Study setting
Zewditu Memorial Hospital (ZMH) is a general hospital located in Addis Ababa, Ethiopia. It has been providing antiretroviral therapy since 2003. Addis Ababa has a projected population of 3 million, and is divided in to 10 administrative sub cities and 99 localities [7, 8].
As a standard of care, the Ethiopian national guidelines for TB/HIV collaboration advised offering HIV testing to those with cough > 2 weeks, provision of IPT to HIV positives screened negative for TB, cotrimoxazole prophylactic therapy (CPT) to co- infected patients, and regular TB screening of clients in HIV care [5].
Study design and data collection
This cross-sectional study was conducted between January and December 2008. Three methods were used to evaluate the performance of the TB/HIV collaborative activities: review of registers of TB patients to determine the HIV testing rate, retrospective review of charts of patients co-infected with TB and HIV, and exit interviews. The registers of all the 241 TB patients who visited the clinic between January and December 2008 were reviewed, as well as the charts of 238 randomly selected TB/HIV co-infected patients aged 18 years and above and treated at the ZMH during the specified period. In addition, 309 randomly selected TB/HIV co-infected patients were interviewed during the data collection period.
Information was retrieved from TB and provider-initiated counseling and testing (PICT) registers and from HIV care/anti-retroviral treatment (ART) charts using a data abstraction checklist. Data from registers and charts included information on HIV testing and post test counseling of TB patients, referral to HIV care of HIV positive TB patients, screening of HIV positives for (cough, fever, and night sweating > 2 weeks), weight lost > 3 kg in the past 4 months, and history of TB contact in the past 1 year, sputum microscopy for acid-fast bacilli (AFB), sputum culture, lymph node fine needle aspiration (FNA) test, linkage to IPT and CPT. Structured questionnaire containing standard TB screening criteria(if the client had cough, fever, and night sweats for > 2 weeks, weight loss > 3 kg in the last 4 weeks, and TB contact in the past 1 year) were used for exit interview of clients how they screened for TB. The groups of patients included in the exit interview were those screened for TB in the past 1 year.
The data abstraction checklist and the exit interview questionnaire were adapted from the national TB/HIV guideline [5], and pretested before being applied for data collection. The questionnaire for exit interview was translated to Amharic (local language) and translated in English to maintain consistency. We used experienced and trained data collectors for all data collections activities.
Evaluation criteria
The following indicators adapted from World Health Organization (WHO) guidelines were used to evaluate the level of linkage implemented between TB and HIV services: TB patients who are tested for HIV, HIV positive clients given IPT, co infected patients put on CPT, proportion of patients with cough > 2 weeks duration and sputum for AFB is ordered, proportions of TB suspect patients diagnosed correctly for TB [5, 9].
TB screening of HIV positives included asking questions based on a combination of symptoms of the five TB screening criteria indicated in the national protocol. The screening checklist included cough, fever, night sweats (> 2 weeks), weight loss > 3 kg in the last 4 weeks, and history of TB contact in the past 1 year. If the client said yes for cough > 2 weeks or if no to cough > 2 weeks but yes to two or more of the other questions the patient was further evaluated [5].
Diagnosis of TB in HIV positive patients was based on the national TB/HIV guidelines. Pulmonary TB (PTB) diagnosis was established if at least one sputum smear-positive for AFB was detected. The algorithm for smear negative PTB diagnosis required at least 2 slides negative for sputum AFB, no response to broad spectrum antibiotic for 10-14 days, and radiographic abnormalities consistent with active TB; or, at least 2 slides negative for sputum AFB plus sputum culture positive for M. tuberculosis. Extra pulmonary TB (EPTB) diagnosis was based on FNA suggestive of, or consistent with, active extra pulmonary TB, one specimen from an extra pulmonary site culture positive for M.tuberculosis, or smear positive for AFB with the clinician's decision to treat the patient with a full course of anti-tuberculosis treatment.
Statistical analysis
Quantitative data was sorted, cleaned, and coded after double data entry using the EPI-Info version 3.3.2 data entry program. Analysis was conducted with SPSS 16.0 (SPSS inc. Chicago, 2007). Quantitative data was analyzed by calculating percentage of indicators using descriptive statistics. Percentages were used for comparison. We used both bivariate and multivariate analysis to estimate demographic characteristics and TB screening criteria for specific outcome variables in the program. We determined the level of significance at P < 0.05.
Ethical review
The study was approved by the ethics committee of Addis Ababa Regional Health Bureau. The purpose of exit interview was described and participation was fully voluntary and all study subjects gave verbal consent. Interview was done privately and data captured from various sources were kept confidentially.