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 i 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 ii 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. iii 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. iv 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 v 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 vi 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 vii 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 viii