1. PREVALENCE OF MDR-TB AMONGST PATIENTS WITH HIV AND TB CO- INFECTION SEEN AT THE DOTS CLINIC OF N.I.M.R., LAGOS, NIGERIA. Enya V.N.V, Onubogu C.C., Wahab M.O., Efere L.O., Motayo B.O., Nwadike P.O., Onyejepu N., Nwokoye N.N., Kunle-ope C.N., Raheem T.Y., Igbasi U.T., Tochukwu C.E., Ejezie C.E., Omoloye R.M., and Idigbe E.O. Nigerian Institute of Medical Research (NIMR) Lagos, Nigeria.

2. OUTLINE  Background  Aim of study  Objectives  Methodology  Results  Discussion  Conclusions  Recommendations

3. BACKGROUND  The global HIV infection epidemic has caused explosive increases in MDR-TB{ Mycobacterium tuberculosis strain developing resistant to both RIF and INH} (Wells et al, 2007)  Estimated MDR-TB prevalence in Nigeria is 1.9% among new cases and 9.3% among previously treated cases (WHO, 2008)  Nigeria has about 21% of reported HIV-associated TB cases worldwide (WHO, 2008)  Key element in the management of MDR-TB is early diagnosis and institution of appropriate treatment regimen (O’Riordan et al, 2008)  WHO recommends the use of Line Probe Assays (LPAs) for rapid screening of MDR-TB in low and medium income settings (WHO, 2008)  Hain Line-Probe Assay (GenoType®MTBDRplus) showed high sensitivity and specificity in detection of MDR-TB among HIV-TB co-infected Nigerians (Onubogu et al,2011 in press)

4. Aim of study  To determine the prevalence of MDR-TB among HIV-TB co- infected patients using Hain Line-Probe Assay (GenoType®MTBDRplus)

5. OBJECTIVES OF THE STUDY  To diagnose MTB-Complex directly from Sputum Smear-Positive specimens of HIV- TB co-infected Nigerians  To determine prevalence of rifampicin mono- resistant and isonoazid mono- resistant cases among HIV- TB co- infected Nigerians  To determine the prevalence of MDR-TB among HIV- TB co-infected Nigerians

6. METHODOLOGY  Study Site:  DOTS Clinic of NIMR, Lagos, Nigeria  Study type: Cross sectional  Study Period: January to November 2009  Study Population:  169 HIV Patients who were diagnosed to have TB  Inclusion Criteria:  Consenting patients  Ability to produce 3 sputum samples  Patients who were sputum smear- positive

7. Methodology….2  Exclusion criteria:  Patients who were HIV negative  Patients who were sputum smear-negative for TB  Ethical approval was obtained from NIMR Institutional Review Board  Laboratory diagnosis:  Sputum Specimens were examined for AFB using Ziel-Neelsen Method (NTBLCP)  The sputum samples were graded by direct smear microscopy ( IUATLD)  Rapid Drug Resistance Testing for RIF mono -resistance, INH mono- resistance and MDR-TB was performed according to the manufacturer’s instructions (Hain Lifescience Genotype®MTBDR plus TM version1.0 product insert)  Data analysis:  SPSS version 15.0 statistical software was used  Results were considered significant at P< 0.05

8. RESULTS  A total of 169 persons made up of 72(42.6%) females and 97 males were recruited into the study. They have mean age of 34±9.99 years  165 (97.6%) were positive for MTB-Complex (HIV-TB co-infected) and 4 (2.4%) were negative by GenoType®MTBDRplus  New cases: patients who have not received anti-TB treatment for up to 1 month were 126 (76.4%)  Old cases: patients who have received anti TB treatment for >1 month were 39 (23.6%)  Sensitive to both RIF and INH 121 (73.3%)  Resistance to one or more dugs was 44 (26.7%)  RIF mono -resistance was 29 (17.5%)  INH mono -resistance was 6 (3.6%)  MDR-TB was 9 (5.5%)

9. FIG.1: AGE DISTRIBUTION OF HIV-TB CO-INFECTED PATIENTS

10. FIG.2 : SEX DISTRIBUTION OF HIV-TB CO-INFECTED PATIENTS

11. TABLE 1: DRUG RESISTANCE AMONG HIV-TB CO-INFECTED PATIENTS M D R - T B Y N RIF MONO-RES Y N INH MONO-RES Y N Age (yrs) 10-20 21-30 31-40 41-50 50+ 0 (0.0%) 9 (100%) 4 (6.8%) 55 (93.2%) 2(3.2%) 60(96.8%) 2(8.0%) 23(92.0%) 1(10.0%) 9(90.0%) P = 0.925 1(11.1%) 8(88.9%) 7(11.9%) 52(88.1%) 11 (17.7%) 51(82.3%) 9(36.0%) 16(64.0%) 1(10.0%) 9(90.0%) P = 0.355 0 (0.0%) 9(100) 2 (3.4%) 57(96.6%) 3(4.8%) 59(95.2%) 1(4.0%) 24(96.0%) 0(0.0%) 10(100%) P = 0.978 Sex: Male Female 7(7.4%) 87(92.6%) 2(2.8%) 69(97.2%) P = 0.322 18 (19.1%) 76(80.9%) 11(15.5%) 60(84.5%) P= 0.640 2(2.1%) 92(97.9%) 4(5.6%) 67(94.4%) P= 0.379 Category : Old New 2( 5.1%) 37(94.9%) 7(5.6%) 119 (94.4%) P= 0.538 10 (25.6%) 29(74.4%) 19(15.1%) 107(84.9%) P =0.109 2(5.1%) 37(94.9%) 4(3.2%) 122(96.8%) P=0.459

12. DISCUSSION  We found 26.7% of HIV-TB co-infected patients resistant to one or more anti-TB drugs, which is comparable to 26.9% reported in Cameroun by Kuaban et al, 2000  Our result showed MDR-TB prevalence of 5.5% among HIV-TB co-infected Nigerians. This is lower than 14.2% reported in India by Rajasekaran et al,2009  Vanacore et al,2004 from Italy reported prevalence rates of drug resistance and MDR as 14.5% and 2.6% respectively among new cases; but we recorded higher values of 18.3% and 5.6% respectively  Our findings showed drug resistance and MDR of 30.8% and 5.1% respectively for previously treated patients but Vanacore et al, 2004 in Italy found 30.4% and 12.5% respectively

13. CONCLUSIONS/ RECOMMENDATIONS  The prevalence of MDR-TB among HIV and TB co- infected patients is documented. This strongly highlights the need for the national strategies for surveillance and effective clinical management of MDR-TB cases in Nigeria  Although we recorded the prevalence of MDR-TB as 5.5% among HIV-TB co-infected Nigerians, 73.3% of them were sensitive to both RIF and INH, the two most import anti-TB first line drugs  GenoType®MTBDRplus was able detect MDR-TB in HIV-TB co-infected Nigerians which is ordinarily difficult and should be used for rapid screening of MDR- TB in Nigeria to achieve early detection and treatment with appropriate drug regimen

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