Abstract
BackgroundSuccessful tuberculosis (TB) treatment is essential to effective TB control. TB-HIV coinfection, social determinants and access to services influenced by rural residence can affect treatment outcome. We examined the separate and joint effects of rural residence and HIV infection on poor treatment outcome among patients enrolled in a large TB treatment centre in Kano, Nigeria.MethodsWe retrospectively analysed a cohort of patients with TB enrolled in a large urban TB clinic in northern Nigeria, from January 2010 to December 2014. Poor treatment outcome was defined as death, default or treatment failure. We used Poisson regression to model rates and determine the relative risks (and 95% confidence intervals, CI) of poor treatment outcomes.ResultsAmong 1381 patients included in the analysis, 28.4% were rural residents; 39.8% were HIV-positive; and 46.1% had a poor treatment outcome. Approximately 65 and 38% of rural and urban residents, respectively, had a poor treatment outcome. Rural residents had 2.74 times (95% CI: 2.27–3.29) the risk of having a poor treatment outcome compared to urban residents. HIV-positive patients had 1.4 times (95% CI: 1.16–1.69) the risk of poor treatment outcome compared to HIV-negative patients. The proportion of poor treatment outcome attributable to rural residence (population attributable fraction, PAF) was 25.6%. The PAF for HIV infection was 11.9%. The effect of rural residence on poor treatment outcome among HIV-negative patients (aRR:4.07; 95%CI:3.15–5.25) was more than twice that among HIV-positive patients (aRR:1.99; 95%CI:1.49–2.64).ConclusionRural residents attending a large Nigerian TB clinic are at increased risk of having poor treatment outcomes, and this risk is amplified among those that are HIV-negative. Our findings indicate that rural coverage of HIV services may be better than TB services. These findings highlight the importance of expanding coverage of TB services to ensure prompt diagnosis and commencement of treatment, especially among rural-dwellers in resource-limited settings.
Highlights
Successful tuberculosis (TB) treatment is essential to effective TB control
[10] TB in Nigeria is largely externally funded through the Global Fund to fight AIDS, TB and Malaria (GFATM), and the United States Agency for International Development (USAID) through Challenge TB; and to a lesser extent domestically, with persistent funding gaps especially at lower government levels. [11,12,13] TB treatment and microscopy services are provided free across treatment centres and microscopy sites in the country, [14] with lower coverage in the northern states
We show that rural residents have more than twice the risk of having a poor treatment outcome when compared to urban residents, and this relationship is modified by Human immunodeficiency virus (HIV) status and sex
Summary
Successful tuberculosis (TB) treatment is essential to effective TB control. TB-HIV coinfection, social determinants and access to services influenced by rural residence can affect treatment outcome. [16] Though urban residence is a recognised risk factor for TB, especially in rapidly urbanising communities due to poor living conditions, [3] the gap in TB services coverage between the northern and southern part of the country, as well as between the rural and urban areas may have worsened inequalities to treatment access which can affect the treatment outcome. In addition to providing specialist services such as diagnosis of extra-pulmonary and smear-negative TB, several tertiary-level facilities in the country (which are largely urban-based) provide primary care services, such as diagnosis and treatment of pulmonary TB. This imbalance may further worsen rural-urban inequalities in TB care. Establishing the effect of rural residence in the context of the country with the 4th largest global burden of TB and gross inequalities in TB services, while adjusting for confounding factors, which previous studies have not always done, provides important policy-relevant information
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