None listed
Conditions
Brief summary
Background-Ethiopia is a highly affected country by HIV/AIDS epidemic among Sub-Saharan countries with a prevalence rate of 2.2%. The rate of TB/HIV coinfection in Ethiopia is also very high ranging from 40-70%. The majority of the TB patients are smear negative and/or extra pulmonary. The existing guideline of Ethiopia did not adequately reflect the diagnostic and treatment challenges of smear negative and/or HIV-associated tuberculosis. Currently WHO has recommended new guideline (2006) for the diagnosis of HIV-associated tuberculosis. However, this guideline is based on expert opinion and consensus. Objective- The objective of this study is to assess the operational performance of the revised recommendations and algorithm for improving the diagnosis of TB in HIV prevalent setting in selected hospitals of two regional states in Ethiopia. Methods- The study will employ quasi-experimental study (pretest and post test design) which will be conducted in four settings in Ethiopia. In Jimma and Alert hospitals where there is TB culture facility, the new guideline will be implemented. Nekemet and Zewuditu Memorial Hospitals will be selected as a comparison group. In these hospitals, TB management will continue based on the old (2003) guideline. Similarity of the population, patient flow, availability of TB and ART clinics and accessibility were the criteria to select these hospitals as a comparison group. In settings where the new guideline is implemented, all health professionals (medical doctors, nurses, laboratory and X-ray technicians) will be trained about the new guideline using a training manual. Strict observation of the application of the new guideline will be made by trained physicians regularly using observation checklist. Refreshing training on the old guideline will be given to the health professionals who are working in settings where the old guideline is implemented. In both settings, about 3236 TB suspects will be recruited and followed regularly to measure different outcomes. In settings where the new guideline is being implemented, all TB suspects will have two sputum examination using the standard Ziehl-Neelsen technique and HIV counseling and testing. Smear positive individuals based on the new guideline will be referred for Directly Observed Therapy for Short Course(DOTS) therapy. Culture and/or X-ray investigations will be done for smear negative individuals or individuals with extra-pulmonary TB on the second day of their visit. In settings where the 2003 guideline is being implemented, the usual procedure of patient diagnosis and treatment process will be applied. After recruitment of patients, in both settings, there will be regular follow up of patients. Clinical status and progress (such as weight, functional score/WHO staging, occurrence of opportunistic infections, trends in CD4 lymhocyte count, drug adherence and side effects, and death) will be monitored regularly. Several outcomes will be measured. In both settings, exit interviews using structured questionnaires will be done to measure client satisfaction. In-depth interviews will be done to measure satisfaction of the health professionals with the service in both settings. Treatment delay will be using record review. Hospitalization rate will be assessed using observation checklist and record review. Mortality of patients will be measured using standardized verbal autopsy tools or death certificate. Specificity of the new guideline will be computed using culture as a gold standard diagnostic technique. To minimize error, the data will be entered into Epi Info 3.3.2 statistical software. Analysis will be done using SPSS 12.0.1. Descriptive analysis will be done to measure the HIV/TB co- infection, patient satisfaction rate, treatment delay rates, and the level of knowledge and attitude of the TB patients about the disease. Bivariate analysis will be done to see the effect of implementing the new guideline (as compared to the old one) on patient satisfaction, treatment delay and mortality rate of patients. To control the effect of confounding variables, a multivariate technique using logistic regression will be done. The study is expected to document the current morbidity and mortality patterns with regard to the dual infection in this region and to improve the management of HIV related TB. The study will help to design national policy regarding the management of smear negative and extra pulmonary TB patients in HIV prevalent settings.
Interventions
Diagnosis of smear negative tuberculosis (TB) in HIV patients is a challenge for developing countries. Recently, the World Health organization(WHO) has recommended a new guideline to diagnose TB in such settings. The already exisiting guideline(WHO,2003) is inefficient to diagnose TB in HIV Patients. The 2003 guideline recommends the following to diagnose TB in adult HIV patients: three sputum examination, antibiotic trial if the three sputa are negative, repetition of sputum examination after a
Diagnosis of smear negative tuberculosis (TB) in HIV patients is a challenge for developing countries. Recently, the World Health organization(WHO) has recommended a new guideline to diagnose TB in such settings. The already exisiting guideline(WHO,2003) is inefficient to diagnose TB in HIV Patients. The 2003 guideline recommends the following to diagnose TB in adult HIV patients: three sputum examination, antibiotic trial if the three sputa are negative, repetition of sputum examination after antibiotic trial and finally X-ray for the diagnosis of TB. Based on this guideline, at least two sputa should be positive to diagnose TB or there should be evdidences of antibiotic trial failure, X-ray suggestion and physician decision to diagnose TB. On the other hand, the new guideline (WHO, 2006) recommends that HIV adult patients should have only two sputum examination, if one of them is positive, TB is confirmed. If the two sputa are negative, X-ray and culture should be done in the second visit. Based on the X-ray and culture results, patients shoud be treated immediately. Antibiotic trial is not recommended. However, the new guideline is not based on evidence. It is based on experts' opinion. This study will compare the two guidelines in terms of patients' satisfaction, treatment delay and mortality. Two hospitals will implement the 2006 WHO guideline to diagnose tuberculosis in patients with HIV. Two other comparasion hospitals will implement the 2003 WHO guideline to diagnose tuberculosis in HIV patients. We will compare treatment delay, proportion of smear negative TB , mortality between the two settings. The total duration of patient recruitment and follow up will be 2 years
Sponsors
United Nations Children's Fund/United Development Program/World Health Organization/World Bank-Research and Training in Tropical Diseases(TDR)
Eligibility
Sex/Gender
All
Age
15 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Settings which had TB culture facility will be included to implement the 2006 WHO TB guideline. TB suspects who are above 15 years will be included.
Exclusion criteria
Tuberculosis suspects below 15 years will be excluded
Outcome results
None listed