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INTRODUCTION
Tuberculosis (TB) is the leading cause of death among people living with HIV (human immunodeficiency virus) (PVHIV)1,2. Reduced access to TB diagnosis and treatment during the new coronavirus disease pandemic as of 2019 (COVID-19) reversed years of progress in providing essential services to control this disease. Globally, the estimated number of deaths from TB increased between 2019 and 2021, unlike the decline observed between 2005 and 20192. In 2022 it was considered the second leading cause of death worldwide.
In Brazil, between 2012 and 2019, the proportion of new TB cases tested for HIV increased by around 15%, reaching 82.8% in 2019. In 2020 and 2021, there was a decrease in new TB cases tested for HIV, with proportions of 82.6% and 82.7%, respectively, and in 2022 this rate was 79.7%2-4. In 2022, while the co-infection rate was 8.4% in Brazil, the state of Espirito Santo had a co-infection rate of 8.1% in 2020.
In addition to HIV infection, other risk factors are related to TB infection and illness, such as: overcrowding, impoverishment, poor living conditions, injectable drug use, alcohol use, smoking, diabetes, lack of access to health and malnutrition, among other factors1,2,5.
A study published in 2021, carried out in the Republic of Congo6 from 2014 to 2019, with 49,460 people, identified that situations related to poor provision of health services, linked to the inherent characteristics of individuals, such as co-infection, for example, increase the risk of unfavorable outcomes of death, loss to follow-up and absence or suppression of viral load. Furthermore, the study suggests that addressing the social stigmas and clinical challenges faced in TB/HIV co-infection can favor the control of the tuberculosis transmission chain.
Studies that seek to identify and outline the vulnerability profile favor the targeting of necessary interventions to be carried out in people with TB-HIV co-infection, and consequently, achieve strategies to end TB7. The objective of this study was to outline the epidemiological profile of people with TB-HIV co-infection in the State of Espírito Santo, Brazil.
METHODS
This is a cross-sectional and descriptive study, using secondary data reported in the Notifiable Diseases Information System (SINAN-TB), in the period from 2016 to 2018 and in SINAN-HIV, in the period from 2007 to 2019, made available by the State Department of Health (SESA)8.
The study included records of cases diagnosed with tuberculosis and HIV, among those residing in the state of Espírito Santo, a location chosen due to the opportunity to access the nominal database, to carry out a methodological strategy for data processing; and records that were duplicates were excluded8. Subsequently, data preparation was carried out, with duplication analysis and linkage with the HIV bank in order to obtain information regarding HIV; the data was anonymized and removed from the State Department of Health (SESA) in June 2022 to proceed with the analysis, according to figure 1.
Source: The Authors, 2023
Figure 1 : Flowchart on the methodology of the data preparation process in the SINAN-TB database, during the period from 2016 to 2018.
In addition to the variables of Tuberculosis (ICD10: A15-A19) and HIV (ICD10: B20-B24), other variables were used, classified and analyzed according to vulnerability levels, according to the study method published by Maciel and collaborators in 20159. The variables used at the “individual vulnerability level” were: sex, age, race/skin color, educational level and associated diseases; for the “programmatic vulnerability level”, the variables were: form of TB, sputum smear microscopy, culture, DOT, ART during TB treatment, type of entry and closure status; and for the level of “social vulnerability”, the variables used were: special populations and beneficiary of the government’s income transfer program.
The information was encoded and stored anonymously in a database in Excel for Windows®; the STATA statistical package, version 16 (Stata Corp LP, College Station, TX, USA) was used to carry out descriptive analyses with identification of relative and absolute values.
The study was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Espírito Santo (CEP/CCS/UFES) under opinion # 4022892 on 05/12/2020, according to Resolution # 466/12 of the National Health Council (CNS).
RESULTS
The SINAN-TB database, from 2016 to 2018, in Espírito Santo, Brazil, presented a total of 4,428 cases; After carrying out the steps described in figure 1, 325 cases of TB-HIV co-infection were identified, of which 322 cases were located in the SINAN-TB database, and three cases were located after linking with the SINAN-HIV database, which presented a result record negative for the HIV diagnostic test in the SINAN-TB database.
Among the 325 cases of TB-HIV co-infection, 232 (71%) were males, 169 (52%) were between 20 and 39 years old, 190 (59%) declared themselves mixed race, 80 (25%) had completed primary education, 291 (89%) had AIDS, 96 (29%) had alcoholism, 85 (26%) used illicit drugs, and 122 (37%) were smokers. (tables 1 and 2).
Table 1 : Distribution of demographic factors of individual vulnerability related to interruption of TB treatment in PLHIV in Espírito Santo, in the period from 2016 to 2018.
| CHARACTERISTICS | Total N | % |
|---|---|---|
| Gender | N= 325 | |
| Feminine | 93 | 28.6 |
| Masculine | 232 | 71.4 |
| Age, years | N= 325 | |
| < 20 | 6 | 1.9 |
| 20-39 | 169 | 52.0 |
| 40 – 59 | 135 | 41.5 |
| > 60 | 15 | 4.6 |
| Race/skin color | N= 321 | |
| White | 68 | 21.1 |
| Black | 37 | 11.5 |
| Mixed | 190 | 59.2 |
| Ignored | 26 | 8.2 |
| Education, years studied | N= 325 | |
| Illiterate | 9 | 2.88 |
| 1 a 4 years | 52 | 16.6 |
| 5 - 8 years | 80 | 25.5 |
| 9 a 12 years | 69 | 22.0 |
| > 12 years | 14 | 4.5 |
| N/A | 89 | 28.5 |
Source: The Authors, 2023
Table 2 : Distribution of clinical factors of individual vulnerability related to interruption of TB treatment in PLHIV in Espírito Santo, in the period from 2016 to 2018.
| CHARACTERISTICS | Total N | % |
|---|---|---|
| Illness – AIDS | N= 325 | |
| No | 26 | 8.0 |
| Yes | 291 | 89.6 |
| Ignored | 8 | 2.4 |
| Illness – alcoholism | N= 322 | |
| No | 211 | 65.5 |
| Yes | 96 | 29.8 |
| Ignored | 15 | 4.7 |
| Illness – diabetes | N= 322 | |
| No | 289 | 89.8 |
| Yes | 9 | 2.8 |
| Ignored | 24 | 7.4 |
| Illness – mental health | N= 322 | |
| No | 287 | 89.1 |
| Yes | 13 | 4.0 |
| Ignored | 22 | 6.9 |
| Illness – Illicit drug use | N=324 | |
| No | 219 | 67.6 |
| Yes | 85 | 26.2 |
| Ignored | 20 | 6.2 |
| Illness – smoking | N=322 | |
| No | 180 | 55.9 |
| Yes | 122 | 37.9 |
| Ignored | 20 | 6.2 |
| Illness – others | N= 297 | |
| No | 249 | 83.8 |
| Yes | 24 | 8.1 |
| Ignored | 24 | 8.1 |
Source: The Authors, 2023
A total of 215 (66%) had the pulmonary form of TB, only 55 (23%) had a positive result for smear microscopy and 120 (36%) of the cases had a positive result for culture, 143 (61%) cases did not undergo DOT, and 194 (65%) of the cases used ART. Regarding the type of entry, 253 (77%) were considered new cases; regarding the case closure situation, there was a predominance of the cure outcome with 145 (44%) cases, 66 (20%) died from other causes and 40 (12%) abandoned treatment (table 3). Regarding the social aspect, the study showed that only 22 (6.9%) people reported receiving assistance from the government’s income transfer program (table 4).
Table 3 : Distribution of programmatic vulnerability factors related to interruption of TB treatment in PLHIV in Espírito Santo, in the period from 2016 to 2018.
| CHARACTERISTICS | Total N | % |
|---|---|---|
| Type | N= 325 | |
| Pulmonary | 215 | 66.1 |
| Extrapulmonary | 75 | 23.1 |
| Pulmonar + Extrapulmonary | 35 | 10.8 |
| Putum Smear Microscopy | N= 236 | |
| Positive | 55 | 23.3 |
| Negative | 57 | 24.1 |
| Not performed | 51 | 21.7 |
| Not applicable | 73 | 30.9 |
| Culture | N= 325 | |
| Positive | 120 | 36.9 |
| Negative | 90 | 27.7 |
| Underway | 18 | 5.5 |
| Not applicable | 97 | 29.9 |
| Directly Observed Treatment | N= 233 | |
| No | 143 | 61.4 |
| Yes | 84 | 36.0 |
| Ignored | 6 | 2.6 |
| Antiretroviral Therapy | ||
| During TB Treatment | N= 297 | |
| No | 91 | 30.7 |
| Yes | 194 | 65.3 |
| Ignored | 12 | 4.0 |
| Entry | N= 325 | |
| New Case | 253 | 77.9 |
| Recidivism | 26 | 8.0 |
| Re-entry after interruping treatment | 12 | 3.7 |
| Unknown | 1 | 0.3 |
| Transferral | 27 | 8.3 |
| After death | 6 | 1.8 |
| Situation of Closure | N= 323 | |
| Cure | 145 | 44.9 |
| Interrupting treatment | 40 | 12.4 |
| Death | 12 | 3.7 |
| Death due to other causes | 66 | 20.4 |
| Transferral | 36 | 11.1 |
| Change of diagnosis | 15 | 4.6 |
| TB-DR | 3 | 0.9 |
| Change of Plans | 5 | 1.5 |
| Bankruptcy | 0 | 0 |
| Primary Abandonment | 1 | 0.3 |
Source: The Authors, 2023
Table 4 : Distribution of social vulnerability factors related to interruption of TB treatment in PLHIV in Espírito Santo, in the period from 2016 to 2018.
| CHARACTERISTICS | Total N | % |
|---|---|---|
| Beneficiary of the Government Income Transfer Program | N= 315 | |
| No | 203 | 64.5 |
| Yes | 22 | 6.9 |
| Ignored | 90 | 28.6 |
| Special Populations – Immigrants | N= 320 | |
| No | 307 | 95.9 |
| Yes | 0 | 0.0 |
| Ignored | 13 | 4.1 |
| Special Populations – Deprived of liberty | N= 320 | |
| No | 294 | 91.9 |
| Yes | 16 | 5.0 |
| Ignored | 10 | 3.1 |
| Special Populations – Homeless Population | N= 320 | |
| No | 280 | 87.5 |
| Yes | 31 | 9.7 |
| Ignored | 9 | 2.8 |
Source: The Authors, 2023
DISCUSSION
Over the last few years, several advances have been achieved by TB control programs in all spheres of management of the Unified Health System (SUS). However, there are still challenges to be overcome to achieve the objective of ending TB as a public health problem in Brazil. The sociodemographic profile identified in this study corroborates the literature regarding individual, social and programmatic vulnerability10-12. There is a recurrence of cases of TB-HIV co-infection in young men, mixed race/skin color and complete primary education. The majority presented the pulmonary form of the disease, admitted as a new case, a significant number declared that they were smokers and had not undergone DOT. Less than two-thirds of registered cases used ART and not even half of the cases showed a cure outcome at the end of treatment.
The limitations of the study are related to the small sample size due to the period considered for the study, which was chosen as a result of the insertion of new variables of interest available in version 5 of the notification form, such as: the inclusion of special populations (population deprived of liberty, homeless population, health professionals and immigrants), beneficiaries of the government cash transfer program, ART during TB treatment, rapid molecular test for TB (TMR-TB), sensitivity test, and if transferred (inform transfer site), and the change in the variables “if extrapulmonary” (second option removed), “sputum smear microscopy” (second smear microscopy removed), “associated diseases and conditions” (including use of illicit drugs and smoking) and “follow-up smear microscopy” (included after the 6th month)13. A larger sample would allow the creation of more robust analyses in order to evaluate associations and identify predictive profiles.
In addition to being persistent, TB is also a perpetuator of poverty, as it compromises the health of individuals and their families, which causes economic and social impacts14. When considering the variables related to social vulnerability, the findings of this study reveal the maintenance of the unequal distribution of the number of cases, concentrating on disadvantaged social groups. A systematic review published in 2022 identified that the double burden of the disease, TB-HIV co-infection, increases the catastrophic costs of the disease by up to 81%10-12,15. A study carried out in Brazil identified that 41% of people with TB experienced catastrophic costs and an increase in poverty during the diagnosis and treatment of the disease, including loss of income due to inability to work16. Connected to this situation, it is clear that not receiving income transfer resources from the government worsens the state of vulnerability, compromises access to health services and makes adherence to treatment unfeasible17.
When considering the variables related to social vulnerability, the findings of this study reveal the maintenance of the unequal distribution of the number of cases, concentrating on disadvantaged social groups. A systematic review published in 2022 identified that the double burden of the disease, TB-HIV co-infection, increases the catastrophic costs of the disease by up to 81%.
Regarding variables related to programmatic vulnerability, that is, situations in which institutions contribute to unfavorable contexts, the minority of cases had access to DOT, which is monitoring during medication intake, a strategy recommended by the Ministry of Health (MS) for PLHIV, homeless people, drug users and people deprived of their liberty, as they are more likely to give up treatment, which can result in drug resistance and increased disease transmission rates7,18. A study carried out in São Paulo, from 2010 to 2015, with 10,389 cases of TB-HIV co-infection, identified that treatment interruption is related to DOT coverage, that is, the lower the DOT coverage, the higher the treatment interruption rate will be; increasing the disease transmission chain19.
It has also been observed that more than a third of the population assessed did not use ART, unlike what has been proposed by the Ministry of Health since 2013, which recommends timely treatment with ART for all PLHIV14. Adherence to ART is related to a better prognosis of co-infection by minimizing viral replication and favoring the strengthening of CD4 T lymphocytes2,19,20.
The Ministry of Health also recommends that every user diagnosed with TB be tested for HIV, as early diagnosis will enable a better prognosis7. However, it was found that three users were considered negative for HIV in the SINAN-TB database despite having been identified in the SINAN-HIV database after linkage. This again indicates a situation of programmatic vulnerability, which can be resolved through the implementation of an interconnected information system that is capable of identifying and associating records in order to provide data evaluation through monitoring.
Upon considering the outcome, it was observed that a cure was more frequent, but this percentage did not reach even half of the cases. A cross-sectional study carried out in São Paulo, between 2010 and 2014 and using secondary data, identified that the occurrence of the cure outcome in cases of TB-HIV co-infection was lower when compared to cases with TB, which may be associated with the use multiple medications, adverse effects, lack of family support and unpreparedness of the healthcare team in providing care for co-infection cases; thus, it is necessary to strengthen health programs, decentralize care and follow-up of cases, with the aim of increasing cure rates and minimizing unfavorable outcomes20.
Difficulties in accessing citizens’ rights and other situations of vulnerability are the responsibility of the State. It is possible to verify a mobilization in terms of policies in order to promote a better relationship between social assistance and public policies for attention to infectious diseases linked to vulnerability, such as HIV infection and TB. The strategies included are: articulating health promotion and health monitoring activities, in addition to guaranteeing social protection, such as family monitoring and income transfer to users and family members affected by these public health problems21. However, it is not enough simply to have robust and comprehensive policies; it is now time for the creation of a referral system for patients in need of social assistance within SUS, in order to direct the necessary subsidies to control this public health problem.
In addition to identifying a sociodemographic profile of vulnerability, it was also possible to rethink health practices that have not yet been fully implemented, in order to provide control of this double burden of diseases. It is necessary that, combined with the strengthening of health actions, there is also an increase in inclusion and rights protection policy actions, such as social programs, as well as avoiding the growth of treatment interruption rates among PLHIV, with a focus on strategies to end TB by 2035.
CONCLUSION
The profile of TB/HIV co-infection occurred in young men, of mixed race/skin color and with complete primary education, with the pulmonary form of tuberculosis, and type of entry as a new case. There was also a significant number of people who smoked and who did not perform the DOT. Less than two-thirds of registered cases used ART, only 40% of cases showed a cure outcome at the end of treatment, and a minimum number of people had access to the government income transfer program benefit.
In order to ensure greater coverage of tuberculosis control in PLHIV, it is necessary to expand the dialogue between health and social support policies; to enable access to health services such as antiretroviral treatment for all people diagnosed with HIV, and to provide timely directly observed treatment (DOT) for people who present this vulnerability profile. Carrying out new studies is essential to contribute to technological advancement and planning in health service actions.
