Surveillance of tuberculosis among HIV infected persons in three different regions of Nepal

Tuberculosis itself is a major public health problem in Nepal. The emergence of HIV has caused sharp increase in TB incidence in the community. Surveillance of TB/HIV co-infection helps in developing effective TB/HIV control strategies. The objective of this study was to measure prevalence of TB among HIV/AIDS patients in the selected regions. Between December 2006 and May 2008, a cross-sectional study was conducted in three different settings namely Tribhuvan University Teaching hospital, Kathmandu; Regional Tuberculosis Centre, Pokhara and Shree Siddhanath Science Campus, Mahendranagar. After taking informed consent pre-structured questionnaire was administered. Sputum specimen was collected from HIV/AIDS patients to investigate tuberculosis by culture and microscopy. Data analysis was done using SPSS 11.5. Of the 394 HIV infected persons, 225 (57.1%) were male and 169 (42.9%) female. The overall prevalence of TB was found to be 8.1%. Clinical signs and symptoms were significantly lower in those patients undergoing ART (chi2 value ranging from 4.19 to 9.13). However, development of tuberculosis is independent of ART status (chi2 value 1.14) and CD4 level (chi2 value 3.25). TB case detection rate by cultural technique was found to be twice as superior as direct microscopy. It can be concluded that smear negative TB constitute the significant proportion of TB cases in HIV infected persons.

Medication adherence to antiretroviral therapy among patients visiting antiretroviral therapy center at Tribhuvan University Teaching Hospital, Kathmandu Nepal

BACKGROUND

Although antiretroviral therapy has limited efficiency, patients should take multiple drugs in combination in prescribed time for lifelong and they should also require specific food and fluid restriction. Due to these and other factors patients may discontinue their medication and therefore face significant challenges in adherence.

OBJECTIVES

To assess factors associated with non-adherence among people living with HIV receiving the antiretroviral therapy.

METHODS

Between July 2011 to January 2012, a cross sectional survey was conducted among patients visiting HIV/AIDS unit, Tribhuvan University Teaching Hospital for therapy. After taking informed consent, a pre-structured questionnaire was filled up and data were entered into SPSS 11.5 system and analyzed.

RESULTS

Of the 100 studied subjects, 61 (61.0%) were male and 39 (39%) were female. Adherence was found to be 79%. The major barrier to adherence was reported to be simply forgetfulness (33.3% of those non adherents). Non adherence was significantly associated with types of family (X² value, 7.11), smoking (X² value, 5.44) and alcoholic habit (X² value, 5.69) but not with gender (X² value, 2.57). Besides this, poor economic status, and attendance to religious ceremony were reported to be major obstacles to adherence.

CONCLUSION

Adherence at this center was found to be only satisfactory. Forgetfulness was reported to be the major cause of non adherence. Persons living in joint family and those with alcoholic and /or smoking habit were more likely to miss the pills. It can be recommended that effective counseling, moral/financial support for HIV/AIDS patients may increase their adherence.

Prevalence of pulmonary tuberculosis among HIV infected persons in Pokhara, Nepal

BACKGROUND

Tuberculosis (TB) is a major public health problem in Nepal. HIV co-infection has further added a serious challenge to control TB. An early diagnosis and treatment of TB in HIV infected individuals can help reduce not only the morbidity and mortality associated in this high risk group but also to control the TB burden in Nepal.

METHODS

Clinical and bacteriological examination for pulmonary TB was carried out in 184 HIV positive persons from the community in Pokhara. Questionnaire was used to screen for symptoms and collect participants' demographic information and potential risk factors for TB.

RESULTS

Eighty (43.5%) sero-positive participants were young adult (21-30 years), followed by 71 (38.6%) middle aged (31-40 years) persons. Eleven participants were found to have Mycobacterium tuberculosis in their sputum, giving an overall prevalence of tuberculosis of 5.97%. All 11 cases were detected by Acid Fast Bacilli (AFB) culture, of which only three cases were detected by direct microscopy of AFB stained sputum smear. The majority of TB/HIV patients were asymptomatic with low AFB smear positivity. No significant association was found between TB and risk factors like ARV status, common clinical features of tuberculosis and smoking habit. However, significant association was found between the alcohol consumption and TB (X2=4.11, p<0.05).

CONCLUSIONS

High prevalence of tuberculosis (5.97%) was found among HIV infected persons. Alcohol consumption was associated with the development of tuberculosis. Majority of the studied subjects were asymptomatic for common signs and symptoms of TB. Weight loss was observed in 43% of the studied subjects followed by chest pain (39.2%), loss of appetite (34.8%), fever (34.8%) and night sweat (26.1%). Only 27% of the TB cases were found to be smear-positive.

Scenario of HIV/AIDS patients in a government hospital of Nepal

BACKGROUND

With the increase in the severity of immunosupression, due to HIV infection, there is increase in the flow of patients seeking care and support services. Antiretroviral drugs minimize chance of developing AIDS related opportunistic infection and therefore there would be the prolongation of life of the patients. The objectives of this study are to assess the chief complaints, major opportunistic infections, complications of ART and treatment outcome of hospital admitted HIV patients.

METHODS

A cross sectional study was carried out between December 2008 to May 2009 among 66 HIV patients undergoing indoor treatment in Seti Zonal Hospital, Dhangadhi.

RESULTS

Of the total cases, 36 (54.5%) were male and 30 (45.5%) were females with predominant age group of 31- 40 years (47%). About 24% of admitted patients had CD4 count less than 50/cu mm blood. Thirty five (53%) cases presented fever as the major clinical presentation of HIV/AIDS due to different opportunistic infections followed by cough (28.8%), loss of appetite (28.8%), weight loss (27.3%), and diarrhea (24.2%). Tuberculosis was found to be the major opportunistic infection accounting 27.3% followed by gastroenteritis (21.2%) and oral candidiasis (15.5%). Treatment outcome of hospital admitted patients showed the 83.3% recovery rate and 4.3% death rate.

CONCLUSIONS

Hospital admission was found to be efficient to treat the major opportunistic infections and management of ART hypersensitivity reactions. While tuberculosis was the leading opportunistic infection, the most common clinical manifestation was found to be fever among the admitted HIV/AIDS patients.

Clinical features of HIV/AIDS and various opportunistic infections in relation to antiretroviral status among HIV seropositive individuals from Central Nepal

BACKGROUND

So far, antiretroviral therapy is the only effective treatment available to HIV/AIDS patients. Provision of combined package of treatment, care and support service as well as regular assessment of the therapy increases its effectiveness.

OBJECTIVE

The aim of this study was to establish the relationship between antiretroviral therapy status and clinical features/opportunistic infections among HIV seropositive individuals.

MATERIALS AND METHOD

This is a cross-sectional study. Study was carried out between October 2007 and May 2008 in 150 HIV patients of Kathmandu, Central Nepal. After taking informed consent pre-structured questionnaire was filled to assess clinical features and specimen were collected to investigate major OIs as per standard microbiological procedure. All the information were entered into SPSS 11.5 system and analysed.

RESULT

Of the 150 patients, 100 (66.7%) were males and 50 (33.3%) were females. The age group 21-30 years was predominant followed by 31-40 years (42%). Significant relationship could be established between intake of ART and cardinal symptoms of HIV/AIDS (chi2 value ranging from 4.11 to 9.34). However, no significant relationship could be established between the intake of ART and distribution of different OIs (chi2 values ranging from 0.15 to 1.6).

CONCLUSION

Antiretroviral therapy was found to effective enough to reduce the clinical features of AIDS. Diagnosis and treatment of opportunistic infections should be routinely done for both groups of patients.

Opportunistic infections in relation to CD4 level among HIV seropositive patients from central Nepal

CD4 cells status of HIV patients provides one of the benchmarks against the progression of HIV/AIDS. Regular investigation of opportunistic infection in HIV patients is one of the major components of HIV/AIDS care and support service. Between October 2007 and May 2008, a cross-sectional analytical study was carried out in Tribhuvan University Teaching Hospital with an objective to find the relationship between CD4 level and opportunistic infections. After taking informed consent pre-structured questionnaire was filled and specimens were collected to investigate major opportunistic infections (OIs) as per standard microbiological procedure. All the information were entered into SPSS 11.5 system and analyzed. Of the 150 patients, 100 (66.7%) were males and 50 (33.3%) were females. The age group 21-30 years was predominant (42.7%) followed by 31-40 years (42%). Oral candidiasis was found to be the predominant OIs (32.0%) followed by streptococcal pneumonia (28.7%), Salmonella infection (20.7%), cryptosporidial infection (19.3%) and tuberculosis (10.0%). Significant relationship could be established between low CD4 count (<200) and the appearance of oral candidiasis (/2=9.16, p<0.05) but no such relationship could be established regarding other OIs. So, it can be concluded that appearance of oral candidiasis is the strong evidence of advanced stage of HIV infection.

Antiretroviral Service to HIV patients of low CD4 count in Seti Zonal Hospital

INTRODUCTION

Due to unavailability of vaccine against HIV/AIDS, there are no ways other than relying on ART. We select group of late stage HIV/AIDS with CD4<50 so that opportunistic infections and outcome of patients in this late stage of severe immunosuppression after initiation of ART can be known

METHODS

A cross sectional study was carried out in 53 HIV patients with CD4 count <50 cells/cu mm blood undergoing ART in Seti Zonal Hospital Dhangadi between December 2006 and May 2008 with objectives to explore the treatment outcome in this late stage of immunosuppression. Only those patients with CD4 count <50 were consecutively selected and recommended for various laboratory test on the basis of which ART regimen were prescribed.

RESULTS

Among 53 patients, 42 (79.2%) were males and 11 (20.8%) were females, with predominant age group of 30-40 years (49.1%). Fever (71.7%), diarrhea (56.6%), pneumonia (52.8%), weight loss (52.8%) and oral thrush (33.9%) were found to be the major clinical presentation/Opportunistic infections. 19 (35.8%) patients showed normal activity throughout the treatment period with increase in CD4 count, 10 (19%) were recovered and transferred out. Only 1 (1.8%) showed decrease in CD4 count even after taking ART. Significant relationship was established between the intake of ART and increase in CD4 level (pair t = 7.88, p<0.05).

CONCLUSIONS

ART service was found to be efficient enough to increase the CD4 count significantly after 6 months of therapy but the prevalence of OIs/clinical manifestations were sufficiently higher in this group of patients with low CD4 count.

Tuberculosis co-infection in HIV infected persons of Kathmandu

Tuberculosis is itself a major Public health problem in Nepal and the emergence HIV further complicated the issue. A cross-sectional analytical study was conducted between January 2004 and August 2005, with a general objective to determine the Tuberculosis co-infection status in HIV/AIDS cases of Nepal. Altogether 100 HIV infected persons visiting different Voluntary counseling and testing centers (VCT) and HIV/AIDS care centers located in Kathmandu valley were enrolled in the study. Investigation of tuberculosis was done by standard method prescribed by WHO using sputum specimen. Among 100 HIV infected cases, 66 (66.0%) were males and 34 (34.0%) were females. Majority of the HIV cases were in the age group 21-30 (60.0%) followed by 31-40 (31.0%). Tuberculosis was detected in 23 cases with highest prevalence in the age group 21-30 years (65.2%). No significant relationship could be established between gender and TB (c2 = 0.83, p > 0.01).Significant relationship was established between smoking/alcoholic habit and the subsequent development of tuberculosis (c2 = 7.24, p < 0.05 for smoking habit; c2 = 4.39, p < 0.05 for alcoholic habit at 1 degree of freedom). Among 22 culture positive isolates the predominant was Mycobacterium avium complex (40.9%) followed by M. tuberculosis (27.3%), M. kansasii (18.2%), M. fortuitum (9.1%) and M. chelonae (4.5%). Among the 23 cases of tuberculosis, 22 cases were diagnosed by cultural technique of which 4 cases were smear positive while the remaining one case was diagnosed by direct microscopy although it was culture negative. Smear negative Tuberculosis is found to be alarmingly higher in HIV positive individuals of productive age group. The disease significantly higher in smokers and alcoholics.

Characterization of mycobacteria in HIV/AIDS patients of Nepal

Besides Mycobacterium tuberculosis, a number of other Mycobacterium species are also occasional human pathogens. Tuberculosis due to Mycobacterium avium complex (MAC) and Mycobacterium kansasii is particularly prevalent in AIDS patients as compared to the normal population. A cross-sectional study was carried out during January 2004 to August 2005 in 100 HIV-infected persons visiting Tribhuvan University, Teaching Hospital, and about a dozen of HIV/AIDS care centers of Kathmandu with the objectives to characterize the different mycobacterial species in HIV/AIDS patients. Three sputum specimens from each person were used to investigate tuberculosis by Ziehl-Neelsen staining, culture and identification tests. Among the 100 HIV-infected cases, 66 (66%) were males and 34 (34%) were females. Sixty percent of the cases were in the age group of 21-30 years. Mycobacteria were detected in 23 (23%) HIV cases of which 15 (65.2%) were in the age group of 21-30 years ; 17(74%) were males and 6 (26 %) were females. Among 23 co-infected cases, 22 were culture positive for mycobacteria. Among these, the predominant one was Mycobacterium avium complex (MAC), 9 (41%), followed by M. tuberculosis, 6 (27%), M .kansasii, 4 (18%), M. fortuitum, 2 (10%) and M. chelonae 1 (4%). Significant relationship was established between smoking/alcoholism and the subsequent development of tuberculosis (chi(2)=7.24, p<0.05 for smoking habit and chi(2)=4.39, p<0.05 for alcoholism). Fourteen (61%) co-infected cases presented with weight loss and cough whereas diarrhea was presented only by those patients with atypical mycobacterial co-infection, which was as high as 5 (56%) in patients with MAC co-infection. This study demonstrated the predominance of atypical mycobacteria, mainly MAC, in HIV/AIDS cases and most of them were from sputum smear-negative cases.

Tuberculosis and other clinical presentation of HIV/AIDS in patients with or without undergoing antiretroviral therapy in Kathmandu

OBJECTIVES

To screen tuberculosis (TB) and examine the clinical presentation of AIDS in HIV sero-positive persons.

METHODS

A Cross-sectional study was designed. One hundred HIV infected persons were randomly selected from different parts of the country visiting Tribhuvan University, Teaching Hospital, Kathmandu and different HIV/AIDS care centres. After taking informed consent, questionnaires were filled and three sputum specimens from each person were collected to investigate tuberculosis by Ziehl-Neelsen staining and culture. Data generated were entered into SPSS 11.5 and relevant statistical tools were applied.

RESULTS

Among 100 HIV infected cases, 66 (66%) were males and 34 (34%) were females. Sixty percent of the cases were in the age group of 21-30 years. Majority of them were Smokers (41%), alcoholics (34%), illiterates (54%) and unemployed (59%). Heterosexual activity (51%) was found to be the major risk factor for HIV infection. Of the 100 HIV cases, 23 (23%) were co-infected with tuberculosis of which 18(78%) were sputum smear negative tuberculosis, mostly developed in late stage of HIV infection. Weight loss (54%) and diarrhoea (43%) were the major clinical presentations of AIDS. Antiretro-viral therapy non-receiver were more likely to suffer with various clinical disorders/TB as compared to ARV therapy receiver but the values were statistically insignificant, 2 values ranging from 0.003 to 2.24, p>0.05.

CONCLUSION

Prevalence of tuberculosis was still high in HIV/AIDS patients, and specifically, sputum smear negative tuberculosis cases constituted the significant proportion, particularly in late stage of HIV infection. Weight loss and diarrhoea were found to be the major clinical presentation of AIDS. Illiterate and unemployed young adults involved in unsafe sexual practice and drug addiction were high risk of acquiring HIV infection. Key words: Clinical features, HIV/AIDS, Kathmandu; Smear Negative Tuberculosis.