A research done by Dr Mundabi to find out how the impact of TB to HIV patients especially concerning the CD4 for patients on ART and regularly followed up.

1. 1
By Dr Nzasi
Mundabi
IMPACT OF PULMONARY TUBERCULOSIS IN HIV
PATIENTS, RETROSPECTIVE STUDY FROM JANUARY 2013
TO DECEMBER 2013

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TABLE OF CONTENTS
0. Subject presentation……………………………………………………………….1
1. ACRONYMS USED IN THIS STUDY………………………………………………..2
-PTB: pulmonary tuberculosis
-HIV: human immunodeficiency virus
2. Abstract…………………………………………………………………………..3
3. Introduction……………………………………………………………………...4
3.1 Objectives
4. Background and generalities concerning tuberculosis and HIV…………...…….5
5.1 General considerations in TB/HIV collaboration……………………………5
5.2 Main focus about Letlhakane Primary Hospital………………………….….5
5.3 Social marketing in TB/HIV co-infected patients…………………………....6
5. Method…………………………………………………………………………..8
5.1 Prevalence of TB/HIV co-infected patients in Letlhakane PrimaryHospital…8
5.2 The role of patient and community in strengthening HIV/TB
collaboration………………………………………………………………………………11
5.3Monitoring and evaluation of infection control in Letlhakane Primary
Hospital……………………………………………………………………………………..13
6. Result and discussion……………………………………………………………14
7. Conclusion……………………………………………………………………….15
8. Recommendations………………………………………………………………..16
9. References………………………………………………………………………...17

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1. ABSTRACT
In this study, it was clearly shown the Point prevalence of co-infected patients in TB/HIV in
Letlhakane Primary Hospital from January to December 2013 ranges from 25% to 58.3%.
The period prevalence for 2013 in Letlhakane primary Hospital Was 43.9%
There is a need to remember that TB in HIV patient is WHO stage 3 or 4 according to the
localisation and therefore people living with TB/HIV co-infected are eligible for both
treatment regardless CD counts.
Optimal management of dually infected patients will reduce mortality, will improve the
patient outcomes and prevent diverse reactions.
Health workers supposed to monitor and track the TB and HIV co-infection patients by:
-Ensuring that all TB patients referred for HIV testing and vice versa.
- TB/HIV co-infected to be put on both treatment regardless CD counts.

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2. INTRODUCTION
2.1 OBJECTIVES
Since 2004, TB related deaths among people living with HIV have fallen to 28% in
sub-Saharan Africa, WHO estimate that scaling up collaborative HIV and TB
activities meant that an estimated 1.3million people avoided dying from AIDS-
related causes from 2005-2011.(MoH, 2008)
HIV and PTB are among the main diseases in Letlhakane Primary Hospital. The study
has a goal to demonstrate the mutual influence and cohabitation between HIV and
PTB.
To establish or demonstrate by our result if there is a sort of influence due to HIV in
case of PTB.(“Experiences of Batswana women diagnosed with both HIV / AIDS and
cervical cancer,” 2009)
This collaboration is made to combine TB services and HIV services together.
This is by providing HIV services at TB site and vice-versa.
It is done for delivery of decentralization and integrated TB and HIV services with easy
access to patients essential. This is through the use of barriers breaking plan
management of which each facility has to come up with the barriers they have and find
solutions on how to solve them using barriers breaking plan and
• The human immunodeficiency virus (HIV) pandemic presents a massive
challenge for global tuberculosis (TB) control.
• Botswana like other sub-Saharan African countries experiences a huge burden
of TB/HIV co-infection.
• The dramatic increases in TB incidence over the past 2 decades is due to the
increasing of prevalence of HIV, at present the country estimate 60-80% of TB
patients co-infected with HIV.
• Tuberculosis, one of the most opportunistic infection and leading of morbidity
and mortality in HIV patients.

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3. Background and generalities concerning tuberculosis and HIV
3.1 General considerations in TB/HIV collaboration:
Co-infection with TB and HIV markedly increases the mortality and morbidity of both
diseases, and represents ongoing public health crisis in Botswana.
Patients with both infections are more likely to have extra pulmonary TB and so diagnosis
of TB is often difficult, especially in advanced stage of HIV.(“Policy guidelines and service
standards,” n.d.)
HIV increases the rate of progression of TB infection to active diseases and increases the risk
of TB recurrence.
People living with HIV have 10% annual risk of reactivating latent TB infection, compared
to a 10% lifetime risk in HIV negative individuals, tuberculosis also increases HIV
progression AIDS by decreasing CD4 counts and increases viral loads.
People living with HIV have 10% annual risk of reactivating latent TB infection, compared
to a 10% lifetime risk in HIV negative individuals, tuberculosis also increases HIV
progression AIDS by decreasing CD4 counts and increases viral loads.(Africa, 2009)
3.2 Main focus about Letlhakane Primary Hospital
 DIAGNOSIS OF HIV IN TB SERVICES:
This is testing of all TB diagnosed patients for HIV therefore we are focusing to have 100%
of TB patients tested.
Provider initiated testing and counselling for HIV which was established by WHO 2007
through the provider to accomplish the HIV testing for all TB patients, also through the use
of national policy which emphasis to offer testing to all individuals in contact with health
services.(Another & Success, 2009)
Therefore in Letlhakane Primary Hospital our barriers to accomplish this objective are as
follows:

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 Communication challenges between health workers and community (language
barriers)
 Traditional and cultural beliefs hampering HIV testing
 DIAGNOSIS OF TB IN HIV SERVICES
This is the screening for TB in all HIV positive patients. This involves newly HIV diagnosed
patients (not yet on HAART those monitoring CD4) and who are already on HAART to be
screened on every doctors review. It has been a concern that people living with HIV/AIDS
are not recorded.
Therefore every patient diagnosed HIV positive or who is HIV positive on HAART have to be
screened for TB and it has to be recorded.
This screening is done by asking the patients of four main symptoms which are: fever,
persistent cough, night sweats and weight loss.
The main barrier is absence of symptom TB screening tool.(Central Statistics Office & Office,
2011)
3.3 Social marketing in TB/HIV co-infected patients:
Knowing that social marketing and communication may have behavioural impact, then is
important to :
 Establish a clear behavioural objectives
 Determine the strategic roles of variety of social mobilisation and communication
disciplines like: public relations, community mobilisation, advertising, interpersonal
communication and point-of-service promotion.
 Combine the disciplines in a comprehensive plan that provides clarity, consistency
and maximum behavioural impact to your social mobilisation and communication
efforts.
Behaviour changes unfortunately, people do not change all of a sudden and remain
’’changed’’ from that moment on wards; instead, people move through subtle stages.
The adoption of new or recommended behaviours can be illustrated by a simple model.
The model based on traditional behaviour adoption theory and practice, describes the
process by which individuals accept and maintain any new behaviour, such as
presenting themselves for sputum test.(Yin, Cao, Han, Zhai, & Huang, 2011)

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Stigma and discrimination associated with TB/HIV among the greatest barriers to
preventing further infections providing adequate care, support and treatment and all
alleviating impact.
The social marking or programme communication can be defined as the process of
identifying, segmenting and targeting specific groups with particular strategies,
messages, products or training programme through various mass media and
interpersonal channels, traditional and non-traditional.
In other word, social marketing provides no impact for communities and other
programme partners to buy into marketed innovations.
Social marketing in based on appeal to the individual, if he or she can reach.
In Letlhakane Primary Hospital, however reaching individual with new ideas or
products is the difficult thing to do.

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4 Method:
In this study, we selected patients based on the HIV status (patient tested positive of
HIV: Rapid test or Eliza test) and also patient with PTB (tested by sputum, chest x-ray
or gene expect) and the evaluation was measured by the prevalence of Co-infected
patients (having TB and HIV at the same time),(Torgerson & Miles, 2007).
4.2 Prevalence of TB/HIVco-infected patients in Letlhakane Primary Hospital:
The total of patients seen and followed in 2012 at Letlhakane Primary Hospital was as
followed:
mo
nth
Jan Feb Mar
ch
Apr. m ay Jun July. Aug sep oct. nov. dec
cas
es
h
iv
tb h
i
v
t
b
h
iv
t
b
h
iv
t
b
h
iv
t
b
hi
v
t
b
h
iv
t
b
h
iv
t
b
h
iv
t
b
h
iv
t
b
h
iv
t
b
h
iv
t
b
0-
10y
0 0 1 0 1 0 0 0 0 0 0 0 2 0 2 0 0 0 1 1 1 1 0 0
11-
25
3 1 5 1 4 2 6 2 3 2 2 2 4 2 6 2 2 3 1 0 4 1 4 2
26-
45
6 3 6 3 5 4 1
0
5 5 2 7 4 6 4 6 4 8 1 6 2 7 3 6 3
46+ 3 3 4 2 2 1 4 2 4 2 5 1 4 1 6 3 2 1 4 0 8 2 6 2
tota
l
1
2
7 1
6
6 1
2
7 2
0
9 1
2
6 14 7 1
6
7 2
0
9 1
2
5 1
2
3 2
0
7 1
6
7
The number of TB/HIV co-infected patients compare to the total number of patients by
month is represented by the figure as followed:

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As shows by the previous figure, now let calculate the prevalence of TB/HIV co-infected
patients by month:
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
HIV+ 12 16 12 20 12 14 16 20 12 12 20 16
TB/HIV 7 6 7 9 6 7 7 9 5 3 7 7
Period
prevalence
58.3 37.5 58.5 45 50 58 43.8 45 41 25 35 43
According to the previous figure, the period prevalence for co-infected patients in
Letlhakane Primary Hospital in 2013 will be :
(7+6+7+9+6+7+7+9+5+3+7+7)/(12+16+12+20+12+14+16+20+12+12+20+16)
=80/182
=0.4395
=43.9%
The Prevalence of co-infected TB-HIV patients will be:
HIV+
Proportion of TB/HIV co-…0
10
20
30
40
50
60
HIV+
TB/HIV co-infected
Proportion of TB/HIV co-
infected patient in % by month

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Graphic of evolution about HIV, TB/HIV co-infection, Total new patients and prevalence
by month in 2013 ( Letlhakane Primary Hospital):
From January to December 2013, proportion of HIV+ and TB/HIV co-infected patients
Proportion in %
TB/HIV co-infected
HIV +
0
10
20
30
40
50
60
70
jan feb mar apr may jun jul aug sep oct nov dec
HIV+
TB/HIV co-infected
Total new patients
Prevalence/month

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4.3 The role of patient and community in strengthening HIV/TB collaboration:
 This is mobilisation of patients and the community at large about TB/HIV
collaboration.
0
5
10
15
20
25
30
35
TB/HIV co-infected patients
HIV+
HIV+
0
10
20
30
40
50
60
Jan
Feb
March
April
May
June
July
August
Sept
Oct
Nov
Dec
HIV+
TB/HIV co-infected patients
Prevalence of TB/HIV co-
nfected in %

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 The patients and community has to be empowered with information about
TB and HIV signs and symptoms, treatment (drugs) and how to live with
TB/HIV patients and infection control measures.
 The community has to have information about health issues at large and be
aware of any change that happens within our Letlhakane primary Hospital.
 The barrier will be: Lack of knowledge of diseases and treatment (TB/HIV)
among patients and the community at large

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5 Monitoring and evaluation of infection control in Letlhakane Primary
Hospital:
Monitoring and evaluation has been not easy because of some missing information this is
due to poor documentation on registers and patients cards.
For example when the focal person is absent some information is not updated therefore
affecting and even statistics.
The main barrier is poor recording of data by health facilities.
ABOUT DRUG SUPPLY:
It has been concern that some of the drugs or medical equipment can be out of stock for a
long time of which end up hampering the delivery of services to patients and community at
large.

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6 Result and discussion
Retrospective study of TB/HIV co-infected patients in Letlhakane primary hospital shows,
the Point prevalence of co-infected patients in TB/HIV in Letlhakane Primary Hospital from
January to December 2012 ranges from 25% to 58.3%.
The period prevalence for 2013 in Letlhakane primary Hospital was 43.9%
We need to remember that TB in HIV patient is WHO stage 3 or 4 according to the
localisation and therefore people living with TB/HIV co-infected are eligible for both
treatment regardless CD counts.

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7 Conclusion:
The study clearly shows the Point prevalence of co-infected patients in TB/HIV in
Letlhakane Primary Hospital from January to December 2013 ranges from 25% to 58.3%.
The period prevalence for 2013 in Letlhakane primary Hospital Was 43.9%
We need to remember that TB in HIV patient is WHO stage 3 or 4 according to the
localisation and therefore people living with TB/HIV co-infected are eligible for both
treatment regardless CD counts.
Optimal management of dually infected patients will reduce mortality, will improve the
patient outcomes and prevent diverse reactions.
• health workers supposed to monitor and track the TB and HIV co-infection
patients by:
-Ensure that all TB patients referred for HIV testing and vice versa.

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8 Recommendations:
Barriers in collaboration TB/HIV services in Letlhakane Primary Hospital and
Barrier breaking plan
BARRIER ACTION INDICATION(S); JOB
CATEGORIES AND
POTENTIAL SOURCES OF
FINANCING
DIAGNOSIS OF HIV IN TB
SERVICES:
Communication challenges
between health workers and
community
Use of informed volunteers
to overcome communication
barriers
No of TB patients tested for
HIV
Translation of community
educational materials into
the local language
No of materials translated
Traditional and cultural
beliefs hampering HIV
testing
Sensitization of key
community leaders on
TB/HIV
No of TB patients tested for
HIV
DIAGNOSIS OF TB IN HIV
SERVICES
Absence of symptom
screening tool
Development of the
symptom screening tool
Screening tool available
Sensitization of health care
workers on the use of the
screening tool
Number of patients screened
for TB
THE ROLE OF THE PATIENTS
AND THE COMMUNITY IN
STRENGTHENING TB/HIV
COLLABORATION
Conduct community
awareness campaigns on
TB/HIV
Number of awareness
campaigns conducted

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9 References:
Africa, S. (2009). Cervicalcancerprevention in Africa, (November), 27–29.
Another, S., & Success, P. (2009). CDC Botswana.
CentralStatistics Office, & Office, C. S. (2011). Populationof Towns, Villages
and Associated Locatlities. 2011 Population and Housing Census, 1–8.
Retrieved from http://ecastats.uneca.org/aicmd/Portals/0/Census 2011
Preliminary Brief Sept 29 2011.pdf
Experiences of Batswana women diagnosed with both HIV / AIDS and cervical
cancer. (2009), (December).
MoH. (2008). Botswana HIV/AIDS impact Survey III, (Bais Iii), 1–6.
Policy guidelines and servicestandards. (n.d.).
Torgerson, D. J., & Miles, J. N. V. (2007). Simplesample size calculation.
Journalof Evaluation in ClinicalPractice, 13(6), 952–953.
http://doi.org/10.1111/j.1365-2753.2006.00776.x
Yin, Z., Cao, L., Han, J., Zhai, C., & Huang, T. (2011). Geographicaltopic
discovery and comparison. Proceedings of the 20th …, 247–256.
http://doi.org/http://dx.doi.org/10.1145/1963405.1963443