Assessment of the tuberculosis case-finding and prevention cascade among people living with HIV in Zambia \u2013 2018: a cross-sectional cluster survey

Michael Melgar,Amos Nota,Sydney Mwanza,Patrick Lungu,Shepherd Khondowe,Laura J Podewils,Mathias Tembo,David Mwakazanga,Joyce Mulenga,Kelvin Kapungu,Clifford Tende,Brittany Moore,Ray W Shiraishi

doi:10.1186/s12889-021-10929-z

Abstract

BackgroundThe Ministry of Health Zambia recommends tuberculosis preventive treatment (TPT) with 6 months daily isoniazid for all people living with human immunodeficiency virus (HIV) after ruling out active tuberculosis disease. We sought to estimate the percentage of people living with HIV who progress through each stage of the tuberculosis case-finding and prevention cascade in two provinces with the highest tuberculosis burden in Zambia.MethodsIn this cross-sectional survey, we used a two-stage cluster sampling method. We sampled 12 healthcare facilities with probability proportional to size. Patient volume determined facility cluster size. During October 2018, from each facility we systematically sampled medical records of adults and children living with HIV. Our primary outcome of interest was TPT initiation rate among eligible people living with HIV, weighted for complex survey design. The Rao-Scott adjusted chi-square test was used to test for differences in TPT initiation rate and other indicators from the tuberculosis prevention cascade by age group and province of residence. Additionally, we conducted semi-structured interviews with healthcare workers at each facility to assess TPT knowledge and identify challenges to its implementation.ResultsWe sampled 482 records of people living with HIV (including 128 children living with HIV). Excluding two people diagnosed with tuberculosis disease before enrollment in HIV care, 93.4% underwent tuberculosis symptom screening. Of those, 4.7% were diagnosed with tuberculosis disease and 95.3% were TPT-eligible, of whom 24.7% initiated TPT. TPT initiation was lower among eligible children (7.7%) compared with adults (25.2%, p = 0.03) and Copperbelt residents (3.1%) compared with Lusaka residents (35.8%, p < 0.01). TPT completion rate was 38.4% among people living with HIV who initiated the 6-month course. Among interviewed healthcare workers, 58.3% (unweighted) incorrectly relayed the number of symptoms needed for a positive tuberculosis symptom screen, 83.3% (unweighted) reported insufficient isoniazid stockpile for completion at the time of TPT initiation, and only 27.3% (unweighted) reported receiving TPT-specific training.ConclusionsTPT uptake among people living with HIV in Zambia is challenged by inconsistent tuberculosis screening, lack of TPT training for healthcare workers, and supply chain inefficiencies. Addressing these barriers may increase TPT initiations and improve outcomes among people living with HIV.

Highlights

Tuberculosis (TB) is the leading cause of death among people living with human immunodeficiency virus (PLHI V), estimated to account for nearly one third of all deaths [1]
tuberculosis preventive treatment (TPT) uptake among people living with human immunodeficiency virus (HIV) in Zambia is challenged by inconsistent tuberculosis screening, lack of TPT training for healthcare workers, and supply chain inefficiencies
For each sampled People living with human immunodeficiency virus (PLHIV), we reviewed the medical record and the laboratory TB register to determine whether the individual had a diagnosis of active TB disease prior to Antiretroviral therapy (ART) initiation, whether s/he underwent TB symptom screening per World Health Organization (WHO) guidelines, and whether active TB disease was diagnosed at the time of ART initiation

Summary

Introduction

Tuberculosis (TB) is the leading cause of death among people living with human immunodeficiency virus (PLHI V), estimated to account for nearly one third of all deaths [1]. TB preventive treatment (TPT) decreases TB incidence and mortality among PLHIV [5, 6], with an effect independent from that of ART [7]. The World Health Organization (WHO) recommends TPT for PLHIV without active TB disease, including children living with HIV (CLHIV) aged ≥12 months and pregnant and breastfeeding women with HIV, with 6 months of daily isoniazid (with pyridoxine supplementation to prevent peripheral neuropathy) or an equivalent rifamycin-based regimen [8]. The Ministry of Health Zambia recommends tuberculosis preventive treatment (TPT) with 6 months daily isoniazid for all people living with human immunodeficiency virus (HIV) after ruling out active tuberculosis disease.

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