The impact of HIV status on diagnosis of pulmonary tuberculosis in Mbale District.

Abstract

SETTING: This study was carried out in Mbale regional hospital wghich is found on the eastern part of the country. It was a hospital-based cross-sectional descriptive study of newly diagnosed PTB patients aged 15 years and above who had initiated treatment for PTB. OBJECTIVES: The objective was mainly to find out the impact of HIV infection on the traditional diagnostic parameters, the effect on diagnostic delay and on the treatment delay as well. METHODOLOGY: Consecutive recruitment of eligible patients was done, pre-test counseling done, a consent for the study and for HIV serology obtained and then face to face interviews conducted by the principal investigator. The height and weight of the patients was taken. Study instruments included a questionnaire, results of investigations i.e ESR, total and differential white blood cell counts, hemoglobin levels, sputum examination and chest X-ray findings. Serology for HIV 1 and 2 serum antibodies was also done. RESULTS: There were 261 patients of known HIV status out of 620 adult TB patients. The male to female ratio was 1.3:1. While the mean age for the HIV negative patients was 36 that for the HIV positive patients was 33 years. The male HIV negative patients had the highest mean age of 40 while the female HIV positive patients had the lowest mean age of 30 years. HIV positive status significantly lowered the mean age of the respondents (p=0.02). The HIV prevalence rate was 46%. HIV and tuberculosis co-infection was significantly associated with: age group 20 to 30 years (p=0.015), occupation of security officer (p=0.001), being unemployed (p=0.001), the Iteso tribal group (0.04) and less significantly with primary and tertiary level of education (p=0.08). The life style habit of smoking was closely associated with the HIV positive status but not significantly so (p=0.096). A high percentage of respondents gave history of contact with an active case of PTB (43%) and there was no significant difference between the HIV positive and the HIV negative in this respect. The HIV positive status did not affect the symptomatology of the patients. Most patients both HIV positive and HIV negative complained of the classical symptoms of cough (98%), fever (95%), drenching night sweats (82%) and loss of body weight (71%). The only difference was in the order of appearance of these symptoms. In the HIV positive patients, these symptoms appeared later in the course of ill health. In laboratory investigations, the majority of the patients were anemic (73%) and the HIV positive patients significantly had hemoglobin values lower than 10mg dl-1 (P=0.03), they had low TWBC counts of less than 3000 (p=0.000), they had a typical ESR with many having ESR below 50mm (westergren) (p=0.13), they were having more negative sputum smears (p=0.08) and a typical or normal CXR findings (p=0.02). There was no impact of the HIV positive status on the diagnostic delay (p=0.09) and peri-urban residents (p=0.08) who had a long patient delay, female gender had long doctor delay (p=0.05), while male gender (p=0.049) and age beyond 46 years (p=0.03) had longer treatment delay. The mean patient delay was 18 weeks, mean doctor delay 10 weeks, mean total delay 28 weeks and mean treatment delay 5 days. The mean BMI was 16.7kg/m2. CONCLUSION: Although HIV does not have a statistically significant effect on diagnostic delay, it has an impact on the traditional ancillary parameters of diagnosis. The delay of five months is far too long and factors associated with this delay need to be investigated further and addressed vigorously. RECOMMENDATIONS: A Pulmonary tuberculosis predictive model for the frontline health care provider needs to be put in place and should include a protocol for cut-off values of blood test results and CXR findings that will help diagnose PTB in patients who are sputum smear negative or in whom there is no sputum production or in whom it is possible to do sputum examination due to lack of reagents and facilities. The practice of contact tracing needs to be revived alongside the CB-DOTS strategy of patient management. Rapid diagnostic tests (BACTEC) need to be introduced at the nearest diagnostic and treatment units for early and speedy diagnosis of PTB.