PRACA POGLĄDOWA

REVIEW ARTICLE

ANALYSIS OF TUBERCULOSIS/HIV CO-INFECTION TRENDS IN UKRAINE IN 2008-2017

Tetiana V. Stepanova1, Olga P. Nedospasova2, Mykhailo V. Golubchykov1

1Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine

2SI Center for Health Statistics of the MoH of Ukraine, Kyiv, Ukraine

АBSTRACT

Introduction: According to WHO estimates for the European Region in 2017, Ukraine had the highest proportion of active tuberculosis cases co-infected with HIV – 21.6%, with an average of 12% in the Region, and the absolute number of tuberculosis/HIV co-infection cases in Ukraine was estimated at the level of 8,000.

The aim: carry out a comprehensive analysis of the epidemical situation regarding tuberculosis/HIV co-infection in Ukraine according to selected epidemiological and clinical characteristics.

Materials and methods: The retrospective epidemiological study was based on the data from national reporting forms “Annual Active TB Report”, which was being collected by the Center for Health Statistics of the Ministry of Health of Ukraine for period 2008-2017.

Review: The incidence of newly diagnosed active tuberculosis associated with HIV in Ukraine increased by 89,4% – from 6,1 per 100,000 population in 2008 to 11,6 per 100,000 population in 2017, against the backdrop of a gradual decrease in the incidence of active tuberculosis by 36.5% over the same period. The rates of comorbidity TB/HIV increased by 2.8 times from 7.9% to 20.3%. The highest rates of incidence tuberculosis/HIV co-infection are observed in person aged 25-44, males, urban residents, and in the southern region of Ukraine.

Conclusions: The revealed tendency to increase the rate of the incidence and comorbidity of tuberculosis/HIV causes necessitates reviewing the organizational approaches to healthcare delivery for tuberculosis/HIV co-infection patients.

KEY WORDS: tuberculosis/HIV co-infection, incidence, comorbidity

Wiad Lek 2019, 72, 5 cz. I, 903-907

Introduction

Under the concept of WHO, worldwide tuberculosis epidemic is divided into three components: typical tuberculosis (ТB), multidrug-resistant tuberculosis (MDR-TB) and tuberculosis/HIV co-infection (TB/HIV co-infection). Each of these components has its epidemiological characteristics and influences the course of the overall TB epidemic. The Global strategy and targets for TB prevention, care and control after 2015 «The END TB Strategy» (adopted at the 67th World Health Assembly in 2014) emphasizes that HIV-associated TB is one of the main reasons may hinder the achievement of the set goals and objectives of the fight against TB in conditions of high prevalence of HIV infection [1]. Despite the fact that, according to WHO estimates [2], Ukraine is not included in the list of high-burden country for TB/HIV co-infection being used by WHO during the period 2016-2020, the epidemic situation with TB associated with HIV infection in Ukraine is challenging. According to WHO estimates for the European Region in 2017, Ukraine had the highest proportion of active tuberculosis cases co-infected with HIV – 21.6%, with an average of 12% in the Region, and the absolute number of TB/HIV co-infection cases in Ukraine was estimated at the level of 8,000 [3]. Considering the above, the investigation of national trends in the epidemiological situation, the structure and the regional features of TB/HIV co-infection incidence becomes especially relevant.

The aim

Therefore, the main objectives of this study were to: carry out a comprehensive analysis of the epidemical situation regarding TB/HIV co-infection in Ukraine for the main epidemiological and clinical characteristics, identify the epidemiological features of the incidence of TB/HIV co-infection compared to incidence of active TB disease without HIV-infection in dynamics based on data from national TB surveillance for 10 years period.

Materials and methods

The retrospective epidemiological study was based on the data from national reporting forms “Annual Active TB Report”, which was being collected by the Center for Health Statistics of the Ministry of Health of Ukraine for period 2008-2017.

In the first stage of our study was analyzed the trend of incidence of newly diagnosed active TB cases under the selected demographic characteristics (age, gender and place of residence) for the 2008-2017 period. The analysis was carried out separately for incidence of active TB combining with HIV and incidence of TB without HIV, rate of increase calculated for each indicator. The number of patients who have TB without HIV was determined as the difference between the total number of registered patients and patients who had reported as non-HIV-infected TB patients. The TB/HIV comorbidity rate, was expressed as a percentage, was defined as the prevalence of HIV-infection among patients with the newly diagnosed active TB.

The second phase of the study analyzed the structure of the incidence of active TB by the main clinical forms and the type of TB. For each of these groups, the comorbidity rate of TB/HIV was also determined.

To avoid shifting of the statistical indicators in the dynamics associated with the change in the population of Ukraine after the annexation of the Crimea and Sevastopol city, calculations from 2008 were carried out without these regions data. In the calculation of indicators from 2015, for the Donetsk and Luhansk oblasts, the population of only the controlled territory was taken into account. For the calculation of the incidence rate, information was used on the average annual population (person) and the structure of the population of Ukraine from the data bank “Statistics of the Population of Ukraine”, which is published on the website of the State Statistics Service of Ukraine [4], with a population recount for the Donetsk and Luhansk oblasts from 2015 year according to the operational data of the Center of Medical Statistics of the Ministry of Health of Ukraine. The regions of Ukraine were grouped according to the territorial principle (south, north, west, east and center), which corresponds to the distribution presented in the HIV infectious bulletin for 2017 [5].

The statistical analysis of the research materials was performed using the Microsoft Excel 2010 statistical analysis package.

The study was conducted on generalized secondary data using epidemiological and statistical methods, so the conclusion of the ethics commission was not provided.

Review

During the study period the incidence of newly diagnosed active TB decreased to 26.6% from 77.7 per 100,000 population (33,966 persons) in 2008 to 57.0 per 100,000 population (21,995 persons) in 2017. These changes occurred due to 36.5% decrease in the incidence of active TB without HIV-infection. At the same time, the incidence of TB/HIV co-infection has increased by 89.4%. As a result, the comorbidity rate of TB/HIV increased by 2.8 times from 7.9% to 20.3%.

Table I presents the incidence of TB and of TB/HIV co-infection and comorbidity rate of TB/HIV for 2008 and 2017 for selected demographic characteristics. During the study period, the incidence of co-infection of TB/HIV has increased in all regions. If, in 2008, the regional rate of TB/HIV co-infection varied from 1.3 per 100,000 population in the western region of Ukraine to 15.3 per 100,000 population in the south, then in 2017 the lower range of the indicator increased to 4.1 per 100,000 population, and the upper range to 29.8 per 100,000 population. Although, for 10 years the highest growth rate of incidence of TB/HIV co-infection were in the western region, in the southern region has had the highest rates of incidence of co-infection and comorbidity TB/HIV.

In addition, a regional redistribution occurred of patients with newly diagnosed TB. In 2008, in the eastern region of Ukraine lived 47.8% of all registered TB/HIV co-infected patients and 37.9% of all newly diagnosed TB patients without HIV. But in 2017 the southern region went up in the first place by the number of TB/HIV co-infected patients (30.6% all registered patients) and the western region has the first place by the number of patients with the newly diagnosed TB without HIV (27.2% all registered patients).

Rates of TB in combination with HIV and without it have a different focus for the rural and urban population. In 2008 and 2017 the rural population was characterized by higher rates of incidence of active TB without HIV infection than for urban population. Among urban residents, conversely, inherent higher incidence of TB/HIV co-infection and TB/HIV comorbidity rates. At the same time, the growth rate of the incidence of TB/HIV in rural areas is 3.1 times higher than the growth rate of incidence in urban areas.

Over 10 years of co-infected TB/HIV gradually increased the proportion of women from 31.8% in 2008 to 36.2% in 2017. As a result, the ratio of men and women TB/HIV co-infected in Ukraine decreased from 2.1 to 1.8, respectively, in 2017 the rates of comorbidity TB/HIV in women with active TB by 21% over the rate of comorbidity in men.

In 2017 the proportion of adolescents aged 15-24 years among patients co-infected TB/HIV decreased to 2.0% (from 6% in 2008) and the proportion of patients aged 45-64 years conversely increased to 24.1 % (from 11% in 2008). However, the incidence of TB/HIV co-infection and TB/HIV comorbidity rate for 10 years remains the highest in the group of patients aged 25-44 years.

The structure of active TB incidence by type of TB process and the main clinical forms and its changing dynamics presented in Table II. Against the background of a decrease in the total incidence of active TB in 10 years, the proportion of patients with relapse TB increased, as among TB patients without HIV to 18.3%, and among those with TB/HIV co-infection to 21.0%. And although proportion of extrapulmonary TB patients among co-infected TB/HIV almost unchanged rate of comorbidity TB/HIV in this group increased by 2.7 times among patients with newly diagnosed TB and 6.5 among patients with relapse TB. The highest rate of comorbidity of TB/HIV in 2017 was among the patients with miliary TB – 71.6%.

Discussion

The results of our comprehensive research on the epidemic situation of TB in Ukraine showed that during 2008-2017 years, reducing the overall incidence of active TB occurred against a background of growing incidence of co-infection of TB/HIV, indicating the growing influence of HIV on TB epidemic.

Regional changes in the epidemiology of co-infection of TB/HIV on the one hand reflects the impact of military operations in the Donetsk and Luhansk oblasts, causing a redistribution of patients from the eastern regions to the others, and the second side – the deterioration of the epidemiological situation of HIV infection in the western region, where 2017 the proportion of persons aged 15-24 among newly diagnosed with HIV infection was the largest [5]. That is the percentage of HIV-infected young people between the ages of 15-24 new cases of HIV characterizes the spread of new infections. [6]

Epidemic of co-infection of TB/HIV shifted to older age groups 45-64 years repeating trends inherent in the HIV epidemic. Such changes in the age structure of TB/HIV co-infected patients indicate that the “aging” of the HIV epidemic is also confirming the tendency for HIV-infected individuals to be identified at later stages of the disease when TB becomes a major opportunistic infection [5].

The impact of HIV on TB epidemic in Ukraine is also evident higher rate of comorbidity TB/HIV among women and urban residents [7].

Clinical characteristics of TB/HIV co-infection cases in Ukraine, obtained according to the routine monitoring of TB, are consistent with the results of individual studies on TB in HIV-infected people [8-10], which confirms a higher proportion of extrapulmonary TB and relapse TB in TB/HIV co-infection patients. However, routine epidemiological monitoring does not allow to monitor the number of combined forms of TB (pulmonary and extrapulmonary TB together), which according to individual studies range from 18.7% to 61.8% of patients [8-9].

However, there is some limitation of our study that deserves discussion. Since the data is taken from generalized reporting forms, it is not known whether all patients with active TB have a precisely defined HIV status. According to the information of the Public Health Center of the Ministry of Health of Ukraine in 2017, the coverage of HIV testing for TB patients on average in Ukraine was 91.4%. [11].

Conclusions

TB/HIV co-infection as a part of the overall TB epidemic has a significant impact on the rate of decline in the overall incidence of TB in Ukraine and slows them down. To accelerate the rate of TB morbidity and achieve the target intermediate indicators of the global «The END TB Strategy» by 2025 (50% reduction in TB incidence compared to 2015), this means for Ukraine – up to 35.2 per 100,000 population, it is necessary first of all, providing comprehensive access to existing means of assistance and social protection and improving the social-economic development.

Thus, the revealed tendency to increase the rate of TB/HIV comorbidity necessitates the revision of organizational approaches to helping TB/HIV co-infected patients to increase access to prevention, early detection and proper treatment.

References

1. World Health Organization. The end TB Strategy. Global strategy and targets for tuberculosis prevention, care and control after 2015. Geneva: WHO. 2014. resolution WHA 67.1. URL: https://www.who.int/tb/strategy/End_TB_Strategy.pdf?ua=1

2. World Health Organization, et al. Global tuberculosis report 2018. World Health Organization, 2018. URL: https://apps.who.int/iris/handle/10665/274453

3. World Health Organization, et al. Tuberculosis surveillance and monitoring in Europe 2019: 2017 data. 2019. URL: http://www.who.int/iris/handle/10665/311349

4. State Statistics Service of Ukraine. Databank of State Statistics Service of Ukraine. URL: http://database.ukrcensus.gov.ua/MULT/Dialog/statfile_c.asp

5. Kurpita V. et al. VIL-infektsiia v Ukraini. Informatsiinyi biuleten No 49 [HIV infection in Ukraine. News bulletin No 49]. Kyiv: Public Health Center; 2018, 121 p. URL: https://phc.org.ua/sites/default/files/uploads/documents/files/40fc8f955d5286e602e5ce1e8fac0fe2.pdf (UA)

6. Joint United Nations Programme on HIV/AIDS, et al. Monitoring the declaration of commitment on HIV/AIDS: guidelines on construction of core indicators. UNAIDS, 2003.

7. Horton KC, MacPherson P, Houben RMGJ, White RG, Corbett EL (2016) Sex Differences in Tuberculosis Burden and Notifications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis. PLoS Med 13(9): e1002119. https://doi.org/10.1371/journal.pmed.1002119.

8. Melnyk V. P., Khursa T. H., Yakymova Ya. O. et al. Analiz osoblyvostei vyiavlennia, diahnostyky ta perebihu tuberkulozu u khvorykh na ko-infektsiiu tuberkuloz/VIL [Analysis of peculiarities of identification, diagnostics and course of tuberculosis in patients with tuberculosis/HIV co-infection]. Zaporozhye medical journal. 2017; Vol. 19, 5(104):604-608. DOI: 10.14739/2310-1210. 2017.5.110163 (UA)

9. Nikolaieva O. D. Osoblyvosti diahnostyky pozalehenevykh form tuberkulozu u VIL-infikovanykh [Peculiarity diagnosis of tuberculosis in HIV-infected]. Tuberculosis, lung diseases, HIV infection. 2018; 2(33):33-37. DOI: http://doi.org/10.30978/TB2018-2-33 (UA)

10. Pustovyi Yu. H., Baranova V. V., Roienko H. M., et al. Analiz rozpovsiudzhenosti tuberkulozu u VIL-infikovanykh osib ta efektyvnist yikh likuvannia u Luhanskyi oblasti [Analysis the prevalence of TB infection at the combined TB and HIV infection, and the effectiveness of treatment of these patients]. Ukrainian medical almanac. 2013; Vol. 16, 1:93-95. (UA)

11. Kurpita V. et al. Tuberkuloz v Ukraini. Analitychno-statystychnyi dovidnyk. [Tuberculosis in Ukraine. Analytical and statistical guide]. Kyiv: Public Health Center; 2018, 105 p. URL: http://aph.org.ua/wp-content/uploads/2018/09/proekt-dovidnika-TB-2018.pdf (UA)

The article is written in the framework of the implementation of the research work of the Department of Medical Statistics of the NMAPE named after P. L. Shupyk “Information and Analytical Support for the Modernization of the Health Care System” No. of the State Registration Number 0113U002210, the term of implementation: 2013-2020.

Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Tetiana V. Stepanova

Department of Medical Statistics,

Shupyk National Medical Academy of Postgraduate Education

9 Dorohozhytska street, 04112, Kyiv, Ukraine

tel: +380662279442

e-mail: tetstepanova@gmail.com

Received: 28.03.2019

Accepted: 01.05.2019

Table I. Incidence of newly diagnosed active tuberculosis with and without HIV (per 100,000 population), comorbidity rate of TB/HIV (%), demographic characteristics, Ukraine, 2008 and 2017

Characteristics

2008

2017

Rate of increase/decrease 2017/2008

TB/HIV

Non-HIV TB

Comorbidity TB/HIV

TB/HIV

Non-HIV TB

Comorbidity TB/HIV

TB/HIV

Non-HIV TB

Number
(per 100,000)

%

Number
(per 100,000)

%

%

Overall

2 668
(6,1)

3 1298 (71,6)

7,9

4 458
(11,6)

17 537 (45,5)

20,3

+89,4

-36,5

Geographical region

 

Southern

718
(15,3)

3 961 (84,6)

15,3

1 363
(29,8)

2 654 (58,1)

33,9

+94,6

-31,3

Northern

345
(4,3)

4 917 (61,1)

6,6

985
(12,3)

3 389 (42,5)

22,5

+187,9

-30,5

Central

197
(3,6)

3 650 (66,3)

5,1

447
(8,7)

2 213 (42,8)

16,8

+141,7

-35,4

East

1 274
(8,6)

11 864 (80,0)

9,7

1 234
(12,0)

4 504 (43,8)

21,5

+39,6

-45,3

West

134
(1,3)

6 906 (64,7)

1,9

429
(4,1)

4 777 (45,2)

8,2

+223,2

-30,2

Types of settlements

 

Urban

2 298
(7,7)

20 362 (68,3)

10,1

3 370
(13,1)

10 588 (41,3)

24,1

+70,5

-39,6

Rural

370
(2,7)

10 936 (78,4)

3,3

1 088
(8,4)

6 949 (53,7)

13,5

+216,7

-31,6

Gender

 

Male

1 820
(9,0)

22 215 (110,1)

7,6

2 843
(15,9)

12 126 (67,7)

19

+75,8

-38,6

Female

848
(3,6)

9 083 (38,5)

8,5

1615
(7,8)

5 411 (26,2)

23

+117,3

-32

Age (years)

 

0-14

29
(0,5)

516
(8,4)

5,3

44
(0,7)

553
(9,1)

7,4

+53,7

8,6

15-24

159
(2,4)

4 028 (60,9)

3,8

88
(2,2)

1 361 (34,5)

6,1

-7,2

-43,4

25-44

2 172
(17,3)

14 024 (111,6)

13,4

3 215
(27,1)

7 878 (66,3)

29

+56,6

-40,6

45-64

308
(2,7)

9 967 (87,9)

3

1 076
(10,3)

5 796 (55,2)

15,7

+277,5

-37,2

>65

2 763 (39,2)

35
(0,6)

1 949 (31,6)

1,8

-19,4

Table II. Structure of the incidence of active tuberculosis with and without HIV, comorbidity rate of TB/HIV (%), clinical characteristics, Ukraine, 2008 and 2017

Characteristics

2008

2017

TB/HIV

Non-HIV
TB

Comorbidity TB/HIV

TB/HIV

Non-HIV
TB

Comorbidity TB/HIV

Number (%)

%

Number (%)

%

The type of tuberculosis process

newly diagnosed tuberculosis
– all forms А15-А19

2 668 (90,0)

31 298 (86,1)

7,9

4 458 (79,0)

17 537 (81,7)

20,3

relapse tuberculosis
– all forms А15-А19

298 (10,0)

5035 (13,9)

5,6

1 188 (21,0)

3 938 (18,3)

23,2

Clinical forms of active tuberculosis

pulmonary tuberculosis
А15.0-3, А16.0-2, А19.-part.

2 217 (83,1)

28 105 (89,8)

7,3

3 601 (80,8)

15 959 (91,0)

18,4

extrapulmonary tuberculosis
A15.4-9, А16.3-9, А17, А18, А19.
-part.

402 (15,1)

3067 (9,8)

11,6

688 (15,4)

1 511 (8,6)

31,3

miliary tuberculosis
А19 (except А19.- part.)

49 (1,8)

126 (0,4)

28,0

169 (3,8)

67 (0,4)

71,6

Clinical forms relapse tuberculosis

pulmonary tuberculosis
А15.0-3, А16.0-2, А19.-part.

270 (90,6)

4 771 (94,8)

5,4

1 022 (86,0)

3 796 (96,4)

21,2

other forms relapse TB
А15-А18, А19.-part.

28 (9,4)

264 (5,2)

9,6

166 (14,0)

142 (3,6)

53,9