Who takes the medicine? Adherence to antiretroviral therapy in Southern Ethiopia.

BACKGROUND: Treatment adherence is critical for the success of antiretroviral therapy (ART) for people living with HIV. There is limited representative information on ART drug adherence and its associated factors from Southern Ethiopia. We aimed at estimating the level of adherence to ART among people living with HIV and factors associated with it in 20 randomly selected ART clinics of Southern Ethiopia. METHODS: In this cross-sectional study, we interviewed consecutive HIV patients on first-line antiretroviral regimen attending the clinics in June 2014 using a pretested and structured questionnaire. For measuring adherence, we used 4-day recall method based on "The AIDS Clinical Trial Group adherence assessment tool". Patients were classified as "Incomplete adherence" if they missed any of the doses in the last 4 days. Data were singly entered using EpiData and descriptive analysis, and unadjusted odds ratios were calculated using EpiDataStat software. Multivariate logistic regression analysis was performed using Stata v12.0. RESULTS: Of 974 patients interviewed, 539 (56%) were females, and mean age was 35 years. The proportion of patients with incomplete adherence was 13% (95% confidence interval: 11%-15%). In multivariate analysis, factors significantly associated with incomplete adherence included young age, being Protestant Christian, consuming alcohol, being single, and being a member of an HIV association. Psychosocial factors like stigma, depression, and satisfaction to care were not associated with incomplete adherence in the current context. CONCLUSION: The overall adherence to ART was good. However, there were certain subgroups with incomplete adherence who need special attention. The health care providers (especially counselors) need to be aware of these subgroups and tailor their counseling to improve adherence among these groups. Exploratory qualitative studies may help uncover the exact reasons for incomplete adherence.

Prevalence and determinants of Tuberculosis among HIV infected patients in south Ethiopia.

INTRODUCTION: Tuberculosis (TB) is a chronic infectious disease that has represented a major health problem over the centuries. The human immune deficiency virus (HIV)/AIDS has substantially altered the epidemiology of TB by increasing the risk of reactivating latent TB, increasing chance of TB infection once exposed to tubercle bacilli (re-infection) and by increasing the risk of rapid progression soon after infection. METHODOLOGY: This study employs a retrospective review analysis of patient medical records. A total of 499 HIV/AIDS patient cards were reviewed and variables were recorded. Frequencies and odds ratio were calculated to determine prevalence and associated risk factors respectively. RESULTS: A total of 499 HIV/AIDS positive patient cards were reviewed. Ninety one (18.2%) of the study participants were found to have tuberculosis of which 20 (22%), 58 (64%) and 13 (14%) were smear positive, smear negative and extra-pulmonary tuberculosis cases, respectively. In multivariate logistic regression being female (AOR=0.39; 95% CI:0.20-0.77), WHO clinical stage 3 (AOR=5.66; 95%CI:1.79-17.94); WHO clinical stage 4 (AOR=7.89;95%CI:2.01-30.96); and functional status being ambulatory (AOR=2.22; 95%CI:1.06-4.64) were independently associated with tuberculosis-HIV co-infection with p value <0.05. CONCLUSION: Prevalence of tuberculosis was high. Among tuberculosis positive cases, the proportion of smear negative cases was also high which requires strengthening of TB diagnostic techniques. Tuberculosis was associated with some social demographic characteristics and clinical variables.

Detection of immunological treatment failure among HIV infected patients in Ethiopia: a retrospective cohort study.

BACKGROUND: Timely detection of treatment failure with subsequent switch to second-line regimen reduces mortality among HIV infected people on antiretroviral therapy (ART). This paper aims to investigate the detection of immunological treatment failure and switch rate to second line regimen in Ethiopia. METHODS: A retrospective cohort study was conducted among HIV infected patients (age > 15 years) who initiated ART between 2007 and 2009. The required data were collected from patient registers and formats. Data were entered and validated using EpiData software and then exported to SPSS version 20.0 for analysis. Odds ratio with 95% CI was used to assess whether immunological treatment failure was associated with experiencing unfavorable treatment outcomes (death or lost to follow up). RESULTS: Records of 293 patients were reviewed with a total of 1545 Person-Years of Observation (PYO). The median baseline CD4 count was 115 cells/mm(3) (IQR: 64-176). A total of 46 (15.7%) patients experienced immunological treatment failure. The immunological failure rate was 3.0 per 100 PYO. Treatment was switched to second-line regimen for six (2.1%) patients. The rate of treatment switch to second-line regimen for any purpose was 0.4 per 100 PYO. Out of the six patients, only two fulfilled the WHO criteria for immunological failure; the remaining four patients had their treatment switched to second-line regimen for other purposes. This implies that only 4.3% (2/46) of patients with immunological failure were switched to second-line regimen. The risk of experiencing unfavorable outcome was 5.75 (95% CI 1.11, 29.8) times higher among those who had immunological failure than their counterparts after adjusting for baseline CD4 count. CONCLUSIONS: Majority of patients with immunological treatment failures were not detected and continued taking the failed regimen. Further studies are required to assess and explore why patients with immunological failure are not switched to second-line regimen as per the standard protocol.

Do loss to follow-up and death rates from ART care vary across primary health care facilities and hospitals in south Ethiopia? A retrospective follow-up study.

BACKGROUND: Decentralization and task shifting has significantly improved access to antiretroviral therapy (ART). Many studies conducted to determine the attrition rate in Ethiopia have not compared attrition rates between hospitals and health centers in a relatively recent cohort of patients. This study compared death and loss to follow-up (LTFU) rates among ART patients in hospitals and health centers in south Ethiopia. METHODS: Data routinely collected from patients aged older than 15 years who started ART between July 2011 and August 2012 in 20 selected health facilities (12 being hospitals) were analyzed. The outcomes of interest were LTFU and death. The data were entered, cleaned, and analyzed using Statistical Package for the Social Sciences version 20.0 and Stata version 12.0. Competing-risk regression models were used. RESULTS: The service years of the facilities were similar (median 8 and 7.5 for hospitals and health centers, respectively). The mean patient age was 33.7±9.6 years. The median baseline CD4 count was 179 (interquartile range 93-263) cells/mm(3). A total of 2,356 person-years of observation were made with a median follow-up duration of 28 (interquartile range 22-31) months; 24.6% were either dead or LTFU, resulting in a retention rate of 75.4%. The death rates were 3.0 and 1.5 and the LTFU rate were 9.0 and 10.9 per 100 person-years of observation in health centers and hospitals, respectively. The competing-risk regression model showed that the gap between testing and initiation of ART, body mass index, World Health Organization clinical stage, isoniazid prophylaxis, age, facility type, and educational status were independently associated with LTFU. Moreover, baseline tuberculous disease, poor functional status, and follow-up at a health center were associated with an elevated probability of death. CONCLUSION: We observed a higher death rate and a lower LTFU rate in health centers than in hospitals. Most of the associated variables were also previously documented. Higher LTFU was noticed for patients with a smaller gap between testing and initiation of treatment.

Assessment of antibiotic- and disinfectant-resistant bacteria in hospital wastewater, south Ethiopia: a cross-sectional study.

INTRODUCTION: Large quantities of antimicrobials are used in hospitals for patient care and disinfection. Antibiotics are partially metabolized and residual quantities reach hospital wastewater, exposing bacteria to a wide range of biocides that could act as selective pressure for the development of resistance. METHODOLOGY: A cross-sectional study was conducted between December 2010 and February 2011 on hospital wastewater. A total of 24 composite samples were collected on a weekly basis for bacteriological analysis and susceptibility testing. Indicator organisms and pathogenic and potentially pathogenic bacteria were found and isolated on selective bacteriologic media. Disinfectant activity was evaluated by use-dilution, and minimum inhibitory concentration (MIC) was determined by the agar dilution method. Similarly, antibiotic susceptibility tests were performed using the Kirby-Bauer disk diffusion method. RESULTS: Pathogenic (Salmonella, Shigella, and S. aureus) and potentially pathogenic (E. coli) bacteria were detected from effluents of both hospitals. Dilution demonstrated tincture iodine to be the most effective agent, followed by sodium hypochlorite; the least active was 70% ethanol. MIC for ethanol against S. aureus and Gram-negative rods from Yirgalem Hospital (YAH) showed 4 and 3.5 log reduction, respectively. Salmonella isolates from YAH effluent were resistant to ceftriaxone, tetracycline, and doxycycline. Isolates from Hawassa University Referral Hospital (HURH) effluent were resistant to the above three antibiotics as well as gentamycin. CONCLUSIONS: Hospital effluents tested contained antibiotic-resistant bacteria, which are released into receiving water bodies, resulting in a threat to public health.

Predictors of immunological failure of antiretroviral therapy among HIV infected patients in Ethiopia: a matched case-control study.

BACKGROUND: In resource constrained settings, immunological assessment through CD4 count is used to assess response to first line Highly Active Antiretroviral Therapy (HAART). In this study, we aim to investigate factors associated with immunological treatment failure. METHODS: A matched case-control study design was used. Cases were subjects who already experienced immunological treatment failure and controls were those without immunological failure after an exactly or approximately equivalent duration of first line treatment with cases. Data were analyzed using SPSS v16.0. Conditional logistic regression was carried out. RESULTS: A total of 134 cases and 134 controls were included in the study. At baseline, the mean age ± 1 SD of cases was 37.5 ± 9.7 years whereas it was 36.9 ± 9.2 years among controls. The median baseline CD4 counts of cases and controls were 121.0 cells/µl (IQR: 47-183 cells/µl) and 122.0 cells/µl (IQR: 80.0-189.8 cells/µl), respectively. The median rate of CD4 cells increase was comparable for the two groups in the first six months of commencing HAART (P = 0.442). However, the median rate of CD4 increase was significantly different for the two groups in the next 6 months period (M6 to M12). The rate of increment was 8.8 (IQR: 0.5, 14.6) and 1.8 (IQR: 8.8, 11.3) cells/µl/month for controls and cases, respectively (Mann-Whitney U test, P = 0.003). In conditional logistic regressions grouped baseline CD4 count (P = 0.028), old age group and higher educational status (P<0.001) were significant predictors of immunological treatment failure. CONCLUSION: Subjects with immunological treatment failure have an optimal rate of immunological recovery in the first 6 months of treatment with first line HAART, but relative to the non-failing group the rate declines at a later period, notably between 6 and 12 months. Low baseline CD4 count, old age and higher educational status were associated with immunological treatment failure.

Total delay in treatment among smear positive pulmonary tuberculosis patients in five primary health centers, southern Ethiopia: a cross sectional study.

INTRODUCTION: The global burden of Tuberculosis (TB) remains enormous. Delay in TB diagnosis may lead to a higher infectious pool in the community and a more advanced disease state at presentation increasing the risk of mortality. This study is conducted to determine the total delay before treatment among smear positive Pulmonary Tuberculosis (PTB) patients. METHODS: A health institution based cross sectional study was conducted in five primary health centers in southern Ethiopia from June to December 2012. A total of 328 smear positive PTB patients were enrolled in the study. A structured and pre-tested questionnaire was used. Median patient, diagnostic, and treatment delays were calculated to determine the total delay. Multiple logistic regression analysis was used to identify factors associated with total delay. RESULTS: The median patient, diagnostic, treatment and total delays measured in days were 30 (IQR 20.2, 60), 7 (IQR: 3, 14), 3 (IQR: 1, 4) and 45 (IQR: 34.5, 69.5) days respectively. Patients for whom treatment was not initiated within 45 days of onset of symptom(s) (total delay) constituted 49% of the study participants (59.5% among males and 39.2% among females; P<0.001). Total delay was found to be associated with: being female [AOR  = 0.34, 95% CI: 0.18-0.62], having attended tertiary level education [AOR  = 0.11, 95% CI: 0.02-0.55], perceived severity of stigma during the current TB disease course [AOR = 2. 18, 95% CI: 1.07, 4.42] and living in houses with higher family size [AOR = 0.26, 95% CI: 0.11, 0.61]. CONCLUSION: Total delay in treatment of TB is still high in the study area. Patient's sex, perceived stigma, educational status and family size are significantly contributing for total delay. Therefore, a concerted effort should be taken in order to improve health seeking behavior of the community on TB and to reduce delays from seeking care after experiencing TB symptoms.

Cryptosporidiosis and Isosporiasis among HIV-positive individuals in south Ethiopia: a cross sectional study.

BACKGROUND: Cryptosporidium spp and I. belli are intestinal opportunistic infections associated with HIV/AIDS. A decline in the incidence of these opportunistic infections due to HAART was reported. We aim to investigate these parasites among HAART naïve and experienced HIV patients in south Ethiopia. METHODS: A cross sectional study was carried out among 268 HIV- positive patients between January and September, 2007. Interview with questionnaires and document reviews were used to collect data. Stool samples were obtained from each patient and parasites were examined by direct, formol-ether and modified Ziehl-Neelsen stain for Cryptosporidium spp and I. belli. Univariate and multivariate analysis were carried out. Level of significance was set at p-value of 0.05. RESULTS: A total of 268 patients participated in the study. The mean age was 34.0 (±1 SD of 8.34) years. Females constituted 53.4% (143) of the study participants. Half of the study participants were on HAART; majorities (85.8%) of such patients were within the first year of treatment. The prevalence of Cryptosporidium spp was 34.3% (92/268) and I. belli was 1.5% (4/268). Dual infection was detected in two patients (0.75%). The crude analysis revealed significant reduction in the odds of Cryptosporidium spp infection among patients who have started HAART (crude OR = 0.59, 95% CI 0.35, 0.98). The adjusted analysis remained in the same direction but has lost significance (Adj OR 0.65, 95%CI 0.35, 1.24). No differences in the risk of developing infection with Cryptosporidium spp were observed between groups based on most recent CD4 counts, sex, duration on HAART and age (p > 0.05 for all variables). Patients with Cryptosporidium spp were more likely to report vomiting [Adj OR 2.34 (95% CI 1.22, 5.41)], weight loss [Adj OR 2.10 (95% CI 1.15, 3.81)] and chronic diarrhea [Adj OR 3.35 (95%CI 1.05, 10.63)]. CONCLUSION: There is high burden of infection with Cryptosporidium spp among HIV infected individuals in southern Ethiopia but that of I. belli is low. We recommend considering infection with Cryptosporidium spp in HIV infected people with chronic diarrhea, weight loss and vomiting for HAART naïve patients and/or for patients who are within the first year of starting HAART.

Prevalence of parasitic infections in HIV-positive patients in southern Ethiopia: a cross-sectional study.

INTRODUCTION: Intestinal parasitic infections are a major public health burden in tropical countries. Although all HIV/AIDS patients are susceptible to parasitic infections, those having lower immune status are at greater risk. The aim of this study was to determine the prevalence of intestinal parasitic infections in patients living with HIV/AIDS. METHODOLOGY: This was a facility-based cross-sectional study. A total of 343 consecutively sampled HIV/AIDS patients from the HIV care clinic of Hawassa University Referral Hospital were included. Subjects were interviewed for demographic variables and diarrheal symptoms using structured questionnaires. Stool examinations and CD4 cells counts were also performed. RESULTS: The prevalence of intestinal parasitic infection was 47.8% among HIV/AIDS patients; single helminthic infection prevalence (22.7%) was higher than that the prevalence of protozoal infections (14.6%). About 54% of study participants had chronic diarrhea while 3.4% had acute diarrhea. The prevalence of intestinal parasites in patients with chronic diarrhea was significantly higher than in acute diarrhea (p <0.05). Non-opportunistic intestinal parasite infections such as Ascaris lumbricoides, Taenia spp., and hookworm were commonly found, regardless of immune status or diarrheal symptoms. Opportunistic and non-opportunistic intestinal parasitic infection were more frequent in patients with a CD4 count of <200/mm(3) (OR=9.5; 95% CI: 4.64-19.47) when compared with patients with CD4 counts of ≥500 cells/mm(3). CONCLUSIONS: Intestinal parasitic infections should be suspected in HIV/AIDS-infected patients with advanced disease presenting with chronic diarrhea. Patients with low CD4 counts should be examined critically for intestinal parasites, regardless of diarrheal status.