13.97-16.85) for the No-ART group. Mean outpatient visits PPY was 7.62 (95% CI: 6.81-8.49) compared with 6.60 (95% CI: 5.69-7.62) respectively. Average service provision PPY was $3,520 for the No-ART group versus $1,513 and $964 for the HAART group for scenario 1 and 2, respectively, whereas the incremental cost per LYG was cost saving for both scenarios. In a sensitivity analysis based on the lower (25%) and upper (75%) interquartile range survival percentiles, the incremental cost per LYG ranged from $1,557 to $1,772 for the group without AIDS and from cost saving to $111 for patients with AIDS.

CONCLUSION

HAART is a cost-effective intervention in South Africa, and cost saving when HAART prices are further reduced. Our estimates, however, were based on direct costs, and as such the actual cost saving might have been underestimated if indirect costs were also included.

Tuberculosis control in the era of HIV

Without HIV, the tuberculosis (TB) epidemic would now be in decline almost everywhere. However, instead of looking forward to the demise of TB, countries that are badly affected by HIV are struggling against a rising tide of HIV-infected patients with TB. As a consequence, global TB control policies have had to be revised and control of TB now demands increased investment. This paper assesses what is being done to address the issue and what remains to be done.

Costs and effectiveness--the impact of economic studies on TB control

This paper assesses the impact of economic studies on TB control during the period 1982-2002, with a focus on cost and cost-effectiveness studies. It begins by identifying broad categories of economic study relevant to TB control, and how economic studies can, theoretically, have an impact on TB control. The impact that economic studies of TB control have had in practice is then analysed through a systematic review of the literature on cost and cost-effectiveness studies related to TB control, and three case studies (one cost study and two cost-effectiveness studies). The results show that in the past 20 years, 66 cost-effectiveness studies and 31 cost studies have been done on a variety of important TB control topics, with a marked increase occurring after 1994. In terms of numbers, these studies have had most potential for impact in industrialized countries, and within industrialized countries are most likely to have had an impact on policy and practice related to screening and preventive therapy. In developing countries with a high burden of tuberculosis, far fewer studies have been undertaken. Here, the main impact of economic studies has been influencing policy and practice on the use of short-course chemotherapy, justifying the implementation of community-based care in Africa, and helping to mobilize funding for TB control based on the argument that short-course treatment for TB is one of the most cost-effective health interventions available. For the future, cost and cost-effectiveness studies will continue to be relevant, as will other types of economic study.

Hospital costs of high-burden diseases: malaria and pulmonary tuberculosis in a high HIV prevalence context in Zimbabwe

This paper explores the measurement of hospital costs and efficiency in a context where data is scarce, incomplete or of poor quality. It argues that there is scope for using tracers to examine and compare hospital cost structures and relative efficiency in such contexts. Two high-burden diseases, malaria and pulmonary tuberculosis, are used as tracers to calculate the average costs of inpatient care at selected tertiary hospitals. This study shows that it is feasible to prospectively collect cost data for specific diseases and explore in detail both patient cost distribution and susceptible areas for efficiency improvement. The present study found that the critical source of efficiency variation in public hospitals in Zimbabwe lies in the way hospital beds are used.

HIV and tuberculosis in rural sub-Saharan Africa: a cohort study with two year follow-up

The objective was to examine the effect of HIV seropositivity on outcomes in tuberculosis (TB) patients in a rural African setting, including rates of TB relapse, other morbid events and mortality. The study setting was a district level hospital in Mzuzu, Malawi. Adult TB patients presenting between November 1991 and May 1993 were included in the study. Treatment was given according to national guidelines. Patients with smear-positive TB received 8 months of rifampicin-containing short-course chemotherapy. Patients with smear-negative or extrapulmonary TB received 12 months of 'standard' treatment. Subjects were followed until they died or until the study concluded (December 1994). There were 225 eligible patients; 187 were tested for HIV and enrolled in the study (66.8% HIV seropositive). Ninety-four percent had complete follow-up information. The cure rate in smear-positive patients who survived to the end of treatment was over 90% and not significantly affected by HIV. Disorders of the gastrointestinal, neurological and dermatological systems were significantly more common in HIV-seropositive patients. HIV had a significant effect on the risk of relapse of TB (hazard ratio [HR] = 10.55 [95% CI 1.38, 80.93]) and on all-cause mortality (HR = 2.81 [95% CI 1.63, 4.64]). Despite high HIV prevalence, high rates of TB cure are achievable using the usual treatment protocols. However, excess TB relapse, other illnesses and mortality associated with HIV seropositivity have serious implications for TB control. There is an urgent need to identify effective intervention strategies aimed at prevention, early diagnosis and treatment of these illnesses.

Prevalence of HIV infection among hospital patients in north west Tanzania

In order to estimate hospital HIV prevalence, the economic impact of AIDS on health care and to assess the implications of HIV testing on clinical suspicion of AIDS this hospital based study was done at the government regional hospital of Kagera, Tanzania. Consecutive admissions were recruited into the study, and those consenting had a blood specimen taken, one portion of which was used to aid clinical diagnosis, while the other was tested anonymously for HIV antibodies using two ELISA systems. A short questionnaire was used to specify demographic characteristics, hospital ward of admission and diagnosis of each study subject. The overall age adjusted HIV-1 prevalence was 32.8% (N = 1422) and there was no significant difference in the age adjusted sex specific prevalence. The highest prevalence (53.3%) was found in the 25-34 years age group as well as in the gynaecological and medical wards (41.2% and 40.4%, respectively). The diagnostic category of clinical AIDS had a sensitivity of 11.3% and a specificity of 99.3%, indicating that only 11.3% of the HIV seropositives would have been HIV tested on clinical suspicion of AIDS. Similarly, the HIV-1 antibody sensitivity and specificity for tuberculosis were 5.9% and 97.9%, respectively. Patients who were HIV-1 infected were more likely to have a history of previous hospital admissions, RR = 1.34 (95% CI = 1.16-1.56), and were at an increased risk of developing tuberculosis, RR = 2.02 (95% CI = 1.50-2.70). The diagnostic categories with the highest HIV-1 infection prevalence were clinical AIDS (88.5%), herpes zoster and other HIV-1 skin manifestations combined (85.7%) and pulmonary tuberculosis (58.3%). In conclusion, the prevalence of HIV-1 infection was high among hospitalized patients in Bukoba hospital indicating that the major cause of illness leading to admission to the hospital may have been underlying HIV-1 infection. The findings also indicate that in a high HIV-1 prevalence area, testing for HIV infection on the basis of clinical suspicion of AIDS alone is not sufficient to provide rational care to the majority of HIV infected patients.

Some effects of the rising case load of adult HIV-related disease on a hospital in Nairobi

Increasing numbers of HIV-infected adults in Africa need hospital care. It remains unclear what impact this has on health care services or on how hospitals respond. The aim of this study was to describe the effects of a rising case load of adult HIV-related disease by comparing results from a prospective cross-sectional study of acute adult medical admissions to a government hospital in Nairobi conducted in 1992 with results from a previous study done in 1988 and 1989 in the same hospital, using the same study design and protocol. Data on age, gender, number admitted, length of stay, HIV status, clinical AIDS, final diagnosis, case mix, and outcome were compared. In 1992, 374 consecutive patients were admitted in 15 24-hour periods (24.9 patients/period) compared with the 1988 to 1989 study, which enrolled 506 patients in 22 24-hour periods (23.0 patients/period). Patients' age, gender, and length of hospital stay were similar in both studies. In 1992, 39% of patients were HIV-positive compared with 19% in 1988 to 1989 (p < 10(-6)); whereas seropositive admissions rose 123% between the two periods (p < .0001), HIV-negative admissions declined 18% (p < .05). Clinical surveillance for AIDS consistently identified <40% of HIV-positive patients. Irrespective of HIV status, tuberculosis and pneumococcal pneumonia were the leading diagnoses in both surveys. No change was found in the diagnoses recorded for HIV-positive patients, but in HIV-negative patients, reductions were significant in the case mix (p < .00001) and range of diagnoses (p < .001) seen in 1992. Outcome remained unchanged for HIV-positive patients with approximately 35% mortality in both surveys. Outcome significantly worsened, in relative and absolute terms, for HIV-negative patients: in 1992, mortality was 23%, compared with 13.9% in 1988 to 1989 (p < .005), with 3.5 deaths per 24-hour period in 1992 compared with 2.6 deaths per 24-hour period in 1988 to 1989 (p < .05, one-tailed). These data suggest that increasing selection for admission is taking place as demand for care increases because of HIV/AIDS. This process appears to favor HIV-positive patients at the expense of HIV-negative patients who seem to be crowded out and, once admitted, experience higher mortality rates. The true social costs of the HIV epidemic are underestimated by not including the effects on HIV-negative people.

Tuberculosis in Africa: clinical presentation and management

In the last decade, sub-Saharan Africa has experienced an explosive increase in tuberculosis (TB) cases, largely as a result of the co-epidemic of human immunodeficiency virus (HIV) infection. This article reviews the essential background epidemiology of TB in sub-Saharan Africa. The clinical features and diagnostic problems of pulmonary/extrapulmonary TB in adults and children are discussed, particularly in relation to HIV infection. Different treatment regimens, their cost, adverse reactions, the ways in which HIV infection influences treatment response and the extent of drug resistance are reviewed. The recommended approaches to TB control in Africa, including methods used to prevent TB through Bacillus Calmette-Guerin and chemoprophylaxis are examined. The success achieved by good National TB Control Programmes in some African countries allows cautious optimism that this epidemic can be controlled.

Invasive pneumococcal disease in a cohort of predominantly HIV-1 infected female sex-workers in Nairobi, Kenya

BACKGROUND

HIV infection is a major risk factor for pneumococcal disease in industrialised countries. Although both are common infections in sub-Saharan Africa, few studies have investigated the importance of this interaction. We have followed up a cohort of female sex-workers in Nairobi and report here on the extent of invasive pneumococcal disease.

METHODS

A well-established cohort of low-class female sex-workers, based around a community clinic, was followed up from October, 1989, to September, 1992. 587 participants were HIV positive and 132 remained HIV negative. Set protocols were used to investigate common presentations. Cases were identified clinically and radiographically. Streptococcus pneumoniae and other pathogens were diagnosed by culture.

FINDINGS

Seventy-nine episodes of invasive pneumococcal disease were seen in the 587 HIV-positive women compared with one episode in the 132 seronegative women (relative risk 17.8, 95% CI 2.5 to 126.5). In seropositive women the incidence rate was 42.5 per 1000 person-years and the recurrence rate was 264 per 1000 person-years. By serotyping, most recurrent events were re-infection. A wide spectrum of HIV-related pneumococcal disease was seen: only 56% of cases were pneumonia; sinusitis was seen in 30% of cases, and occult bacteraemia, a novel adult presentation, in 11%. Despite forty-two bacteraemic episodes, no deaths were attributable to Strep pneumoniae. At first presentation the mean CD4 cell count was 302/microL(SD 191) and was 171/microL (105) for recurrent episodes. During acute Strep pneumoniae infection the CD4 cell count was reversibly suppressed (mean fall in sixteen episodes, 105/microL [123]). The neutrophil response to acute infection was blunted and was correlated with CD4 count (r=0.50, 95% CI 0.29 to 0.66). Strep pneumoniae caused more disease, at an earlier stage of HIV immunosuppression, than Mycobacterium tuberculosis or non-typhi salmonellae.

INTERPRETATION

Our study highlights the importance of the pneumococcus as an early but readily treatable complication of HIV infection in sub-Saharan Africa.

An economic evaluation of alternative programme designs for tuberculosis control in rural Uganda

Tuberculosis (TB) and AIDS are infections that are among the most feared of all diseases. Both have been widely discussed by the western media in recent months, for a variety of reasons, but it is the combination of the two diseases in an ever increasing number of patients that is causing concern to health planners and health economists. While AIDS is untreatable and prevention of further infection depends largely on changes in sexual behaviour, TB remains eminently treatable. Preventing the spread of TB depends on the effective treatment of active cases, taking 6-12 months, depending on the drugs used. In order to ensure completion of treatment, a programme of registering and following up patients is required. A number of different programme designs are considered and an analysis of both costs and consequences is attempted in order to find the most cost-effective alternative. Data from western Uganda for 1992 are used for the study and the implications of the findings for both Uganda and other African countries are discussed. It is concluded that a programme based on the ambulatory treatment of patients at their nearest health unit, whilst living at home, is the most cost-effective design, largely because of reduced costs to the patients themselves. Specific recommendations are made regarding the implementation of such a programme.