Tuberculosis Preventive Therapy Uptake Among Adults Living with HIV in Zimbabwe: Analyzing Zimbabwe Population-Based HIV Impact Assessment (ZIMPHIA) 2020 and 2015-16 Restricted; Files Only

Abstract

Introduction  

Tuberculosis (TB) is the leading global cause of death among people living with human immunodeficiency virus (PLHIV). Despite effective tuberculosis preventive treatment (TPT), global uptake remains suboptimal. Zimbabwe, with a high TB burden and 12% adult HIV prevalence, has prioritized TPT expansion. We assessed TPT uptake among PLHIV using 2020 Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) data and compared it to 2015-16 ZIMPHIA.   

 

Methods  

ZIMPHIA 2020 was a cross-sectional, nationally representative study among adults aged 15 years and older who completed interviews and HIV-related biomarker testing. We included those who self-reported as HIV-positive and provided complete risk-factor data. Data collection included household- and individual-level variables on demographics, HIV status, antiretroviral therapy (ART) status, and TPT usage, among other clinical factors. Statistical analysis utilized SAS Studio OnDemand, applying weighted biomarker weights and Jackknife replicate weights for variance estimation. Collinearity analysis and logistic regression models examined associations between TPT usage and demographic and clinical factors.  

 

Results  

Among 2,501 self-reported HIV-positive individuals, 35.7% were male and 32.7% were in the 35-44 years age group (32.7%). Most had seen a healthcare professional in the past year (79.5%), were on antiretroviral therapy (ART; 96.1%) and were virologically suppressed (88.0%). However, only 42.5% were screened for TB symptoms at their last HIV care visit. There was an increase in TPT uptake from 15.5% in 2015-16 to 37.7% in 2020. Predictors of not receiving TPT included not seeing a healthcare professional in the last 12 months (aOR = 0.80), not being on ART (aOR = 0.35), being on ART but not achieving viral suppression (aOR = 0.72), and not being asked about TB symptoms during their last HIV care visit (aOR = 0.67). 

 

Conclusion  

We found a substantial improvement in TPT uptake among PLHIV in Zimbabwe in 2020 compared to 2015. However, the persistently low uptake remains a challenge in meeting global targets for universal TPT coverage. Younger age groups, those who were not screened for TB at their last HIV visit, and those who were not virally suppressed had lower TPT uptake, indicating groups for targeted outreach efforts.  

Table of Contents

Introduction………………………………………………………………………….…………..............…...1

Methods………………………………………………………………………………………..……................2

           Study design and setting…………………………………………………………….…..................2

                       Survey methods……………………………………………………………..…....................3

                       Study participants………………………………………….…………….……...................3

           Questionnaire……………………………………………………………………............................3

                       Biomarker and laboratory testing……………………………………………..................4

           Statistical analysis……………………………………………………………............………….…...5

           Ethical Review………………………………………………………………………..…….................6

Results…………………………………………………………………………………………..…...................6

           Characteristics of the analytic population………………………………….............………......6

           Predictors of having received TPT……………………………………………….............……......7

           TB screening and diagnosis, comparison to ZIMPHIA 2015-16………………….................7

           Collinearity analysis……………………………………………………………..….…….................9

Discussion…………………………………………………………………………………..……….................9

Conclusion…………………………………………………………………………………..……..................11

Figures and Tables……………………………………………………………………………..............…....13

           Figure 1. Flow diagram of ZIMPHIA 2020 respondents in relation to taking TPT…….....13

           Table 1. Sociodemographic characteristics of self-reported HIV-positive individuals….14

           Table 2. Health-related characteristics of self-reported HIV-positive individuals……….15

           Table 3. Sociodemographic characteristics associated with TPT uptake………………......17

           Table 4. Health-related characteristics associated with TPT uptake…………………….....19

           Table 5. Comparison of ZIMPHIA 2015-16 and 2020 regarding TPT uptake…….……......21

           Table 6. Comparing TB-related characteristics and TPT uptake in ZIMPHIA surveys…...23

Bibliography…………………………………………………………………………………….....................26

Appendix…………………………………………………………………………………………....................31

           TB-related questionnaire comparisons between ZIMPHIA 2015-16 and 2020…....……....31

           ZIMPHIA 2020 TB-related questionnaire………………………………………………..............33

           ZIMPHIA 2015-16 TB-related questionnaire……………………………………………............34

           Figure 2. Flow diagram of ZIMPHIA 2015-16 respondents in relation to taking TPT…....36

Literature review…………………………………………………………………………………..................37

           TB/HIV coinfection…………………………………………………………………….....................37

           Latent TB infection and TB disease…………………………………………………...........….....38

           Latent TB diagnosis……………………………………………………………………....................40

           TPT in people living with HIV…………………………………………………………..................42

                       Global policy and guidelines……………………………………………….........…….......42

                       TPT regimens and evidence…………………………………………………........….........43

                       Implementation challenges and considerations…………………………..……….......44

                       Effectiveness of TPT and associated factors……………………………………............45

                                   Efficacy of TPT and limitations of ART………………………………................45

                                   Survival benefits and challenges of TPT………………………………..............45

                                   Factors influencing TPT initiation and uptake…………….……………..........46

                       Role of WHO guidelines and global commitments……………………………............47

                       Future directions and global commitments………………………………………..........48

           Zimbabwe country context………………………………………………………………................48           

                       Healthcare landscape and challenges……………………………………………............48

                       Prevalence of HIV and TB……………………………………………………….................49

                       Challenges facing the LGBTQ community in accessing healthcare…………….......50

                       TPT expansion and implementation strategies…………………………..……….........51

           Summary

                       Global TB/HIV coinfection……………………………………………………...................53

                       Expanding access to TPT………………………………………………………..................53

                       Enhancing healthcare infrastructure in Zimbabwe………………………………........53

References………………………………………………………………………………….……....................55

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Global Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology Health Sciences, Public Health
Mot-clé	Population-based HIV impact assessment Tuberculosis screening People living with human immunodeficiency virus Tuberculosis Tuberculosis preventive treatment Isoniazid preventive therapy Zimbabwe Human immunodeficiency virus
Committee Chair / Thesis Advisor	Sarita Shah, Emory University
Committee Members	Drew Voetsch, Emory University

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