Gebreegziabher et al.

BMC Infectious Diseases (2024) 24:499 BMC Infectious Diseases

https://doi.org/10.1186/s12879-024-09403-z

RESEARCH Open Access

Tuberculosis preventive treatment uptake

among people living with HIV during
COVID-19 period in Addis Ababa, Ethiopia:
a retrospective data review
Senedu Bekele Gebreegziabher1*, Akililu Alemu Ashuro1, Tsegaye Hailu Kumssa1, Melese Yeshambaw Teferi1,
Endawoke Amsalu Alemayue1, Daniel Gemechu Datiko2, Solomon Abebe Yimer3,4 and Mulatu Biru Shagre5

Abstract
Background Screening for tuberculosis (TB) and providing TB preventive treatment (TPT) along with antiretroviral
therapy is key components of human immune deficiency virus (HIV) care. The uptake of TPT during the coronavirus
disease 2019 (COVID-19) period has not been adequately assessed in Addis Ababa City Administration. This study
aimed at assessing TPT uptake status among People living with HIV (PLHIV) newly initiated on antiretroviral therapy
during the COVID-19 period at all public hospitals of Addis Ababa City Administration, Ethiopia.
Methods A retrospective data review was conducted from April-July 2022. Routine District Health Information
System 2 database was reviewed for the period from April 2020-March 2022. Proportion and mean with standard
deviation were computed. Logistic regression analysis was conducted to assess factors associated with TPT
completion. A p-value of < 0.05 was considered statistically significant.
Results A total of 1,069 PLHIV, aged 18 years and above were newly initiated on antiretroviral therapy, and of these
1,059 (99.1%) underwent screening for TB symptoms. Nine hundred twelve (86.1%) were negative for TB symptoms.
Overall, 78.8% (719) of cases who were negative for TB symptoms were initiated on TPT, and of these 70.5% and 22.8%
were completed and discontinued TPT, respectively. Of 719 cases who were initiated on TPT, 334 (46.5%) and 385
(53.5%) were initiated on isoniazid plus rifapentine weekly for three months and Isoniazid preventive therapy daily for
six months, respectively. PLHIV who were initiated on isoniazid plus rifapentine weekly for three months were more
likely to complete TPT (adjusted odds ratio [AOR],1.68; 95% confidence interval [CI], 1.01, 2.79) compared to those who
were initiated on Isoniazid preventive therapy daily for six months.
Conclusion While the proportion of PLHIV screened for TB was high, TPT uptake was low and far below the national
target of achieving 90% TPT coverage. Overall a considerable proportion of cases discontinued TPT in this study.
Further strengthening of the programmatic management of latent TB infection among PLHIV is needed. Therefore,

*Correspondence:
Senedu Bekele Gebreegziabher
senedu.bekele@ahri.gov.et
Full list of author information is available at the end of the article

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Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 2 of 11

efforts should be made by the Addis Ababa City Administration Health Bureau authorities and program managers to
strengthen the initiation and completion of TPT among PLHIV in public hospitals.
Keywords Tuberculosis preventive treatment, COVID-19, Uptake status, People living with HIV, Addis Ababa

Background whom 5.2% were co-infected with HIV [11]. Consid-

A quarter of the world’s population is infected with Myco- ering the higher risk of progression to active TB and
bacterium tuberculosis (Mtb), a bacterium that causes the deadly consequence of developing the disease,
TB [1]. Most people infected with Mtb are asymptom- Ethiopia has been implementing Isoniazid preventive
atic and classified as having latent TB infection (LTBI), therapy (IPT) provision for PLHIV since 2007 [12].
which is the presence of immune responses to previously The country adopted the WHO updated and consoli-
acquired Mtb infection without clinical evidence of active dated guidelines to access shorter and safer TPT, and
TB [2, 3]. since 2020, the country has been implementing isonia-
About 5–10% of people with LTBI can develop active zid plus rifapentine (HP) regimen provision for PLHIV
TB disease during their life time [4]. The risk of pro- [13]. Furthermore, Ethiopia has continued its commit-
gressing from latent to active TB, however, can be higher ment to achieve the United Nations High-Level Meet-
among people with compromised immunity due to such ing (UNHLM) TPT target [14]. Accordingly, eligible
as HIV infection, therapy that suppresses immunity, and individuals for TPT are being identified based on clini-
among young age group [5]. For instance, the risk of cal symptom-based TB screening (clinical algorithm).
developing active TB is about 15–22 times higher among The current TPT options that Ethiopia uses in the pro-
PLHIV compared to people without HIV [2, 6], and the grammatic management of LTBI for PLHIV include
annual risk of developing active TB among individu- isoniazid plus rifapentine (3HP) weekly for three
als with untreated HIV is 3–16%, which is nearly the life months and daily IPT for Six months [13, 14]. In Ethi-
time risk of TB among the general population. PLHIV opia, uptake of TPT among PLHIV was 47% in 2020.
who develop TB have also a high risk of mortality com- This achievement was lower compared to the national
pared to people with TB alone [2]. target of achieving 90% TPT uptake for the year [15].
The World Health Organization (WHO) has devel- In 2021, TPT uptake among PLHIV increased to 64%
oped a guideline for the programmatic management of at national level [16]. However, although there has
LTBI in PLHIV to prevent TB diseases. The guideline been a progress, the achievement shortfalls compared
states that adults and adolescents living with HIV should to the national target the country has set to achieve.
be screened for TB according to a clinical algorithm, Evidence showed a detrimental effect of COVID-19
and for those who do not report any of the symptoms of pandemic on TB prevention and control activities [17,
TB, including current cough, fever, weight loss or night 18]. Ethiopia reported the first confirmed COVID-
sweats, TPT should be offered, regardless of antiretro- 19 case on 13th March 2020 [19]. TB prevention and
viral treatment (ART) status [3]. Screening for TB and control services are part of essential health services
treating LTBI along with the commencement of ART is in Ethiopia [20], and the Ministry of Health-Ethiopia
the key components of HIV care [2].These interventions set a guide for maintaining essential health services
are imperative to reduce TB incidence among PLHIV [7]. during the COVID-19 pandemic [21]. In Ethiopia,
TPT consists of a course of one or more anti-tubercu- some studies assessed the impact of COVID-19 pan-
lous drugs to treat persons with LTBI who are at high risk demic on TB control activities [22–24]. A study con-
of progressing to active TB disease [5]. Preventive treat- ducted in Addis Ababa reported a decline of 44.7%
ment reduces the risk of progression to active TB disease IPT uptake among children during the COVID-19
for individuals with LTBI, and also averts future Mtb period [25]. In a pre-COVID-19 era, reports of few
transmission in the communities [8]. TPT is effective and studies from Northeast Ethiopia, Northern-Ethiopia,
safe for treatment of LTBI among PLHIV [9]. The efficacy and Southwest Ethiopia showed IPT uptake of 55%,
of currently available TPT ranges from 60 to 90% [3]. 62%, and 66.5% among PLHIV, respectively [26–28].
Although TPT is essential and cost-effective component A former study conducted at public health facilities in
of HIV care, and has been recommended as a standard of Addis Ababa showed that 28.7% of PLHIV had been
care for over a decade, it has remained highly underuti- treated with IPT [29]. Nonetheless, the uptake status
lized [10]. of TPT among PLHIV during the COVID-19 period
Ethiopia is one of the high TB and TB/HIV burden has not been adequately assessed generally in Ethio-
countries in the world [1]. The country notified a total pia and particularly in Addis Ababa; the capital city of
of 104, 606 new TB cases in 2021. Eighty two percent Ethiopia comprised more than 50% of total confirmed
of the total new TB cases knew their HIV status, of COVID-19 cases within the country [30]. Adequate
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 3 of 11

information about LTBI management among PLHIV is TPT status). The overall activities and entire process
important to identify potential areas of improvement of data collection were led by investigators.
and suggest strategies that will improve program per-
formance. Thus, this study aimed at assessing the TPT Data analysis
uptake status among PLHIV who were newly initiated The collected routine DHIS 2 data were cleaned, checked
on ART during the first two years of the COVID-19 for correctness and consistency, and finally entered into
period (April 2020 to March 2022) at public hospitals a Redcap database, and the cleaned data were exported
of Addis Ababa City Administration, Ethiopia. into Stata version 17 statistical software packages for sta-
tistical analysis. Descriptive statistics such as frequency,
Methods proportion, and mean with standard deviation (SD) were
Study design and setting computed. To assess changes in TB prevention service
Health facility based retrospective data review was performance, we compared the achievement for each of
conducted at public hospitals of Addis Ababa City the selected service performance indicators, including
Administration to assess the level of TPT uptake number of cases who were newly initiated on ART, num-
among PLHIV newly initiated on ART during COVID- ber of cases who were screened for TB symptoms, num-
19 period. Addis Ababa is the capital city of Ethiopia, ber of cases screened negative for TB symptoms, number
with an estimated population of over 4.7 million in of cases who were screened negative for TB symptoms
2021 [31]. Six government hospitals and 100 public and started on TPT, number of cases who completed
health centers were providing health services includ- TPT, number of cases who discontinued TPT, and num-
ing TB and HIV health services (HIV testing, preven- ber of cases who were screened negative for TB symp-
tion, treatment and care services) in the city during toms but not started on TPT between the second year
the study period [32]. At health facilities, TB screen- (April 2021-March 2022) and the first year (April 2020-
ing for adults living with HIV is being performed using March 2021) on a quarterly basis during the COVID-19
a clinical algorithm. Accordingly, for those who do period. We used the reported frequency of each quarter
not report any one symptoms suggestive of active TB in the first year during COVID-19 period as a baseline
disease, including current cough, any fever, uninten- to compare with reported frequency of each quarter (the
tional weight loss, and any night sweats, TPT should corresponding quarter) in the second year during the
be initiated regardless of CD4 count and ART status. COVID-19 period. The relative percentage changes of
However, for those cases who report any one of the TB the services performance between corresponding quar-
symptoms, further investigations to diagnose TB and ters across the two years period were computed. Logistic
other diseases are recommended [13, 14]. Addis Ababa regression analysis was conducted to assess the factors
City Administration Health Bureau is responsible for associated with completion of TPT. Variables with p-val-
the health-care administration in the city. ues of < 0.25 in the bivariate analysis were included
in multivariate analysis. Crude odds ratio (COR) and
Data sources, data collection and management adjusted odds ratio (AOR) with 95% confidence interval
We retrospectively reviewed the Routine District (CI) were used to assess the strengths of the association
Health Information System 2 (DHIS 2) ART service between variables and TPT completion. A p-value of
database at all public hospitals of Addis Ababa City < 0.05 was considered statistically significant.
Administration to assess the level of TPT uptake
among adults PLHIV, aged 18 years and above who Ethical consideration
were newly initiated on ART for the period starting The Armauer Hansen Research Institute (AHRI)/All
from April 2020 to March 2022 (the first two years of Africa Leprosy Rehabilitation and Training Center
the COVID-19 period) and who were screened nega- (ALERT) ethics review committee approved this study
tive for TB symptoms. PLHIV, aged less than 18 years and gave waver of informed consent (PO/07/22). In addi-
who were newly initiated on ART during the same tion, permission to review the required routine DHIS 2
period were excluded. A structured data capturing ART service database was obtained from each hospital
template tailored from DHIS 2 was prepared and used authority. The reviewed data used in this study were col-
to collect data related to TB screening and TPT uptake. lected anonymously.
Four trained data collectors reviewed and collected
the data from April to July 2022. The data collected Results
included the demographic and clinical characteristics The routine DHIS 2 reports of 1,069 PLHIV who were
of the cases (Age, sex, functional status, WHO clini- newly initiated on ART during the period from April
cal stage, TB screening status, TB screening result, and 2020 to March 2022 at six public hospitals of Addis
Ababa City Administration were reviewed. Of these
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 4 of 11

Table 1 Demographic and clinical characteristics of PLHIV, April 56.5% were female and 42.8% were male. The mean age
2020 to March 2022, Addis Ababa, Ethiopia. N = 1069 of the cases was 38.5 years (SD: ±11.2 years), and 34.9% of
Variables Frequency Percent (%) the cases were categorized in the age group 35–44 years.
Age group (years)
About 75% of cases had working functional status, and
18–24 98 9.2
56% were classified in WHO clinical stage T1 (Table 1).
25–34 292 27.3
35–44 373 34.9
TPT among PLHIV newly initiated on ART during COVID-19
45–54 203 18.9
period
55–64 77 7.2
Of 1,069 PLHIV who were newly initiated on ART in
65+ 24 2.2
the period April 2020-March 2022, 99.1% were screened
Gender
for TB symptoms, and of these 912 (86.1%) were nega-
Male 457 42.8
tive for TB symptoms. Of 912 cases who were screened
Female 604 56.5
Functional status
negative for TB symptoms, 78.8% were initiated on TPT
Ambulatory 122 11.4
and 21.2% were not initiated treatment during the period.
Bed ridden 62 5.8 Of those who started TPT, 70.5% completed treatment,
Working 802 75.0 22.8% discontinued TPT, and 6.7% of cases were taking
WHO clinical stage TPT. Of the total 719 cases who were initiated on TPT,
T1 599 56.0 46.5% and 53.5% were started on 3HP and IPT, respec-
T2 80 7.5 tively. Of 334 cases who started 3HP, 76.6% completed
T3 101 9.5 treatment, 16.5% discontinued, and 6.9% were taking
T4 132 12.4 their treatment. Of 385 cases who were initiated on IPT,
This table shows the demographic and clinical characteristics of PLHIV who 65.2% completed treatment, 28.3% discontinued, and
were newly initiated on ART from April 2020 to March 2022 (COVID-19 period), 6.5% cases were taking IPT during the period (Table 2).
at public hospitals of Addis Ababa City Administration, Ethiopia
Note: For about 2 (0.2%), 8 (0.7%), 83 (7.8%), and 157 (14.6%) of the cases age,
type of gender, functional status, and the WHO clinical stage were not recorded, Trends in TPT across quarters during COVID-19 period
respectively Program performance indicators trend analysis across
quarters for the period April 2021-March 2022 compared
Table 2 TPT uptake among PLHIV, Addis Ababa, Ethiopia, April to April 2020-March 2021 showed that ART initiation
2020 to March 2022, N = 1069 increased by 15.4% in April-June 2021,1.6% in July-Sep-
Variables Frequency Percent (%) tember 2021, 1.4% in October-December 2021, and 5.3%
TB symptoms screening status in January-March 2022 compared to the same quarters
Screened for TB 1,059 99.1 performance during the first year of COVID-19 period.
Not recorded 10 0.9 Similarly, TB screening increased by 19.6% in April-June
TB symptoms screening results 2021, 2.4% in July-September 2021, and 4.5% in Janu-
Positive 147 13.9 ary-March 2022 compared to the same quarters perfor-
Negative 912 86.1 mance in the previous year. In April-June 2021 and in
TPT initiation
July-September 2021, TPT uptake increased by 28.8%
Started TPT 719 78.8
and 2.2%, respectively compared to the same period
Not started TPT 193 21.2
performance in the first year. For the period October-
TPT treatment outcome
December 2021, TPT uptake reduced by 2% compared to
Completed TPT 507 70.5
in October-December 2020 performance. In the periods
Discontinued TPT 164 22.8
April-June 2021 and July-September 2021, TPT comple-
Currently on TPT 48 6.7
tion increased by 38.9% and 7.1%, respectively compared
TPT initiation by regimen
to the same quarters performance in the first year dur-
Started 3HP 334 46.5%
ing COVID-19 period. TPT completion continuously
Started IPT 385 53.5%
TPT treatment outcome by regimen
decreased by 12.3% in October–December 2021 and
Completed 3HP 256 76.6%
58.8% in January-March 2022 compared to the same
Completed IPT 251 65.2%
quarters performance during the previous year. In the
Discontinued 3HP 55 16.5% period July-September 2021 the number of cases discon-
Discontinued IPT 109 28.3% tinued TPT decreased by 22.2% compared to the number
Currently on 3HP 23 6.9% in July-September 2020. The number of cases discontin-
Currently on IPT 25 6.5% ued TPT increased by 8.3% in October-December 2021
This table shows TPT uptake among PLHIV newly initiated on ART at public and 28.6% in January-March 2022 compared to the peri-
hospitals, Addis Ababa City Administration, Ethiopia, April 2020 to March 2022 ods October to December 2020 and January -March 2021
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 5 of 11

This table shows the TB prevention service performance across quarters for the period April 2021-March 2022 (the second year during COVID-19) compared to the corresponding baseline quarters for the period April 2020
– March 2021 (the first year during COVID-19) performance at public hospitals, Addis Ababa City Administration, Ethiopia╪ cases: PLHIV who were newly initiated on ART. ¶ Percentage change: Percentage change in the
number. Across quarters for the periods April- December

change

+ 28.6%
+ 18.2%
+ 4.5.%

-58.8%
+ 5.3%

+ 3.6%
cent-
2021, the numbers of PLHIV who were screened nega-

0.0%
Jan-Mar Jan-Mar Per-

age
tive for TB symptoms, but not initiated on TPT reduced
by 13% in April-June 2021, 24.1% in July-September,

2022
and 11.1% in October-December 2021 compared to the

139
138
115
89
28
27
26
same quarters number in the first year during COVID-19
period. In the last quarter of the study period (January-

2021

132
132
111
March 2022), the number of PLHIV who were not initi-

89
68
21
22
ated on TPT increased by 18.2% compared to the mean
number for the period in January-March 2021 (Table 3).

Percent-

change

-12.3%

-11.1%
+ 1.4%

+ 8.3%
-4.8%
-2.1%
0.0%
age
TPT among PLHIV newly initiated on ART across the six
hospitals

2021
The proportion of PLHIVwho were screened for TB and

Oct-Dec Oct-
Dec

146
144
119
96
64
26
24
initiated on TPT ranged from 94.6 − 99.7% and 76.2 − 82%
across the hospitals in the period April 2020-March 2022.

Number of cases across quarters for the period April 2020-March 2022

2020
Of all cases screened negative for TB symptoms, 22.9%,

144
144
125
98
73
24
27
23.8%, 23.5%, and 22.9% were not initiated on TPT at

Table 3 Comparison of service performance indicators across quarters from April 2020-March 2022, Addis Ababa, Ethiopia
Menelik Hospital, Ras Desta Hospital, Gandhi Hospital,

Jul-Sep Jul- Sep Percent-

change

-24.13%
-22.2%
+ 1.6%
+ 2.4%

+ 2.2%
+ 7.2%
and Yekatit 12 Hospital, respectively (Table 4).

-3.4%
age
Of the 334 cases who were initiated 3HP regimen, 148
(44.3%), 31 (9.3%), 100 (29.9%), 2 (0.5%), 24 (7%), and 29

2021
(9%) cases started at Zewditu Hospital, Trunesh Beijing

129
129
114
91
75
14
22
Hospital, Yekatit 12 Hospital, Gandhi Hospital, Menelik
Hospital, and Ras Desta Hospital, respectively. A total of
2020

385 cases including 71 (18.4%) at Zewditu Hospital, 74

127
126
118
89
70
18
29
(19.2%) at Trunesh Beijing Hospital, 28 (7.3%) at Yekatit
12 Hospital, 24 (6.2%) at Gandhi Hospital, 124 (32.2%)
centage
change

-13.04%
+ 15.4%
+ 19.6%
+ 18.8%
+ 28.8%
+ 38.9%
at Menelik Hospital, and 64 (16.6%) at Ras Desta Hos-
Apr-Jun ¶Per-

0.0%
pital were initiated on IPT. Of those who were initiated
3HP and IPT at Zewditu Hospital, 92.5% and 84.5% of
cases completed treatment, respectively. The propor-
2021

135
134
114
94
75
17
tion of cases who completed 3HP regimen at Menelik 20
Hospital and Ras Desta Hospital was 45.8% and 58.6%,
2020
Apr-

respectively. 17% of the cases at Gandi Hospital and

Jun

117
112
96
73
54
17
23

54.7% at Ras Desta Hospital completed IPT. 36% of cases

at Trunesh Beijing Hospital, 33.3% at Menelik Hospital,
Cases screened negative for TB symptoms but not initiated on TPT

and 31.0% at Ras Desta Hospital discontinued 3HP. 58%

Cases screened negative for TB symptoms and initiated on TPT

of cases discontinued IPT at Gandi Hospital during the

period April 2020-March 2022 (Fig. 1).

Factors associated with TPT completion

In multivariate analysis PLHIV who were initiated on
Cases screened negative for TB symptoms

TPT at Gandhi Hospital, Trunesh Beijing Hospital,

Yekatit 12 Hospital, Menelik Hospital, and Ras Desta
Service performance indicators

Hospital had 95% (AOR, 0.05; 95% CI, 0.01, 0.16), 85%
Cases screened for TB symptoms
Cases newly initiated on ART

(AOR, 0.15; 95% CI, 0.07, 0.34), 80% (AOR, 0.20; 95% CI,
0.09, 0.42),74% (AOR, 0.26; 95% CI, 0.12, 0.54, and 85%
number in the two quarters
Cases discontinued TPT

(AOR, 0.15; 95% CI, 0.07, 0.33), lower TPT completion,

Cases completed TPT

respectively compared to those who were initiated on

TPT at Zewditu Hospital. PLHIV who were initiated 3HP
regimen were more likely to complete (AOR, 1.68; 95%
CI, 1.01, 2.79) compared to those who were initiated on
IPT (Table 5).
╪
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 6 of 11

Table 4 TPT uptake disaggregated by public hospitals, April 2020 to March 2022, Addis Ababa, Ethiopia. N = 1069
Health facilities Started ART ¶Screened for TB symptoms φScreened negative for TB symptoms ϕInitiated TPT $Not initiated TPT
*
N N (%) N (%) N (%) N (%)
Zewditu Hospital 326 325 (99.7%) 270 (83.1%) 219 (81.1%) 51 (18.9%)
Trunesh Beijing 152 151 (99.3%) 128 (84.8%) 105 (82.0%) 23 (18.0%)
Hospital
Yekatit 12 Hospital 196 195 (99.5%) 166 (85.1%) 128 (77.1%) 38 (22.9%)
Gandhi Hospital 37 35 (94.6%) 34 (97.1%) 26 (76.5%) 8 (23.5%)
Menelik Hospital 218 215 (98.6%) 192 (89.3%) 148 (77.1%) 44 (22.9%)
Ras Desta Hospital 140 138 (98.6%) 122 (88.4%) 93 (76.2%) 29 (23.8%)
Total 1,069 1,059 (99.1%) 912 (86.1%) 719 (78.8%) 193 (21.2%)
This table shows TPT uptake among PLHIV newly initiated on ART from April 2020 to March 2022, disaggregated by public hospitals, Addis Ababa City Administration,
Ethiopia
N: number; ¶ Screened for TB: screened for TB using symptom algorism; φTB screening negative: negative TB screening result;ϕStarted TPT: screened negative for TB
symptoms and started TPT;$ not started TPT: screened negative for TB symptoms, but not started TPT

Fig. 1 TPT outcome status, April 2020-March 2022, disaggregated by treatment regimens, Addis Ababa, Ethiopia
This graph illustrates the TPT outcome status of PLHIV newly initiated on ART in the period April 2020-March 2022, disaggregated by treatment regimens,
across public hospitals, Addis Ababa City Administration, Ethiopia

Discussion (the first quarter during the first year of the COVID-19
The COVID-19 pandemic posed substantial challenges period). Studies from various regions of Ethiopia showed
on routine health services [33]. In this study, we assessed reduction in routine health services performance includ-
TB screening, TPT uptake, and associated factors of TPT ing TB prevention and control during the early period of
completion among PLHIV newly initiated on ART dur- the COVID-19 pandemic [25, 34, 35]. This may be related
ing the first two years of the COVID-19 period (April to that April-June 2020 was the period when national
2020-March 2022). We also compared service perfor- lockdown declared to control COVID-19 in Ethiopia [36].
mance indicators a quarter by quarter bases between the The country adopted a variety of response measures such
two years. as travel restrictions, reorganization of health facilities
We observed that ART initiation, TB screening, TPT [25, 30], and reallocating human workforce and services
uptake, and TPT completion increased in April-June towards responding to COVID-19 pandemic [30], which
2021 (the first quarter during the second year of the may hinder routine health services provision. Moreover,
COVID-19 period) compared to in April-June 2020 as part of response, there was intense media coverage
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 7 of 11

Table 5 Factors associated with TPT completion, April 2020 to March 2022, Addis Ababa, Ethiopia
Variables Number of cases Number of cases COR (95% CI) P-value AOR (95% CI) P-value
who initiated completed TPT
TPT
Gender
Female 427 299 (70.0%) 0.99 (0.69–1.42) 0.97 1.22 (0.79–1.90) 0.37
Male 288 205 (71.2%) 1 1
Age group (years)
18–24 67 42 (62.7%) 0.82 (0.23–2.92) 076 0.85 (0.18–4.07) 0.84
25–34 187 115 (61.49%) 0.63 (0.19–2.03) 0.44 0.78 (0.18–3.35) 0.73
35–44 261 192 (73.56%) 1.14 (0.35–3.68) 0.82 1.10 (0.26–4.71) 0.89
45–54 134 102 (76.12%) 1.55 (0.46–5.24) 0.49 1.83 (0.40–8.35) 0.43
55–64 53 44 (83.02%) 3.67 (0.79–16.86) 0.09 2.86 (0.49–16.85) 0.25
65+ 17 12 (70.58%) 1 1
WHO clinical stage
T1 464 320 (68.9%) 0.89 (0.45–1.77) 0.75 0.94 ( 0.39–2.19) 0.88
T2 61 47 (77.0%) 1.35 (0.54–3.39) 0.53 0.71 (0.24–2.08) 0.53
T3 48 39 (81.3%) 1.76 (0.63–4.95) 0.28 1.70 (0.54–5.35) 0.36
T4 54 38 (70.4%) 1 1
TPT regimen
6H 385 251 (65.2%) 1 1
3HP 334 256 (76.6%) 1.98 (1.37–2.87) < 0.001* 1.68 (1.01–2.79) 0.04*
Functional status
Working 605 435 (71.9%) 1 1
Ambulatory 55 34 (61.8%) 0.61 (0.33–1.13) 0.12 0.47 (0.22–1.03) 0.06
Bed ridden 17 10 (58.8%) 0.61 (0.21–1.82) 0.38 0.68 (0.17–2.78) 0.59
Health facilities
Zewditu Hospital 219 197 (89.9%) 1 1
Gandhi Hospital 26 6 (23.1%) 0.03 (0.01–0.10) < 0.001* 0.05 (0.01–0.16) < 0.001*
Trunesh Beijing Hospital 105 69 (65.7%) 0.16 (0.08–0.29) < 0.001* 0.15 (0.07–0.34) < 0.001*
Yekatit 12 Hospital 128 88 (68.8%) 0.24 (0.12–0.46) < 0.001* 0.20 (0.09–0.42) < 0.001*
Menelik Hospital 148 95 (64.2%) 0.22 (0.12–0.42) < 0.001* 0.26 (0.12–0.54) < 0.001*
Ras Desta Hospital 93 52 (55.9%) 0.13 (0.65 − 0.25) < 0.001* 0.15 (0.07–0.33) < 0.001*
This table shows the factors associated with TPT completion among PLHIV newly initiated on ART for the period April 2020 to March 2022, at public hospitals, Addis
Ababa City Administration, Ethiopia
*statistically significant

about the COVID-19 outbreak, particularly during the increment in the period July-September 2021 and Jan-
early period of the pandemic, and this was a time when uary-March 2022 compared to July-September 2020
the daily COVID-19 reported cases in Ethiopia, partic- and January-March 2021 performance. Overall, 99% of
ularly in Addis Ababa were high [30]. This might make cases were screened for TB symptoms during the study
the clients/patients fear of acquiring COVID-19 and may period, which might be explained by Addis Ababa com-
have forced them to stop using health care services. prised more than 50% of total confirmed COVID-19
Ruling out active TB proceeding to commencement of cases within the country [30], and this condition may
preventive treatment is one of the crucial steps in LTBI have forced health workers for performing simultaneous
treatment pathway [3]. The national TB control program TB and COVID-19 screening for PLHIV during the pan-
guideline of Ethiopia recommends clinical screening demic period as both disease share same symptoms such
using symptom-based criteria as a requirement to iden- as cough, fever, and shortness of breath [37, 38].
tify those eligible for TPT and for initiating preventive In this study, although increment trend was observed
treatment [13]. We observed increment in TB screen- in TPT initiation in April to June 2021 and in July to
ing in April-June 2021 compared to in April-June 2020 September 2021 compared to in April to June 2020 (first
(lockdown period). A study conducted in other region quarter during lockdown period) and in July-September
of Ethiopia showed a reduction trend in TB screening in 2020 (second quarter during lockdown period), reduc-
routine HIV care services in the early period of COVID- tion was observed in October to December 2021com-
19 pandemic [34]. The trend in TB screening also showed pared to the same quarter performance in the first year.
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 8 of 11

This may be partially related to decrement in the number trend; however, in the last quarter of the study period
of cases who were screened for TB and screened nega- (January to March 2022) increment was observed. Simi-
tive for TB symptoms during the same period as Table 2 larly, our hospital based analysis revealed that nearly
showed. Overall, during the study period more than a quarter of PLHIV in each of four hospitals, including
three-fourths of eligible cases were initiated on TPT. This Yekatit12, Gandi, Menelik, and Ras Desta were not initi-
is similar to the result of a former study from Eastern ated on TPT. However, the reasons for not initiating TPT
Ethiopia whereby 78.7% of PLHIV were initiated on TPT and discontinuing TPT after initiating were not docu-
[39]. Nevertheless, the TPT uptake in this study was far mented in the data bases and ART registers. The possi-
below the national target of achieving 90% TPT coverage ble explanation might be that the repurposing of health
[15]. Intensive screening with TPT has the potential to workers may have led to hesitation to provide routine
significantly decrease the incidence of TB among high- services and continue recording the required information
risk groups like PLHIV and ultimately reduce transmis- of each cases profile during the pandemic. PLHIV receiv-
sion in the community [40]. ing ART remain at considerable risk for developing TB
Although a decreasing trend was observed in the [29, 42]. TPT works synergistically with ART to reduce
number of cases discontinued TPT in the period July to progression LTBI to active TB, mortality, and incidence
September 2021 compared to in July to September 2020 in PLHIV [29, 45]. Reservoir of TB infection like PLHIV
(lockdown period), however, it continuously increased with the highest risk of progression to active TB must be
in October to December 2021 and in January to March addressed to end the TB epidemic globally [29].
2022 compared to the same quarters number in the pre- More than half (70.5%) of cases completed TPT. Find-
vious year during the COVID-19 period. We observed ings of a study from Brazil revealed 74% TPT completion
that overall, 22.8% of cases discontinued TPT during during the COVID-19 pandemic [44]. In trend analysis,
the study period. This is in line with a study conducted although TPT completion was increased in the first two
at health centers in Addis Ababa whereby 27.4% PLHIV quarters during the second year of the COVID-19 pan-
who were on ART missed their appointments/visits for demic, however, decrement trend was observed in the
refill during the COVID-19 pandemic [41]. Our hospi- periods October to December 2021 and January to March
tal-based analysis also showed that a substantial propor- 2022. This may be related to increment of cases who dis-
tion of cases discontinued IPT at most of the hospitals, continued TPT during the same quarters. Our study
including Gandi, Yekatit 12, Trunesh Beijing, Menelik, showed that cases who were initiated on 3HP were more
and Ras Desta. Likewise, more than a third of cases in likely to complete TPT than those who were initiated
each of three hospitals, including Trunesh Beijing, Yekatit on IPT. In a recent systematic review and meta-analysis
12, and Ras Desta discontinued 3HP. The high proportion report, high completion rate of shorter, rifampicin-con-
of cases discontinued TPT in the current study might be taining regimens including 3HP than isoniazid-based
related to inadequate health education and psychosocial regimens has been reported [45]. The high 3HP comple-
support for clients due to redirection of most health care tion in the current study may be due to the fact that 3HP
providers to care COVID-19 cases [30]. In a recent meta- regimen is simpler, requires fewer doses, and is taken for
analysis, poor patient adherence, poor patient empower- shorter period of time than IPT [46, 47]. In Ethiopia, the
ment and proper counseling on IPT, fear of side effects introduction of 3HP increased acceptance among health
and developing isoniazid resistant TB, and as well as lack care providers [48]. The high 3HP completion in our
of commitment of health managers to scale up the pro- study may also be related to the counseling service that
gram were challenges in Ethiopia [42]. Discontinuation health care providers have been providing and the com-
of TPT is an obstacle to effective TB control and has the mitment of PLHIV. In relation to concerns about toxicity
potential of worsening the emergence of drug resistant and the long duration of treatment, acceptance and com-
TB and death [43]. Our result underscores the impor- pletion of IPT in PLHIV have been poor worldwide [49].
tance of strengthening adherence on TPT. Cases who attended at Gandhi Hospital, Trunesh Bei-
In this study, overall 22% of cases who were screened jing Hospital, Yekatit 12 Hospital, Menelik Hospital, and
negative for TB symptoms were not initiated onTPT Ras Desta Hospital
during the study period. A study from Brazil reported a were less likely to complete TPT than those who
reduction in TPT prescription during the COVID-pan- attended at Zewditu Hospital. This may be explained by
demic [44]. In trend assessment, the number of PLHIV Zewditu Hospital is a well-known model hospital which
who were not started on TPT continuously declined has a well-functioning HIV care program. The hospital
across quarters in April to June 2021, in July to September is the first hospital started provision of ART services in
2021, and in October to December 2021 compared to the Ethiopia in 2003 [50]. Zewditu Hospital has extensive
same quarters number in the first year during the pan- experience in providing better HIV care services and a
demic period and this was found to be an encouraging large number of PLHIV who had been enrolled for HIV
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 9 of 11

care and put on ART [51]. This is also supported by the documentation system is essential for improving the reg-
current data whereby near to a third (30.4%) of the cases istration and tracking reasons for not initiating TPT and
were initiated on ART at this hospital. discontinuing treatment. These might enhance, monitor,
The study attempts to assess the level of TPT uptake and support evidence-informed decision-making. Addi-
among PLHIV who were newly initiated on ART at all tional research is needed to understand the reasons for
public hospitals of Addis Ababa City Administration the low TPT uptake and high discontinuation of TPT
during the COVID-19 period, and the results indicate among PLHIV in the study hospitals.
important issues that need to be addressed to improve
Abbreviations
programmatic management of LTBI in the study hospi- AHRI Armauer Hansen Research Institute
tals. The study has potential limitations: Firstly, due to AOR Adjusted odds ratio
time and other resource constraints we had, the study ART Antiretroviral therapy
CI Confidence interval
was carried out only at government hospitals; therefore, CEPI Coalition for Epidemic Preparedness Innovations
the results do not reflect the TPT uptake status among COVID-19 Coronavirus disease 2019
PLHIV who attended at public health centers and pri- COR Crude odds ratio
DHIS 2 District Health Information System 2
vate health facilities in Addis Ababa City Administration. HIV Human immune deficiency virus
Moreover, the study focused on adult PLHIV who were HP Isoniazid plus rifapentine
newly initiated on ART; hence the findings can not be IPT Isoniazid preventive therapy
LTBI Latent TB infection
generalized to all PLHIV who were newly enrolled into Mtb Mycobacterium tuberculosis
HIV care during the study period. Secondly, as the study MOH Ministry of Health
used routine data, we could not report on the reasons for PLHIV People living with HIV
SD Standard deviation
cases who were not initiated on TPT and who discontin- TB Tuberculosis
ued TPT because this information was not recorded in TPT TB preventive treatment
the data bases and ART registers. Thirdly, the study used USAID United States Agency For International Development
UNHLM United Nations High-Level Meeting
routine data which were collected for programmatic pur- WHO World Health Organization
poses and patient management; therefore, some variables
which might have an association with TPT completion Acknowledgements
We also would like to thank Addis Ababa City Administration Health Bureau,
were not routinely collected and recorded in the data- and the study health facilities heads, ART focal persons and data managers for
base, which is an inherent limitation of retrospective their unlimited support. We are very much grateful to data collectors.
study designs.
Author contributions
SBG, AAA and MBS participated in the conception and design of the study.
Conclusions SBG and AAA participated in data collection. SBG, AAA and, THK participated
Most of the TB prevention service performance indica- in data analysis and interpretation SBG, AAA, THK, MYT, EAA, DGD, SAY and
MBS participated in writing and revising, and editing the manuscript. All
tors showed increment during the second year of the authors finally read and approved the final manuscript.
COVID-19 period, which may indicate health service
recovery. While the overall proportion of PLHIV who Funding
We would like to thank the AHRI for providing financial support for data
were screened for TB was high, TPT uptake was low collectors.
and far below the national target of achieving 90% TPT
coverage. Overall a considerable proportion of cases dis- Data availability
The datasets used and/or analyzed during the current study are available from
continued TPT and near to a quarter of cases who were the corresponding author on reasonable request.
screened negative for TB symptoms were not initiated on
TPT during the period, which may have implications for Declarations
LTBI progress to TB disease. Nonetheless, the reasons for
not initiating TPT and discontinuation of TPT after initi- Ethics approval and consent to participate
All research methods were performed in accordance with the Declaration
ation were not properly documented in the data sources. of Helsinki. The Armauer Hansen Research Institute (AHRI)/ All Africa Leprosy
PLHIV who started TPT at Zewditu Hospital and cases Rehabilitation and Training Center (ALERT) ethics review committee approved
who initiated 3HP regimen were predictors for TPT this study and gave waver of informed consent (PO/07/22). In addition,
permission to review the required routine District Health Information System 2
completion. Further strengthening of the programmatic (DHIS 2) ART service database was obtained from each hospital authority. The
management of LTBI for PLHIV is needed. Therefore, reviewed data used in this study were collected anonymous.
efforts should be made by the Addis Ababa City Admin-
Consent for publication
istration Health Bureau authorities and program manag- “Not applicable” in this section.
ers to strengthen TPT initiation and completion among
PLHIV in public hospitals. Due emphasis should be given Competing interests
The authors declare no competing interests.
on recording the required information for all cases who
are enrolled for HIV care. Additionally, digitalizing the
Gebreegziabher et al. BMC Infectious Diseases (2024) 24:499 Page 10 of 11

Author details 16. World Health Organization. Tuberculosis profile: Ethiopia Generated 2022-11-
1
Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia 28 by the World Health Organization. Accessed: 30 November 2022: https://
2
USAID Eliminate TB Project Health Programs Group Management worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22countr
Sciences for Health, Addis Ababa, Ethiopia y%22&lan=%22EN%22&iso2=%22ET%22
3
Vaccine Research and Development Department, Coalition for Epidemic 17. Alene KA, Wangdi K, Clements ACA. Impact of the COVID-19 Pandemic on
Preparedness Innovations (CEPI), Oslo, Norway Tuberculosis Control: An Overview. Trop Med Infect Dis. 2020; 24;5(3):123.
4
Faculty of Medicine, Unit for Genome Dynamics, University of Oslo, Oslo, 18. Kessel B, Heinsohn T, Ott JJ, Wolff J, Hassenstein MJ, Lange B. (2023) Impact
Norway of COVID- 19 pandemic and anti-pandemic measures on tuberculosis, viral
5
USAID Eliminate TB Project KNCV Tuberculosis Foundation-Ethiopia, hepatitis, HIV/AIDS and malaria–A systematic review. PLOS Glob Public
Addis Ababa, Ethiopia Health.2023; 3(5): e0001018.
19. World Health Organization. First case of COVID-19 confirmed in Ethiopia, 13
Received: 8 July 2023 / Accepted: 13 May 2024 March 13, 2020. Accessed 14 September 2022: https://www.afro.who.int/
news/first-case-covid-19-confirmed-ethiopia.
20. Ministry of Health-Ethiopia. Essential Health Services Package of Ethiopia.
November 2019; Addis Ababa, Ethiopia. Accessed 23 Feb 2024: https://www.
uib.no/sites/w3.uib.no/files/attachments/essential_health_service_pack-
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