tuberculosis and hiv correlation and co-infection in bangladesh

141 Pages·2017·8.12 MB·English

TUBERCULOSIS AND HIV CORRELATION AND CO-INFECTION
IN BANGLADESH: AN EXPLORATION OF THEIR IMPACTS ON
PUBLIC HEALTH

DOCTOR OF PHILOSOPHY THESIS

ABUL KALAM LUTFUL KABIR

MARCH 2015
DEPARTMENT OF PHARMACEUTICAL TECHNOLOGY
FACULTY OF PHARMACY
UNIVERSITY OF DHAKA, BANGLADESH
TUBERCULOSIS AND HIV CORRELATION AND CO-INFECTION
IN BANGLADESH: AN EXPLORATION OF THEIR IMPACTS ON
PUBLIC HEALTH

THESIS SUBMITTED TO THE DEPARTMENT OF PHARMACEUTICAL
TECHNOLOGY, UNIVERSITY OF DHAKA, BANGLADESH IN FULFILLMENT OF
THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY

BY
ABUL KALAM LUTFUL KABIR

MARCH 2015
DEPARTMENT OF PHARMACEUTICAL TECHNOLOGY
FACULTY OF PHARMACY
UNIVERSITY OF DHAKA, BANGLADESH
DECLARATION

I, Abul Kalam Lutful Kabir, hereby declare that this thesis is my own work in design and in
execution and that it has not previously been submitted for any degree or examination at this or
any other university. I also affirm that all reference material(s) contained herein have been duly
acknowledged.

_________________________________
Signature

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ABSTRACT

Globally TB and HIV are overarching public health issues. Although a few people in
Bangladesh suffering with HIV, it remains a serious threat especially for TB-infected persons.
A positive correlation exists between tuberculosis incidence and HIV/AIDS prevalence. I
general the lifetime risk of increasing active TB is around 10 percent. On the other hand the risk
is around 60 percent for TB/HIV co-infection. HIV is considered to be the most potent common
risk factor which is responsible for reactivation of latent TB to its active form of disease. When
HIV infected people are exposed to Mycobacterium they are most susceptible to be TB, HIV
infection increases rate of recurrent TB and TB-HIV pose an increase risk of transmission of
tuberculosis to general community, whether or not they are HIV infected. Considering the facts,
functional collaboration has been recognized between NTP and NASP for the implementation
of collaborative TB/HIV programs in Bangladesh. However, systematic information on TB,
HIV and TB/HIV co-infection, their public health impacts and health needs of this population
are lacking here. Moreover, in-depth knowledge of how the people who are living with
HIV/AIDS and the people in Bangladesh know the relationship between TB and HIV/AIDS
right now does not exist for health care service providers and also for policy makers. The
community knowledge and ideas about their health and various diseases have important impact
on health seeking performance and outcomes of the treatment. With the above background, this
study sought to firstly explore the evaluation of the patients’ knowledge about tuberculosis,
HIV/AIDS and their co-infection and estimation of the adherence and the patients’ awareness
of the importance of adherence and secondly, to evaluate the knowledge regarding tuberculosis,
HIV/AIDS and their co-infection among the general people and also to study common gaps and
misconceptions of knowledge among them. The study was divided into two, with the first and
second studies using both quantitative and qualitative research approaches. In the case of first
study, questionnaires with structured multiple-choice questions (MCQ) were handed out to 52
HIV positive patients attending for treatment at different centers (NGOs). All of them had been
diagnosed with HIV and/or TB infection. The key findings of this study are that the self
reported adherence to medication was high; only seven of the patients stated to ever have
missed taking their TB medication on any occasion. The biggest obstacles that these patients
are facing in order to follow the treatment are as follows: paying for transport to the medical
center, long way to the clinic, and the side effects of drugs. TB was diagnosed only in four
patients (7.69%) who are living with HIV also. Among HIV and TB co-infected persons all of
them were diagnosed with pulmonary tuberculosis. All the respondents were asked about the
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symptoms of TB, where everyone stated rightly that cough is one of the major signs &
symptoms of tuberculosis, but of the other two classic symptoms of TB, more than 50%
mentioned weight loss, and only 40% respondents replied night sweats and skin rash. Among
the co-infected patients only one had been diagnosed with tuberculosis first and then with HIV.
The frequency of pulmonary TB was lower in this study than showed earlier, but the study
material might not be representative because it was not randomized and there was no admitted
patient here. The second one assessed the knowledge regarding TB, HIV and both their co-
infection among the common people in Bangladesh which was a cross-sectional mixed method
research using a multi stage survey method of design (n=400) as well as also focus groups
discussions (FGD). This study showed that mean knowledge scores were 40% for TB and 42%
for HIV but only 38% for TB/HIV co-infection which was statistically lower than both TB and
HIV knowledge score by 2 and 4 points respectively (p<0.0001). The education predicted
higher knowledge of HIV but low TB/HIV co-infection knowledge. The population having
tertiary level of education had been connected with higher tuberculosis & HIV/AIDS
knowledge where as people without income or low income became associated with lower
tuberculosis knowledge and people with other religion (other than Muslim and Hindu) as well
as students of the study participants were associated with smaller knowledge of HIV. The study
participants believed that transfer of TB occurred by sharing of drinking water glass (cups or
mugs), smoking cigarettes and that TB was totally untreatable. Fear on this disease is obsessed
by an assumption that “HIV means TB and TB means HIV”. The knowledge about TB is lower
but HIV knowledge is higher, both TB and HIV co-infection knowledge is very close to the
score of TB knowledge. In this context the alertness campaigns for co-infection knowledge
should be a major concern.

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DEDICATION

I wish to humbly dedicate this project to the Almighty Allah whose bountiful and unmerited
favors saw me through this research project and the degree program.

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ACKNOWLEDGEMENT

Many persons of different institutions had contributed a lot to make this work a reality. It is
here not possible to talk about all names, in this regard, for those whose names will not be
particular in this list of acknowledgement, please admit my sincere apologies and I thank you
all.

I wish to express my sincere gratefulness to the participants of this study first and foremost
because they had participated in this study willingly. I would like to acknowledge Bangladesh
Medical Research Council, Biomedical Research Center (BMRC), University of Dhaka and the
academic committee of the department of Pharmaceutical Technology, PhD subcommittee of
the Faculty of Pharmacy, academic council of the University of Dhaka for granting ethical
approval to conduct the study. My sincere gratitude also goes to the Middlesex University of
UK for providing very conducive learning materials throughout my study period.

I am really indebted to my supervisor Professor Dr. Abu Shara Shamsur Rouf and Co-
supervisor Professor A B M Faroque of the Department of Pharmaceutical Technology,
University of Dhaka for their untiring dedication and extremely competent support, productive
comments, responsiveness inspiration and kind understanding. Their continuous support, advice
and encouragement gave me confidence to think critically and reasonably. Without their
inspiration and close leadership, it would have been impossible to accomplish this work. I am
particularly indebted to the Chairman of the department of Pharmaceutical Technology of
University of Dhaka Professor Dr. MD. Selim Reza and all other Faculty members and staffs at
the Department of Pharmaceutical Technology for their affability logistical support and sensible
support.

Among groups of other different personalities, I would like to concede Dr. Hafiz T A Khan,
Professor in Applied statistics of Middlesex University, UK, Dr. Mohammad Billal Hossain,
Chairman of the Department of Population Sciences, Mr. Poritosh Roy, Assistant Professor of
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ISRT, University of Dhaka, and Mr. Samiul Alam Rajib, Lecturer at Stamford University for
their continuous support, guidance and discussion during my works.

Many people have been working with the HIV/AIDS care and treatment clinic at different
NGOs; I would like to express my sincere gratitude to Ms. Habiba Khatun, Executive Director
of Ashar Alo Society, and Mr. Gazi Nazrul Islam, CEO of Light House Bangladesh. I would
also like to thank the administration of Ashar Alo Society, Light House, HASAB, Mukto
Akash and CAAP for giving me friendly working atmosphere. I am especially grateful to Dr.
Viqarunnesa and Dr. Nazmunnahar for their tireless efforts and determination to carry out the
study.

To my colleagues at the department of Pharmaceutical Technology, other departments of the
Faculty of Pharmacy at University of Dhaka earnest gratitude for their precious support always.

In conclusion, I am everlastingly thankful to my family, especially to, my spouse for her
devotion, insistence, infatuation in education and incessant moral and ethical support and my
daughter Afiza Kabir who loved as ever despite my neglect. I am very proud to have you in my
life.

To All, lasting gratitude
Abul Kalam Lutful Kabir
March, 2015
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TABLE OF CONTENT

Declaration i
Abstract ii
Dedication iv
Acknowledgement v
Table of content vii
List of tables x
List of figures x
List of appendixes
Abbreviations

CHAPTER ONE: INTRODUCTION
1.0 Background 1
1.1.1 Pathogenesis of Tuberculosis (TB) 1
1.1.2 Epidemiology of Tuberculosis 1
1.1.3 Scenario of TB in Bangladesh 3
1.1.4 Evolution of TB control program 3
1.1.5 Estimation of TB burden in Bangladesh 3
1.1.6 Stop TB strategy in Bangladesh at a glance 4
1.1.7 Quality assurance 5
1.1.8 Global and national fund 6
1.1.9 Different collaborations 6
1.1.10 Multidrug-resistant tuberculosis in Bangladesh 7
1.1.11 National guidelines and operational manual for tuberculosis control 9
1.1.12 Pathogenesis of HIV 11
1.1.13 Epidemiology of HIV/AIDS 12
1.1.14 National strategic plan for HIV and AIDS 14
1.1.15 Way to prevent an epidemic 15
1.1.16 HIV-associated tuberculosis in developing countries 15
1.1.17 TB/HIV co-infection 16
1.1.18 Sputum smears microscopy and culture 17
1.1.19 Tuberculosis drugs susceptibility 18
1.1.20 CD4 T cells count 18
1.1.21 Challenges in tuberculosis and HIV/AIDS co-infection 19
1.1.22 Difficulties of diagnosis of tuberculosis in HIV infected patient 19
1.1.23 Both tuberculosis and HIV/AIDS are stigmatizing diseases 20
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1.1.24 Complexity of treatment of tuberculosis and HIV/AIDS co-infection 20
1.1.25 Difficulties in fitting the HIV/AIDS and tuberculosis program together 20
1.1.26 National ART guidelines 20
1.2.1 Aims and objectives of study-I 25
1.2.2 General objective 25
1.2.3 Specific objective 25
1.2.4 Aims and objectives of study-II 25
1.2.5 General objective 25
1.2.6 Specific objective 26

CHAPTER TWO: LITERATURE REVIEW
2.0 Literature review 27

CHAPTER THREE: METHODOLOGY
3.0 Methodology 36
3.1 Study I: Evaluation of the patients’ knowledge about TB, HIV and TB/HIV co- 36
infection
3.1.1 Study area and population 36
3.1.2 Study design 44
3.1.3 Statistical methods 45
3.1.4 Ethical considerations 45
3.2 Study II: Assessment of knowledge about TB, HIV and TB/HIV co-infection 46
among the general population and examination of common knowledge gaps and
misconceptions among them
3.2.1 Study area and population 46
3.2.2 Study design 51
3.2.3 Focus group discussion 51
3.2.4 Statistical methods 52
3.2.5 Ethical considerations 52
CHAPTER FOUR: RESULTS AND DISCUSSION OF STUDY I
4.0 Socio-demographic characteristics of study respondents 55
4.1 Description of patients 55
4.2 Level of education 56
4.3 Employment history 57
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