Uptake of isoniazid preventive therapy for tuberculosis among HIV patients in Kano, Nigeria

Rabiu Ibrahim Jalo

doi:10.4103/njbcs.njbcs_9_19

ORIGINAL ARTICLE

Year : 2020 | Volume : 17 | Issue : 1 | Page : 57-63

Uptake of isoniazid preventive therapy for tuberculosis among HIV patients in Kano, Nigeria

Rabiu Ibrahim Jalo
Department of Community Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria

Date of Submission	28-Apr-2019
Date of Acceptance	13-Apr-2020
Date of Web Publication	30-May-2020

Correspondence Address:
Dr. Rabiu Ibrahim Jalo
Department of Community Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/njbcs.njbcs_9_19

Abstract

Context: Despite convincing data on its efficacy and recommendation by the World Health Organisation that isoniazid preventive therapy (IPT) be included as part of the minimum package of care for people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome, IPT has not been widely implemented. Aims: The study assessed uptake and predictors of IPT among HIV patients in Kano, Nigeria. Methods and Material: Using a cross-sectional study design, an interviewer-administered questionnaire was used to collect information from 320 HIV patients from 2 primary health-care centres using systematic sampling technique. Statistical analysis used: Data were analysed using SPSS version 20.0. Results: Majority of the respondents (309; 96.9%) believed that tuberculosis (TB) poses a threat to health and well-being of HIV patients and up to 307 (95.9%) knew that TB is preventable, but slightly over a half (172; 53.8%) of the respondents were using IPT for prevention of TB. Age, education, awareness and disclosure were found to be independent predictors of IPT uptake. Respondents who were 30 years or older (adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI] = 1.16–5.24) and those who disclosed their HIV status to partner/family (AOR = 1.52, 95% CI = 1.15–3.68) had higher odds of IPT uptake, whereas respondents with informal education (AOR = 0.46, 95% CI = 0.14–0.93) and those who lack awareness of IPT were less likely to uptake IPT (AOR = 0.23, 95% CI = 0.08–0.68). Conclusions: IPT is being underutilised for the prevention of TB among HIV patients in Kano. This implies the need for health-care workers to introduce strategies to improve counseling and disclosure.

Keywords: Tuberculosis, human immunodeficiency virus, isoniazid preventive therapy, uptake

How to cite this article:
Jalo RI. Uptake of isoniazid preventive therapy for tuberculosis among HIV patients in Kano, Nigeria. Niger J Basic Clin Sci 2020;17:57-63

How to cite this URL:
Jalo RI. Uptake of isoniazid preventive therapy for tuberculosis among HIV patients in Kano, Nigeria. Niger J Basic Clin Sci [serial online] 2020 [cited 2023 Jun 10];17:57-63. Available from: https://www.njbcs.net/text.asp?2020/17/1/57/285473

Introduction

Infection with Mycobacterium tuberculosis is the precursor to tuberculosis (TB) disease, which is responsible for 1.5 million deaths each year, more than any other infectious disease.^[1] Once infected, the individual is at highest risk of developing TB within the first 2 years, but can remain at risk for their lifetime. The population carrying a latent TB infection is commonly quoted as 'one-third' of the global population, a reservoir of approximately 2.3 billion individuals.^[1] Evidence suggests that TB prevalence and mortality have been underestimated in many high-burden countries, with revised estimates from Nigeria changing global figures in recent years.^[1],[2] Nigeria, the most populous country in Africa, has an estimated population of over 170 million people and it is among the identified 22 high TB burden countries.^[2] TB is the most common opportunistic infection among HIV-infected individuals. It is a major cause of mortality among patients with HIV and poses a risk throughout the course of HIV disease. Overall, the risk of developing TB is many times greater among people living with human immunodeficiency virus (PLWHIV) than those who do not have HIV infection. The risk of TB in HIV-infected persons continues to increase as HIV disease progresses and immunity decreases. IPT was also found to be effective in reducing the incidence of TB and death from TB in HIV-infected patients.^[3],[4]

Isoniazid preventive therapy (IPT) is a crucial, cost-effective component of HIV care for adults and children.^[3] IPT use has been recommended as an international standard of care for over a decade; it remains highly underutilised.^[1] To end the global TB epidemic, strategies must be put in place to address the significant reservoir of TB infection, especially among PLHIV, who are most likely to progress to active TB disease. Therefore, finding and treating people with both latent and active TB disease and thereby interrupting further transmission remains a top global health priority. It has been estimated that nearly a quarter of the global population is infected with TB, the vast majority of whom do not have active disease.^[2] Without detecting and treating TB infection and halting its progression to active disease, the TB epidemic will not end. An emphasis on TB prevention not only spares individuals the burden of TB-associated morbidity and mortality but also reduces the economic impact of the disease on the health system as a whole.

Sub-Saharan Africa has the highest number of PLWHIV/acquired immunodeficiency syndrome (AIDS) and HIV-associated TB.^[1] The impact of HIV on TB patients and programmes has implications for TB control and policies. Mechanisms of HIV effect on TB control include the effects on diagnosis and on the patterns of HIV-related TB, the differential response of HIV-infected TB patients to TB treatment, the benefits of antiretroviral therapy (ART) and the quality and continuity of care for TB patients.^[3] More TB cases in PLWHIV/AIDS pose an increased risk of TB transmission to the general community, whether or not HIV-infected.^[3] The World Health Organization (WHO) had proposed a framework of TB/HIV/AIDS collaborative activities to prevent the occurrence of TB-HIV disease, including IPT, intensified TB case finding and infection prevention/control. There is now strong evidence from several randomised controlled trials about the efficacy of preventive therapy in the prevention of TB in persons infected with human immunodeficiency virus.^[4],[5] However, one of the primary reasons for failure of IPT is poor uptake and adherence.

The proportion of TB patients in Nigeria in 2014 who tested for HIV was 79%, with a 25% TB-HIV co-infection rate, 59% of these patients were started on co-trimoxazole (CPT) prophylaxis, but only 1.8% were provided with isoniazid (IPT) prophylaxis.^[6] Furthermore, Lagos, Kano and Oyo have the highest TB prevalence rates in Nigeria that is attributable to a high HIV prevalence.^[7] This study aimed to assess uptake and predictors for IPT among HIV patients in Kano.

Methodology

Study design

A cross-sectional study design was used to collect information from HIV patients attending two primary health-care centres (PHCs) in Kano, Nigeria (Unguwa Uku and Kumbotso health-care centres).

Study setting

At the two selected primary health centres, antiretroviral drugs (ARVs), anti-TB drugs and IPT are provided at no charge (cost) to all patients. IPT is offered to all HIV-positive patients who meet a simple screening criteria (clinical algorithm) based on the absence of the following symptoms: current cough, fever, weight loss and night sweats based on the recommendation of the 2016 National Guideline for HIV Prevention, Treatment and Care.^[8] The recommended regimen for TB preventive therapy in adults is isoniazid (isonicotinic acid hydrazide – INH), 300 mg daily for at least 6 months.^[8]

Study population

The study population comprised adult HIV-positive patients (18 years and above), who had been receiving care in the study sites for at least 6 months before the survey. The study was conducted between March and October 2018.

Inclusion criteria

1. HIV patients who are 18 years and older and have been receiving care for at least 6 months prior to the survey.

Exclusion criteria

HIV patients receiving anti-TB treatment
HIV patients on admission on the wards.

Sample size determination

The sample size of this study was determined using the formula for single proportion stated below:^[9]

n = Z²pq/d²

Where,

n = Minimum sample size required.

Z = Value of standard normal deviate corresponding to 95% confidence interval (CI) = 1.96.

p = Proportion of HIV patients on IPT obtained from a previous similar study ^[10] = 30%.

q = Complementary probability.

= 1 − p = 1 − 0.30 = 0.70.

d = Desired level of precision at 95%.

= 0.05.

n = (1.96)² × 0.30 × 0.70/(0.05)² = 313.

Adding a non-response of 5% to the calculated minimum sample size, a sample size of 329 was obtained.

Sampling technique

A two-stage sampling technique was used.

Stage I

In the first stage, two PHCs were selected (U/uku and Kumbotso) from the list of PHCs providing HIV prevention, treatment and support.

Stage II

A systematic sampling technique was used to select respondents from the two selected health facilities. Sample size and sampling frame (average monthly patients attendance at the two ART clinics which is 750 from the 2018 attendance records) was used to determine sampling fraction. Thus, the sampling fraction was obtained using sample size and sampling frame.

The reciprocal of the sampling fraction yields a sampling interval of 2; simple random sampling (balloting) was used to determine the starting point and every 2^nd patient was then selected.

Data collection method

An interviewer-administered, pre-tested, semi-structured questionnaire adapted from previous studies was used to collect data from eligible respondents.^[11],[12] The questionnaire was translated into the local Hausa language by a professional Hausa tutor in a higher institution in Kano (Bayero university, Kano). Two female and two male research assistants were recruited for this study; research assistants had a minimum qualification of ordinary national diploma or bachelor's degree in health-related areas and have been involved in community/hospital-level survey in the past. They were also fluent in Hausa language and sensitive to the local culture. They were trained for 1 day on the contents of the questionnaire, obtaining consent and interviewing process.

Statistical analysis

Data collected were cleaned, entered into excel spread sheet and analysed using IBM SPSS version 20.0 (Armonk, New York, USA). Age was summarised using mean and standard deviation (SD), whereas frequencies and percentages were used to summarise qualitative variables: sex, religion, marital status, ethnicity, educational status, partner's education, occupation, awareness, side effect, willingness, counselling and disclosure. Question used to assess uptake of IPT was dichotomised as 'Yes' or 'No' responses. Respondents were then categorised as having used IPT or not based on their responses.

Chi-square test and Fisher's exact test (where appropriate) were used to analyse factors associated with respondent's IPT uptake. In all tests of significance, P < 0.05 was considered statistically significant. All variables found to have P< 0.10 and those found to be predictors of IPT uptake from literature review were entered into the binary logistic regression model.^[13] Binary logistic regression analysis was used to obtain crude and adjusted odds ratio (AOR) with 95% CIs for predictors of IPT uptake.

Ethical considerations

The protocol for this study was submitted to the Health Research Ethics Committee of Aminu Kano Teaching Hospital Kano, Nigeria, for review and approval before commencement of data collection. Ethical approval with reference number (NHREC/21/08/EC/AKTH/2361) was obtained. Written informed consent form was given to literate respondents to sign before the questionnaire was administered, and for those who cannot read and write, details of the consent form were explained to them and they subsequently append their thumbprint to the form to indicate consent. The Helsinki declaration was respected throughout the research.

Results

A total of 329 respondents were recruited for the study, of which 320 questionnaires were correctly filled, giving a response rate of 97.3%.

The mean (±SD) age of the respondents was 35.07 (±11.53) years. Majority of the respondents were female (71.9%) and in the age group 25–34 years (32.5%). Many participants (88.1%) were Muslims and of either Hausa (77.8%) or Fulani (12.8%) tribes. Almost all the respondents (94.1%) were ever married, up to a third (33.1%) had secondary level of education and 44.3% had no formal education and. Over a third of the partners (38.1%) had secondary education, whereas 20.9% had tertiary level of education. Up to 60.3% of respondents earn less than the national minimum wage of ₦18,000 [Table 1].

Table 1: Sociodemographic characteristics of human immunodeficiency virus patients in Kano

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Majority of the respondents (309; 96.9%) believed that TB poses a threat to health and well-being of HIV patients and up to 307 (95.9%) knew that TB is preventable [Table 2]. Slightly over a half (172; 53.8%) of the respondents interviewed were currently using IPT for TB [Table 3]. Of these, the main reasons given for uptake of IPT were the fear of TB/HIV co-infection (92.1%), recommendation by health-care workers (83.8%), advise by members of HIV support group (62.2%), ease of IPT administration (51.9%) and adequate counselling by health-care providers (62.8%). On the other hand, the main reason for non-use of IPT was fear of additional pill burden (75.6%). At bivariate level of analysis, IPT uptake was found to be significantly associated (P< 0.05) with age, tribe, IPT awareness, formal education, partner's education, willingness to use IPT, advise by support group, ease of administration and disclosure of HIV status to partners/relatives [Table 4].

Table 2: Respondent's perception about tuberculosis and isoniazid preventive therapy uptake

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Table 3: Uptake of isoniazid preventive therapy among human immunodeficiency virus patients in Kano

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Table 4: Factors associated with isoniazid preventive therapy uptake among human immunodeficiency virus patients in
Kano

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Eleven factors with a P< 0.10 (age, tribe, awareness about IPT, level of education, partner's education, willingness to use IPT in the future, disclosure of HIV status, marital status, ease of IPT administration, support group and counselling) and two other factors reported to be associated with IPT uptake from literature review (counselling and age) were further subjected to multivariate analysis.^{[14],[15],[16]} After adjusting for other covariates, age, education, awareness and disclosure were found to remain independent predictors of IPT uptake. Respondents who were 30 years or older (AOR = 2.46, 95% CI = 1.16–5.24) and those who disclosed their HIV status to partner/family (AOR = 1.52, 95% CI = 1.15–3.68) had higher odds of IPT uptake. Respondents with informal education (AOR = 0.46, 95% CI = 0.14–0.93) and those who lack awareness (AOR = 0.23, 95% CI = 0.08–0.68) of IPT were less likely to uptake IPT [Table 5].

Table 5: Predictors of isoniazid preventive therapy uptake among human immunodeficiency virus patients in Kano

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Discussion

IPT is a key public health intervention for the prevention of TB among PLWHIV. The study found that majority of the respondents (309; 96.9%) believed that TB poses a threat to health and well-being of HIV patients and up to 307 (95.9%) knew that TB is preventable. Two-third (211; 65.9%) of the participants were aware of the use of isoniazid for the prevention of TB among HIV/AIDs patients. The study found that slightly over a half (172; 53.8%) of the respondent were using IPT for prevention of TB in Kano. The finding from this study was higher than the uptake level reported from Enugu (Nigeria) where only 30% of new HIV clients were started on IPT.^[10] This difference might be due to the fact that this study reported uptake for both new and old HIV clients and the low uptake of IPT in the previous study could be due to small sample size.

The result of this study was also higher than IPT uptake reported globally, at the end of 2013, where only 21% of countries globally and 14 of 41 high TB/HIV burden countries reported provision of IPT to PLWHIV/AIDS which is similar to IPT uptake of 19.4% reported in Ethiopia.^[15],[17] The lower IPT uptake reported from these surveys could be attributed to implementation gap following the WHO recommendation for inclusion of this intervention as part of minimum package of care for PLWHIV/AIDs. Other studies reported higher uptake of IPT among HIV patients ranging from 79.0% in South Africa, 84.4% in Ethiopia and 87.8% in DR Congo, while a multi-country survey conducted in 2016 reported IPT uptake of 42.0% among newly enrolled PLHIV.^{[18],[19],[20]} IPT recommendation by health-care workers, advise by members of HIV support group, ease of administration of IPT and adequate counselling about IPT were the main reason given for uptake. Overall, these studies reported an increased level of IPT uptake around the globe and this buttress the need to improve access to IPT services across all health facilities providing HIV care, prevention and treatment in Kano. Health-care workers should ensure that correct and consistent information is always provided to all eligible HIV clients so that they can fully understand the benefit of IPT and the risk of TB infection among HIV patients.

IPT uptake was found to be significantly associated with age, tribe, awareness, educational level, partner's education, willingness, support group advise, ease of administration and disclosure of HIV status. After adjusting for other covariates, age, education, awareness and disclosure were found to remain independent predictors of IPT uptake. Respondents who were 30 years or older and those who disclosed their HIV status to partner/family had higher odds of IPT uptake, whereas respondents with informal education and those who lack awareness of IPT were less likely to uptake IPT. The finding, therefore, indicates the need to provide awareness about IPT to all clients, encourage disclosure and improvement in educational status. This result is in contrast with the result of survey among a total of 849 PLHIV, who were under HIV care follow-ups at public health facilities in Addis Ababa (Ethiopia); the study reported nearly a third (28.7%) of all interviewed PLHIV self-reported that they had been treated with IPT and regression analysis of INH preventive therapy among the various independent variables did not show any association;^[11] this study collected few information on personal factors from the respondents.

This study explored the uptake of IPT and associated factors for the prevention of the leading cause (TB) of mortality among HIV patients in Kano. However, the study did not look into health system-related factors/constraints. In addition, only adult HIV patients attending two primary health facilities were studied.

Conclusion

IPT is being underutilised for the prevention of TB among HIV patients in Kano. This implies the need for health-care workers to introduce strategies to improve counselling and disclosure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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