Tuberculosis & HIV in India

An Article From NEJM
Tuberculosis and HIV in India

Robert Steinbrook, M.D.

Tuberculosis is the most common HIV-related opportunistic infection in India, and caring for patients with both diseases is a major public health challenge. India has about 1.8 million new cases of tuberculosis annually, accounting for a fifth of new cases in the world — a greater number than in any other country (see pie chart). Patients with latent Mycobacterium tuberculosis infection are at higher risk for progression if they are coinfected with HIV. Patients with HIV infection have a similar bacteriologic response to tuberculosis treatment as those who are not infected but have higher risks of recurrence and death. The influence of tuberculosis coinfection on the progression of HIV disease is controversial.

Source NEJM

In 2004, about 330,000 people in India died from tuberculosis. Two of every five persons — more than 400 million — have latent tuberculosis infection. Tuberculosis can be expected to develop in more than half of those who are also infected with HIV. At present, however, only about 5% of new tuberculosis cases in India occur in people with HIV coinfection. The situation differs from that in sub-Saharan Africa, where the incidence of tuberculosis in many countries is higher than in India and as many as 80% of patients with tuberculosis are coinfected with HIV. In Africa, HIV has reversed gains in tuberculosis control that were achieved a quarter-century ago.Such a reversal is unlikely to occur in India.

India began its Revised National Tuberculosis Control Program in 1993.5 Its mainstay is the strategy of directly observed treatment, short course (DOTS). Typically, during the initial 2 to 3 months of treatment, medication is administered three times a week under direct observation. During the subsequent 4 to 5 months, at least one of the three weekly administrations is directly supervised.

After pilot testing, rapid expansion of DOTS began in the late 1990s, and in March 2006, India achieved nationwide coverage (see line graph). Each month, more than 100,000 Indian patients — about two fifths of them persons with a new positive sputum smear — begin treatment. The success rate of treatment — the percentage of new smear-positive patients who are cured (i.e., whose sputum smear is negative) plus the percentage who complete treatment without bacteriologic confirmation of cure — is about 86%.1 In about 2% of patients, treatment fails; in 7% treatment is interrupted for 2 consecutive months or more; and 4% die despite treatment. The estimated incidence of multidrug-resistant tuberculosis is 2.4% among patients with new cases and 15% among those who have previously received treatment. In 2006, the national budget for treatment was $57 million and the total cost of tuberculosis control was $100 million.

Source NEJM

India's national tuberculosis-control program provides care, diagnosis, and treatment on a huge scale — offering an example that the National AIDS Control Program may be able to learn from as it expands. Of course, HIV treatment is often more complex and expensive than tuberculosis treatment and must continue indefinitely. When patients with HIV infection are treated at the same facility as those with tuberculosis, effective infection-control measures are essential, given the high risk of nosocomial transmission of tuberculosis. When caring for coinfected patients, physicians must consider many clinical issues, such as those related to the prevention of disease; the timing of treatment; the choice of medications; drug interactions, side effects, and resistance; and potential reinfection with other mycobacterium strains. Antiretroviral therapy is essential for reducing the number of deaths from tuberculosis that are related to HIV infection.

In India, tuberculosis care and HIV care are increasingly being coordinated, but the full benefits have yet to be realized. An example of successful coordination is the referral of people with suspected tuberculosis from voluntary counseling and testing centers for HIV to tuberculosis-control facilities. Between January and September 2006, a total of 15,000 people with suspected tuberculosis who were HIV-positive and 16,420 who were HIV-negative were referred to such facilities by centers in the six Indian states with the highest HIV prevalence (Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland, and Tamil Nadu); tuberculosis was diagnosed in 22.3% and 23.9% of patients in these groups, respectively. DOTS was begun in many of these patients. The control of both tuberculosis and HIV is likely to be most successful if programs collaborate whenever possible and are closely integrated with the rest of medical care.