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HIV-seroprevalence among pulmonary tuberculosis patients in a tertiary care hospital in Douala, Cameroon Bertrand Hugo Mbatchou Ngahane b

a b

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, Henry Luma , Yacouba Mapoure Njankouo

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b

a b

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Martine Nida , Achu Joko , Marthe Mbenoun , Samuel Wato & Albert Mouelle Sone b a

Douala General Hospital , Internal Medicine , PO Box 4856, Douala , Cameroon

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Faculty of Medicine and Pharmaceutical Sciences , University of Douala , PO Box 2701, Douala , Cameroon Published online: 12 Dec 2012.

To cite this article: Bertrand Hugo Mbatchou Ngahane , Henry Luma , Yacouba Mapoure Njankouo , Martine Nida , Achu Joko , Marthe Mbenoun , Samuel Wato & Albert Mouelle Sone (2012) HIV-seroprevalence among pulmonary tuberculosis patients in a tertiary care hospital in Douala, Cameroon, African Journal of AIDS Research, 11:4, 349-352, DOI: 10.2989/16085906.2012.754835 To link to this article: http://dx.doi.org/10.2989/16085906.2012.754835

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African Journal of AIDS Research 2012, 11(4): 349–352 Printed in South Africa — All rights reserved

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ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2012.754835

HIV-seroprevalence among pulmonary tuberculosis patients in a tertiary care hospital in Douala, Cameroon Bertrand Hugo Mbatchou Ngahane1,2*, Henry Luma1, Yacouba Mapoure Njankouo1,2, Martine Nida2, Achu Joko1, Marthe Mbenoun2, Samuel Wato1 and Albert Mouelle Sone1,2 Douala General Hospital, Internal Medicine, PO Box 4856, Douala, Cameroon University of Douala, Faculty of Medicine and Pharmaceutical Sciences, PO Box 2701, Douala, Cameroon *Corresponding author, e-mail: [email protected]

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A retrospective study was carried out at Douala General Hospital, Cameroon, between July 2007 and July 2011, to determine the prevalence of HIV infection among the pulmonary tuberculosis (pTB) patients and to compare epidemiological profiles with respect to TB/HIV co-infection. The cases of all patients aged 15 years and above and diagnosed with pTB during the study period were reviewed. Sociodemographic data, sputum examination for acid-fast bacilli, previous TB-treatment status, and HIV status were recorded. The chi-square or Fisher’s exact tests were used to compare the proportions. The independent sample t-test was used to compare means for the quantitative data. Of the 383 pTB patients included, 56.1% were males. The mean age was 38.9 ± 13.9 years (range 15–95). The age group 25–44 years was most represented, with 55.6% of the patients, while the least represented age group was that of patients over 65 years. The mean age of the females (36.2 ± 13.6 years) was statistically lower than that of the males (41.1 ± 13.8 years). Smear-positive pTB was diagnosed in 208 cases (54.6%). All the patients were tested for HIV infection. The overall prevalence of HIV among the pTB patients was 50.4%. There were no significant differences between the HIV-positive and HIV-negative groups with respect to age, sex, sputum examination for acid-fast bacilli, and previous TB-treatment status. The results suggest that the TB/HIV co-infection rate in Cameroon is high. Intensification of the screening of HIV infection in the general population and early management of HIV disease, especially in young women, could reduce the incidence of TB. Keywords: co-infection, epidemiology, health management, quantitative research, screening, sub-Saharan Africa

Introduction Tuberculosis (TB) is a major public health issue worldwide, particularly in low- and middle-income countries. It is estimated that one third of the world’s population is infected with Mycobacterium tuberculosis, with the highest prevalence of the disease found in sub-Saharan Africa and Asia (World Health Organization [WHO], 2011). More than half of these live in countries heavily affected by HIV and AIDS. Cameroon is among the countries with a high TB burden, with incidence and mortality of all forms of TB estimated, respectively, at 177/100 000 and 14/100 000 of the population (WHO, 2011). HIV is known to be responsible for the resurgence of TB during the last three decades. In addition, prolonged activation of the immune system induced by infection with TB leads to a prolonged increase in HIV replication, and consequently accelerates disease progression (Badri, Ehrlich, Wood, Pulerwitz & Maartens, 2001). Worldwide, TB is the most common opportunistic infection among people with HIV infection. In addition, it is also associated with substantial morbidity and mortality. Of the 8.8 million incidence cases of TB that occurred in 2010, an estimated 1.2 million (14%) were HIV-positive. Sub-Saharan Africa accounted for 80% of the burden of TB/ HIV co-infection, followed by South-East Asia (WHO, 2011).

Cameroon has an estimated HIV prevalence of 4.3% (Institut National de la Statistique & ICF International, 2012), and is therefore considered a country with a high HIV burden. According to the World Health Organization, the proportion of TB patients with associated HIV infection in Cameroon is 40% (WHO, 2011). A previous study carried out in Cameroon’s biggest TB clinics showed increased HIV prevalence among pTB patients, from 10% in 1989 to 22.2% in 1997 (Bercion, Cunin & Kuaban, 2000). In addition, a study conducted in an urban district hospital reported 43.8% HIV prevalence among the pTB patients (Sume, Etogo, Kabore, Gnigninanjouena, Epome & Metchendje, 2008), while a more recent one conducted in a rural district hospital reported 53% HIV prevalence (Yumo, Kuaban & Neuhann, 2011). Recent data on TB/HIV co-infection at a tertiary care hospital in Cameroon are lacking. Therefore, we conducted this study to determine the prevalence of HIV infection among patients treated for pTB and to compare the epidemiological profiles of pTB patients without and with HIV co-infection. Methods Study setting Douala General Hospital (DGH) is one of two tertiary care hospitals in Douala, a city of 1.9 million inhabitants (Bureau

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Central des Recensements et des Populations, 2010) and the headquarters of Littoral Region as well as the country’s economic capital. Patients receiving care at DGH are mostly from households with a moderate to high socioeconomic level because of the relatively high related health expenses. The hospital offers care in different medical specialties. The HIV clinic of the DGH has been operating for 10 years. Since 2006, the hospital also has a TB clinic and there is close collaboration between these two clinics.

0.001). New cases of pTB were diagnosed in 372 patients (97.1%), while 11 patients (2.9%) represented cases of retreatment (three relapses and eight who returned after TB-treatment default). Smear-positive pTB was diagnosed in 208 cases (54.6%). HIV testing was done for all the patients; of them, 193 were HIV-seropositive, giving an overall HIV prevalence of 50.4% among the pTB patients. TB/HIV co-infection among the males and females, respectively, was 48.8% and 52.4% (p = 0.49). As shown in Figure 1 and Table 1, there was no significant difference between the HIV-positive and HIV-negative groups with respect to age, the result of the sputum examination for acid-fast bacilli, and history of previous TB treatment. The proportion of HIV-seropositive patients in the group of hospitalised patients (63.3%) was significantly higher than that (45.7%) observed in pTB patients treated in the outpatient department (p = 0.002). In the group of 193 HIV-seropositive patients, the mean age was 40 ± 10.9 years (range 15–78 years). In the same group, the mean age of males (43.1 ± 9.1 years) was significantly higher than that of females (36.5 ± 12 years; p ≤ 0.001).

Study design This retrospective study was carried out between July 2007 and July 2011 at Douala General Hospital (DGH). All patients aged 15 and above and diagnosed with pTB during the above-mentioned period were enrolled in the study. The TB register was analysed regarding the patients’ sociodemographic data (sex, age, and residence), previous TB-treatment status, and HIV status. The diagnosis of pTB was based on criteria established by the National Tuberculosis Program. Patients with at least two of three sputum smears showing positive for acid-fast bacilli were considered as having smear-positive pulmonary tuberculosis (SPPT). Smear-negative pulmonary tuberculosis (SNPT) was diagnosed in patients presenting with persistent signs and symptoms of TB, two series of negative sputum tests taken at a 10-day interval, and with/without a suspicious chest X-ray film after receiving non-specific antibiotic therapy for 10 days (Programme National de Lutte contre la Tuberculose, 2004). HIV infection was diagnosed by performing two ELISA tests with two different kits, according to the WHO recommendation for developing countries (UNAIDS/WHO, 1997). The samples were first tested using a routine ELISA test (HIV Combi PT, Roche Diagnostics, Indiana). For confirmation, a second sample was taken from patients with an HIV-positive result from the first test, using the Determine HIV1/2 (Inverness Medical, Japan) or the enzyme-linked fluorescent assay (VIDAS HIV Duo Ultra, Biomérieux, France). The study was approved by the ethics committee of Douala General Hospital. Statistical analysis All data were entered and analysed using SPSS 11.5. The chi-square test or Fisher’s exact test were used to compare proportions. The independent sample t-test was used to compare means for the quantitative data. A 95% confidence interval was calculated and values of p ≤ 0.05 were considered significant. Results A total of 383 patients with diagnosed pTB were included in the study. The characteristics of this population are shown in Table 1. Of these patients, 215 (56.1%) were males and 168 (43.9%) were females. The mean age was 38.9 ± 13.9 years (range 15–95 years). The age group 25–44 years was most represented, with 213 (55.6%) patients, while the least represented age group were patients over 65 years. The mean age of females (36.2 ± 13.6 years) was statistically lower than observed for males (41.1 ± 13.8 years) (p ≤

Discussion The major findings of the study are a high prevalence (50.4%) of HIV infection among the pTB patients, and lower mean age of the female patients as compared to the males. Cameroon is a country with a high burden of TB, with a prevalence of 185 per 100 000 people (WHO, 2011). The prevalence of HIV in the general population in Cameroon is 4.3% (Institut National de la Statistique & ICF International, 2012) and the national prevalence of TB/HIV co-infection among people with pTB infection was estimated at 40% in 2009 (WHO, 2011). This value is lower than 50.4% co-infection found in our study. Thus, TB/HIV co-infection in the country appears to be very high and increasing with time. Sixteen years ago, Kuaban & Bercion (1996) found 16.8% pTB/HIV co-infection in a tertiary care hospital in Yaoundé. A study conducted in an urban district hospital in Douala found 52% TB/HIV co-infection (Sume et al., 2008). In other sub-Saharan countries, similar studies have reported a lower prevalence of TB/HIV co-infection, with 23.7% in Togo (Dagnra, Adjoh, Tchaptchet Heunda, Patassi, Sadzo Hetsu, Awokou & Tidjani, 2010), 41.2% in Nigeria (Pennap, Makpa & Ogbu, 2010), and 42.6% in Tanzania (Range, Ipuge, O’Brien, Egwaga, Mfinanga, Chonde et al., 2001). In our study, there was no significant difference in overall HIV-seropositivity between the men and women. The same result was observed by Kuaban & Bercion (1996). Patients in the age group 25–44 years were the most affected by pTB as well as TB/HIV co-infection. In this age group, TB/ HIV co-infection was higher among females than among males. This finding is similar to national data on TB/HIV infection which shows 8.8% HIV-seroprevalence among females aged 25–44 years, and 6.8% among males of the same age group, but lower HIV-seroprevalence in the other age groups (Institut National de la Statistique & ICF International, 2012).

African Journal of AIDS Research 2012, 11(4): 349–352

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Table 1: Characteristics of the pulmonary tuberculosis patients in the study population according to HIV-serological status Total (n = 383)

HIV-positive (n = 193)

Gender: Males 215 (56.1%) 105 (48.8%) Females 168 (43.9%) 88 (52.4%) Age (years): Mean age 38.9 ± 13.9 40.1 ± 11 Females’ mean age 36.2 ± 13.6 36.5 ± 12 Males’ mean age 40.1 ± 13.8 43.1 ± 9.1 Age group (years): 15–24 55 10 25–34 101 50 35–44 112 73 45–54 68 42 55–64 31 15 ≥65 16 3 Sputum examination for acid-fast bacilli: Smear-positive 208 (54.3%) 102 (49%) Smear-negative 175 (45.7%) 91 (52%) Previous TB-treatment status: New cases 372 (97.1%) 186 (50%) Re-treatment cases* 11 (2.9%) 7 (63.6%) Hospitalisation: Yes 98 (25.6%) 62 (63.3%) No 285 (74.4%) 131 (46%) *Re-treatment cases include those with TB-treatment failure, relapse or return after default.

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56.9

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59.1 55

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p-value

110 (51.2%) 80 (47.6%)

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37.8 ± 16.3 35.8 ± 15.2 39.2 ± 17

0.10 0.7 0.03

45 51 39 26 16 13 106 (51%) 84 (48%)

0.56

186 (50%) 4 (36.4%)

0.37

36 (36.7%) 154 (54%)

0.002

co-infection was more prevalent in patients with smearnegative pTB (52%) than in those with smear-positive pTB (49%). This is consistent with many other studies in sub-Saharan Africa (e.g. Chum et al., 1996; Range et al., 2001). Our study had one main limitation: due to the retrospective study design, the quality of the data collected could not be controlled, being a source of information biases. Conclusions

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HIV-negative (n = 190)

7.7

15–24

25–34

35–44 45–54 AGE (years)

55–64

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Figure 1: HIV-seroprevalence with respect to sex and age group among the pulmonary tuberculosis patients at Douala General Hospital, Cameroon, July 2007 and July 2011 (n = 383)

This study provides evidence that TB is highly associated with HIV infection in Cameroon and that TB/HIV co-infection in the population is likely to be increasing with time. Young adults appear to be the most affected population group. Therefore, we recommend the intensification of HIV screening in the general population in order to ensure early management of HIV-infected patients and thus reduce the incidence of opportunistic infections such as TB. References

In the age group 15–24 years, TB/HIV co-infection was higher among females than among males. A similar finding, but with lower rates of infection, was reported by Kuaban, Ndoumou, Koulla-shiro, Afane Ze, Ghipponi & Pignon (1995), also in Cameroon, and by Chum, O’Brien, Chonde, Graf & Reider (1996) in Tanzania. This difference is likely due to the fact that, in Africa, transmission of HIV infection is mainly heterosexual and women are more exposed to HIV. Though the difference was not significant, TB/HIV

Badri, M., Ehrlich, R., Wood, R., Pulerwitz, T. & Maartens, G. (2001) Association between tuberculosis and HIV disease progression in a high tuberculosis prevalence area. International Journal of Tuberculosis and Lung Disease 5(3), pp. 225–232. Bercion, R., Cunin, P. & Kuaban, C. (2000) Evolution sur neuf ans (1989–1998) de la séroprevalence du VIH chez les tuberculeux pulmonaires bacillifères au Cameroun. Médecine Tropicale 60(4), pp. 409–410. Bureau Central des Recensements et des Populations [Cameroun]

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(2010) ‘3e recensement général de la population, 2005.’ Online at: [Accessed 11 January 2012]. Chum, H.J., O’Brien, R.J., Chonde, T.M., Graf, P. & Reider, H.L. (1996) An epidemiological study of tuberculosis and HIV infection in Tanzania, 1991–1993. AIDS 10(3), pp. 299–309. Dagnra, A.Y., Adjoh, K., Tchaptchet Heunda, S., Patassi, A.A., Sadzo Hetsu, D., Awokou, F. & Tidjani, O. (2010) Prévalence de la co-infection VIH-tuberculose et impact de l’infection VIH sur l’évolution de la tuberculose pulmonaire au Togo. Bulletin de la Société de Pathologie Exotique 104(5) pp. 342–346. Institut National de la Statistique (INS) [Cameroun] & ICF International (2012) Enquête Démographique et de Santé et à Indicateurs Multiples EDS-MICS 2011. Février 2012. Yaoundé, Cameroun, INS. Kuaban, C. & Bercion, R. (1996) Séroprévalence de l’infection à VIH chez les adultes atteints de tuberculose pulmonaire bacillifère à Yaoundé, Cameroun. Médecine Tropicale 56(4), pp. 357–360. Kuaban, C., Ndoumou, A., Koulla-shiro, S., Afane Ze, E., Ghipponi, P.M. & Pignon, D. (1995) Seroprevalence of HIV infection among patients with pulmonary tuberculosis in Yaounde-Cameroun. West African Journal of Medicine 14(2), pp. 112–115. Pennap, G., Makpa, S., Ogbu, S. (2010) Sero-prevalence of HIV infection among tuberculosis patients in a rural tuberculosis referral clinic in northern Nigeria. Pan African Medical Journal 5(22) [online].

Programme National de Lutte contre la Tuberculose (PNLT) [Cameroun] (2004) Programme National de Lutte contre la Tuberculose: Guide Technique pour le Personnel de Santé. Yaoundé, Ministère de la Santé Publique du Cameroun, PNLT. Range, N., Ipuge, Y., O’Brien, R.J., Egwaga, S.M., Mfinanga, G.G., Chonde, T.M., Mukadi, Y.D., Borgdorff, M.W. (2001) Trend in HIV prevalence among tuberculosis patients in Tanzania, 1991–1998. International Journal of Tuberculosis and Lung Disease 5(5), pp. 405-412. Sume, G.E., Etogo, D., Kabore, S., Gnigninanjouena, O., Epome, S.S. & Metchendje, J.N. (2008) Seroprevalence of human immunodeficiency virus infection among tuberculosis patients in the Nylon district hospital tuberculosis treatment centre. East African Medical Journal 85(11), pp. 529–536. UNAIDS/WHO (1997) Revised recommendations for the selection and use of HIV antibody tests. Weekly Epidemiological Record 72(12), pp. 81–87. World Health Organization (WHO) (2011) Global Tuberculosis Control 2011. WHO/HTM/TB/2011.16. Geneva, WHO. Yumo, H.A., Kuaban, C. & Neuhann, F. (2011) WHO recommended collaborative TB/HIV activities: evaluation of implementation and performance in a rural district hospital in Cameroon. Pan African Medical Journal 10(30) [online].

HIV-seroprevalence among pulmonary tuberculosis patients in a tertiary care hospital in Douala, Cameroon.

A retrospective study was carried out at Douala General Hospital, Cameroon, between July 2007 and July 2011, to determine the prevalence of HIV infect...
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