Bernt Lindtjørn

Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia

BackgroundDelay in the diagnosis of tuberculosis may worsen the disease, increase the risk of death and enhance tuberculosis transmission in the community. This study aims to determine the length of delay between the onset of symptoms and patients first visit to health care (patient delay), and the length of delay between health care visit and the diagnosis of tuberculosis (health service delay).MethodsA cross sectional survey that included all the public health centres was conducted in Addis Ababa from August 1 to December 31 1998. Patients were interviewed on the same day of diagnosis using structured questionnaire.Results700 pulmonary TB patients were studied. The median patient delay was 60 days and mean 78.2 days. There was no significant difference in socio-demographic factors in those who delayed and came earlier among smear positives. However, there was a significant difference in distance from home to health institute and knowledge about TB treatment among the smear negatives. The health service delay was low (median 6 days; mean 9.5 days) delay was significantly lower in smear positives compared to smear negatives. Longer health service delay (delay more than 15 days) was associated with far distance.ConclusionsThe time before diagnosis in TB patients was long and appears to be associated with patient inadequate knowledge of TB treatment and distance to the health centre. Further decentralization of TB services, the use of some components of active case finding, and raising public awareness of the disease to increase service utilization are recommended.

Determinants of treatment adherence among smear-positive pulmonary tuberculosis patients in Southern Ethiopia.

Background Defaulting from treatment remains a challenge for most tuberculosis control programmes. It may increase the risk of drug resistance, relapse, death, and prolonged infectiousness. The aim of this study was to determine factors predicting treatment adherence among smear-positive pulmonary tuberculosis patients. Methods and Findings A cohort of smear-positive tuberculosis patients diagnosed and registered in Hossana Hospital in southern Ethiopia from 1 September 2002 to 30 April 2004 were prospectively included. Using a structured questionnaire, potential predictor factors for defaulting from treatment were recorded at the beginning of treatment, and patients were followed up until the end of treatment. Default incidence rate was calculated and compared among preregistered risk factors. Of the 404 patients registered for treatment, 81 (20%) defaulted from treatment. A total of 91% (74 of 81) of treatment interruptions occurred during the continuation phase of treatment. On a Cox regression model, distance from home to treatment centre (hazard ratio [HR] = 2.97; p < 0.001), age > 25 y (HR = 1.71; p = 0.02), and necessity to use public transport to get to a treatment centre (HR = 1.59; p = 0.06) were found to be independently associated with defaulting from treatment. Conclusions Defaulting due to treatment noncompletion in this study setting is high, and the main determinants appear to be factors related to physical access to a treatment centre. The continuation phase of treatment is the most crucial time for treatment interruption, and future interventions should take this factor into consideration.

Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial

Background One of the main strategies to control tuberculosis (TB) is to find and treat people with active disease. Unfortunately, the case detection rates remain low in many countries. Thus, we need interventions to find and treat sufficient number of patients to control TB. We investigated whether involving health extension workers (HEWs: trained community health workers) in TB control improved smear-positive case detection and treatment success rates in southern Ethiopia. Methodology/Principal Finding We carried out a community-randomized trial in southern Ethiopia from September 2006 to April 2008. Fifty-one kebeles (with a total population of 296, 811) were randomly allocated to intervention and control groups. We trained HEWs in the intervention kebeles on how to identify suspects, collect sputum, and provide directly observed treatment. The HEWs in the intervention kebeles advised people with productive cough of 2 weeks or more duration to attend the health posts. Two hundred and thirty smear-positive patients were identified from the intervention and 88 patients from the control kebeles. The mean case detection rate was higher in the intervention than in the control kebeles (122.2% vs 69.4%, p<0.001). In addition, more females patients were identified in the intervention kebeles (149.0 vs 91.6, p<0.001). The mean treatment success rate was higher in the intervention than in the control kebeles (89.3% vs 83.1%, p = 0.012) and more for females patients (89.8% vs 81.3%, p = 0.05). Conclusions/Significance The involvement of HEWs in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This could be applied in settings with low health service coverage and a shortage of health workers. Trial Registration ClinicalTrials.gov NCT00803322

Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia

Background Previous studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. One of the reasons was late presentation of patients to care. With improved access to HIV services, we expect improvements in disease stage at presentation. Our objective was to assess the effect of improved availability of HIV services on patient presentation to care and subsequent pre-ART and on-ART outcomes. Methodology and Principal Findings At Arba Minch Hospital in Ethiopia, we reviewed baseline characteristics and outcomes of 2191 adult HIV patients. Nearly a half were in WHO stage III at presentation. About two-thirds of the patients (1428) started ART. Patients enrolled in the early phase (OR = 4.03, 95% CI 3.07–5.27), men (OR = 1.78, 95%CI 1.47–2.16), and those aged 45 years and above (OR = 2.04, 95%CI 1.48–2.82) were at higher risk of being in advanced clinical stage at presentation. The pre-treatment mortality rate was 13.1 per 100 PYO, ranging from 1.4 in the rapid scale-up phase to 25.9 per 100 PYO in the early phase. A quarter of the patients were lost to follow-up before starting treatment. Being in less advanced stage (HR = 1.9, 95% CI = 1.6, 2.2), being in the recent cohort (HR = 2.0, 95% CI = 1.6, 2.6), and rural residence (HR = 1.8, 95% CI = 1.5, 2.2) were independent predictors of pre-ART loss to follow-up. Of those who started ART, 13.4% were lost to follow-up and 15.4% died. The survival improved during the study. Patients with advanced disease, men and older people had higher death rates. Conclusions and Significance Patients started to present at earlier stages of their illness and death has decreased among adult HIV patients visiting Arba Minch Hospital. However, many patients were lost from pre-treatment follow-up. Early treatment start contributed to improved survival. Both pre-ART and on-ART patient retention mechanisms should be strengthened.

DOTS improves treatment outcomes and service coverage for tuberculosis in South Ethiopia: a retrospective trend analysis

BackgroundDOTS as a strategy was introduced to the tuberculosis control programme in Southern region of Ethiopia in 1996. The impact of the programme on treatment outcomes and the trend in the service coverage for tuberculosis has not been assessed ever since. The aim of the study was to assess trends in the expansion of DOTS and treatment outcomes for tuberculosis in Hadiya zone in Southern Ethiopia.Methods19,971 tuberculosis patients registered for treatment in 41 treatment centres in Hadiya zone between 1994 and 2001 were included in the study. The data were collected from the unit tuberculosis registers. For each patient, we recorded information on demographic characteristics, treatment centre, year of treatment, disease category, treatment given, follow-up and treatment outcomes. We also checked the year when DOTS was introduced to the treatment centre.ResultsPopulation coverage by DOTS reached 75% in 2001, and the proportion of patients treated with short course chemotherapy increased from 7% in 1994 to 97% in 2001. Treatment success for smear-positive tuberculosis rose from 38% to 73% in 2000, default rate declined from 38% to 18%, and treatment failure declined from 5% to 1%. Being female patient, age 15–24 years, smear positive pulmonary tuberculosis, treatment with short course chemotherapy, and treatment at peripheral centres were associated with higher treatment success and lower defaulter rates.ConclusionThe introduction and expansion of DOTS in Hadiya has led to a significant increase in treatment success and decrease in default and failure rates. The smaller institutions exhibited better treatment outcomes compared to the larger ones including the zonal hospital. We identified many patients with missing information in the unit registers and this issue needs to be addressed. Further studies are recommended to see the impact of the programme on the prevalence and incidence of tuberculosis.

Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients

BackgroundAlthough highly active antiretroviral therapy (HAART) reduces mortality in the developed world, it remains undocumented in resource-poor settings. We assessed the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in Ethiopia. The objective of this study was to assess the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in a resource-limited setting in south Ethiopia. Starting in January 2003, we followed all consecutive adult HIV infected patients who visited the HIV clinic. Since August 2003, we treated patients with HAART. Only basic laboratory services were available.ResultsWe followed 185 patients in the pre-HAART cohort and 180 patients in the HAART cohort. The mortality rate was 15.4 per 100 person-years of observation (PYO) in the HAART group and tuberculosis incidence rate was 3.7 per 100 PYO. In the pre-HAART group, the mortality rate was 58.1 per 100 PYO and the tuberculosis incidence rate was 11.1 per 100 PYO. HAART resulted in a 65% decline in mortality (adjusted hazard ratio [95%CI] = 0.35 [0.19–0.63]; P < 0.001). Tuberculosis incidence rate was lower in the HAART group (adjusted hazard ratio [95%CI] = 0.11 [0.03–0.48]; P < 0.01). Most of the deaths occurred during the first three months of treatment.ConclusionHAART improved survival and decreased tuberculosis incidence to a level similar to that achieved in the developed countries during the early years of HAART. However, both the mortality and the tuberculosis incidence rate were much higher in terms of absolute figures in this resource-limited setting. Attention should be paid to the early weeks of treatment when mortality is high. The high tuberculosis incidence rate, when coupled with the improved survival, may lead to increased tuberculosis transmission. This highlights the need for strengthening tuberculosis prevention efforts with the scale-up of treatment programmes

Predictors of early death in a cohort of Ethiopian patients treated with HAART

BackgroundHAART has improved the survival of HIV infected patients. However, compared to patients in high-income countries, patients in resource-poor countries have higher mortality rates. Our objective was to identify independent risk factors for death in Ethiopian patients treated with HAART.MethodsIn a district hospital in Ethiopia, we treated adult HIV infected patients with HAART based on clinical and total lymphocyte count (TLC) criteria. We measured body weight and complete blood cell count at baseline, 4 weeks later, then repeated weight every month and complete blood cell count every 12 weeks. Time to death was the main outcome variable. We used the Kaplan Meier and Cox regression survival analyses to identify prognostic markers. Also, we calculated mortality rates for the different phases of the follow-up.ResultsOut of 162 recruited, 152 treatment-naïve patients contributed 144.1 person-years of observation (PYO). 86 (57%) of them were men and their median age was 32 years. 24 patients died, making the overall mortality rate 16.7 per 100 PYO. The highest death rate occurred in the first month of treatment. Compared to the first month, mortality declined by 9-fold after the 18th week of follow-up. Being in WHO clinical stage IV and having TLC<= 750/mcL were independent predictors of death. Haemoglobin (HGB) <= 10 g/dl and TLC<= 1200/mcL at baseline were not associated with increased mortality. Body mass index (BMI) <= 18.5 kg/m2 at baseline was associated with death in univariate analysis. Weight loss was seen in about a third of patients who survived up to the fourth week, and it was associated with increased death. Decline in TLC, HGB and BMI was associated with death in univariate analysis only.ConclusionThe high mortality rate seen in this cohort was associated with advanced disease stage and very low TLC at presentation. Patients should be identified and treated before they progress to advanced stages. The underlying causes for early death in patients presenting at late stages should be investigated.

Traditional values of virginity and sexual behaviour in rural Ethiopian youth: results from a cross-sectional study

BackgroundDelaying sexual initiation has been promoted as one of the methods of decreasing risks of HIV among young people. In traditional countries, such as Ethiopia, retaining virginity until marriage is the norm. However, no one has examined the impact of this traditional norm on sexual behaviour and risk of HIV in marriage. This study examined the effect of virginity norm on having sex before marriage and sexual behaviour after marriage among rural Ethiopian youth.MethodsWe did a cross-sectional survey in 9 rural and 1 urban area using a probabilistic sample of 3,743 youth, 15–24 years of age. Univariate analysis was used to assess associations between virginity norm and gender stratified by area, and between sexual behaviour and marital status. We applied Kaplan-Meier and Cox regression analysis to estimate age at sexual debut and assessed the predictors of premarital sex among the never-married using SPSS.ResultsWe found that maintaining virginity is still a way of securing marriage for girls, especially in rural areas; the odds of belief and intention to marry a virgin among boys was 3–4 times higher among rural young males. As age increased, the likelihood of remaining a virgin decreased. There was no significant difference between married and unmarried young people in terms of number of partners and visiting commercial sex workers. Married men were twice more likely to have multiple sexual partners than their female counterparts. A Cox regression show that those who did not believe in traditional values of preserving virginity (adjusted hazard ratio [AHR] = 2.91 [1.92–4.40]), alcohol drinkers (AHR = 2.91 [1.97–4.29]), Khat chewers (AHR = 2.36 [1.45–3.85]), literates (AHR = 18.01 [4.34–74.42]), and the older age group (AHR = 1.85 [1.19–2.91]) were more likely to have premarital sex than their counterparts.ConclusionAlthough virginity norms help delay age at sexual debut among rural Ethiopian youth, and thus reduces vulnerability to sexually transmitted infections and HIV infection, vulnerability among females may increase after marriage due to unprotected multiple risky sexual behaviours by spouses. The use of preventive services, such as VCT before marriage and condom use in marriage should be part of the HIV/AIDS prevention and control strategies.

The rate of TB-HIV co-infection depends on the prevalence of HIV infection in a community

BackgroundA complex interaction exists between tuberculosis (TB) and human immunodeficiency virus (HIV) infection at an individual and community level. Limited knowledge about the rate of HIV infection in TB patients and the general population compromises the planning, resource allocation and prevention and control activities. The aim of this study was to determine the rate of HIV infection in TB patients and its correlation with the rate HIV infection in pregnant women attending antenatal care (ANC) in Southern Ethiopia.MethodsAll TB patients and pregnant women attending health institutions for TB diagnosis and treatment and ANC were consecutively enrolled in 2004 – 2005. TB diagnosis, treatment and HIV testing were done according to the national guidelines. Blood samples were collected for anonymous HIV testing. We used univariate and multivariate logistic regression analysis to determine the risk factors for HIV infection and linear regression analysis to determine the correlation between HIV infection in TB patients and pregnant women.ResultsOf the 1308 TB patients enrolled, 226 (18%) (95%CI: 15.8 – 20.0) were HIV positive. The rate of HIV infection was higher in TB patients from urban 25% (73/298) than rural areas 16% (149/945) [AOR = 1.78, 95%CI: 1.27–2.48]. Of the 4199 pregnant women attending ANC, 155 (3.8%) [95%CI: 3.2–4.4] were HIV positive. The rate of HIV infection was higher in pregnant women from urban (7.5%) (80/1066) than rural areas (2.5%) (75/3025) [OR = 3.19, 95% CI: 2.31–4.41]. In the study participants attending the same health institutions, the rate of HIV infection in pregnant women correlated with the rate of HIV infection in TB patients (R2 = 0.732).ConclusionThe rate of HIV infection in TB patients and pregnant women was higher in study participants from urban areas. The rate of HIV infection in TB patients was associated with the prevalence of HIV infection in pregnant women attending ANC.

Acceptability of HIV counselling and testing among tuberculosis patients in south Ethiopia

BackgroundTo benefit from available care and treatment options, patients should first be counselled and tested for HIV. Our aim was to assess the acceptability of HIV testing among tuberculosis patients under routine care conditions in south Ethiopia.MethodsWe interviewed all adult tuberculosis patients who were treated at Arba Minch Hospital in Ethiopia between January and August 2005. After recording socio-demographic information and tuberculosis treatment history, we referred those patients who showed initial willingness to a counsellor for HIV counselling and testing. Rapid test methods were used following a pretest counselling session. The results were disclosed during a post-test counselling session. We used the logistic regression method to assess factors associated with willingness and acceptability.Results190 adult tuberculosis patients were treated at the hospital and all of them consented to take part in the study. Their median age was 30 years (range, 15–68) and 52% of them were males. 49 patients (26%) were previously tested including 29 (59%) HIV positive. Of 161 patients (excluding the 29 already positive), 118 (73%) were willing to be tested and 58% (68/118) of those willing accepted the test. The overall acceptability rate was 35% (56/161). Fourteen (20.6%) were HIV positive and women were more likely to be HIV infected (p = 0.029). Unemployment and self-perceived high risk of HIV infection were associated with initial willingness (OR [95%CI]:2.6 [1.3–5.5] vs. 5.0 [1.1–22.4], respectively). However, only being unemployed was associated with accepting the test (OR = 4.2; 95%CI = 1.9–9.3).ConclusionThe low acceptability of HIV counselling and testing among tuberculosis patients poses a challenge to the scale-up of TB/HIV collaborative efforts. There is a need for alternative counselling and testing strategies.