|Year : 2012 | Volume
| Issue : 3 | Page : 142-146
A study of an association between tuberculosis and HIV among ICTC attendees at a tertiary care hospital of Shimla, Himachal Pradesh, India
Tripti Chauhan1, Ashok K Bhardwaj2, Anupam Parashar1, Anil K Kanga3
1 Department of Community Medicine, Indira Gandhi Medical College, Shimla, India
2 Department of Community Medicine, RPGMC, Tanda, Himachal Pradesh, India
3 Department of Microbiology, Indira Gandhi Medical College, Shimla, India
|Date of Web Publication||26-Dec-2012|
Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Background: In India, HIV epidemic and tuberculosis (TB) have posed enormous challenges in the control of TB. Objectives: To determine the proportion of TB in HIV positive and HIV negative patients. Materials and Methods: This hospital based cross-sectional study was conducted in the ICTC of Indira Gandhi Medical College, Shimla from 1 st January 2007 to 31 st August 2007. A sample of 525 consecutive attendees in the age group of 15 to 50/> years were included as study subjects. After counseling, confirmation of HIV status was done according to NACO and diagnosis of TB as per the RNTCP guidelines. Their clinical presentations, PTB and site of EPTB were studied.A pretested questionnaire was used to collect a detailed history followed by a physical examination. Laboratory and radiological investigations were carried out appropriately. Results: Among the 525 attendees, 198 (37.7%) were seropositives and 327 (62.3%) were seronegatives. Of the seropositives more affected were females, 105 (53%) than males, 93 (47%). Wherein among seronegatives, male to female ratio was 2:1. The most common symptoms of PTB among seropositives were cough >3 weeks in 40%, followed by production of purulent sputum in 33.8% and fever >3 weeks in 23% as compared to seronegatives, where the commonly reported symptom was cough >3 weeks in 25.4% (P < 0.00002). EPTB was observed in almost double the proportion, 24.2% of seropositives as compared to seronegatives, 12% (P < 0.0001). However, 17.7% of seropositives as compared to 10.1% of seronegatives were suffering from PTB infection (P < 0.006). Conclusion: TB in HIV patients presentas extra-pulmonary involvement more frequently.
Keywords: Co-infection, HIV, NACO, RNTCP, TB
|How to cite this article:|
Chauhan T, Bhardwaj AK, Parashar A, Kanga AK. A study of an association between tuberculosis and HIV among ICTC attendees at a tertiary care hospital of Shimla, Himachal Pradesh, India. Int J Health Allied Sci 2012;1:142-6
|How to cite this URL:|
Chauhan T, Bhardwaj AK, Parashar A, Kanga AK. A study of an association between tuberculosis and HIV among ICTC attendees at a tertiary care hospital of Shimla, Himachal Pradesh, India. Int J Health Allied Sci [serial online] 2012 [cited 2020 Feb 21];1:142-6. Available from: http://www.ijhas.in/text.asp?2012/1/3/142/105063
| Introduction|| |
The growing menace of HIV epidemic and its relationship with TB has resulted in an appalling situation since the deadly combination is clinically devastating together than either disease presenting alone. , In India alone, 2.5 million people are currently infected with HIV, of whom 40% are also co-infected with TB. , According to the World Health Organization (WHO), TB is one of the major causes ofdeath among HIV-infected people, and TB/HIV co-infectionhas been found to reduce the effectiveness of directly observed therapy of TB. ,
In this context it is imperative that India monitors and plans for HIV/TB co-infection in order to identify, treat and prevent co-infection, thereby reducing TB burden and increasing the years of healthy life of people living with HIV.
The risk of eventually developing active TB from latent TB infection is about 10% per year in HIV-positive patients in contrast to 10% lifetime risk in HIV-negative patients. HIV-positive patients with TB are more likely to have extra-pulmonary, atypical, and unique clinical and radiological presentations. Moreover, TB is more difficult to diagnose and, therefore, progresses more rapidly in the HIV-positive population. ,
Early detection and effective treatment of TB as well as the provision of prophylaxis against TB is likely to impact favorably on the prognosis of HIV-infected patients. This strategy is of a particular relevance in high TB prevalence areas where access to antiretroviral therapy is currently limited. In Himachal Pradesh further research is needed to have a systematic review of the burden and the associated risk factors of co-infection, so as to plan effective control measures. Increased HIV testing of TB patients and targeted with informed strategies for control and prevention could help curb this epidemic.
Aims and objectives
To determine the proportion of TB in both HIV-positive and HIV-negative patients who attended the ICTC of a tertiary care hospital at Shimla, Himachal Pradesh.
| Materials and Methods|| |
This study was conducted in the ICTC of the Department of Microbiology, of a tertiary care hospital at Shimla, Himachal Pradesh, India, from 1 st January, 2007 to 31 st August, 2007. All the attendees (N = 525) who attended the ICTC consecutively were included as study subjects. Ethical approval for the study was obtained from the institutional committee for ethical reasons. Free and informed written consent was obtained from all the participants and confidentiality of information was maintained in accordance with the principles embodied in the declaration of Helsinki and the International Guidelines for ethical review of Epidemiological Studies. A pre-tested structured questionnaire was administered to all such clients by the candidate. Each question was read out to the respondent and the response was taken in the appropriate boxes on the form. The questionnaire was filled by an investigator, and was not filled in part by study subjects and investigator.
The questionnaire was designed in a manner to obtain a detailed history of every case including socio-demographic, present illness, past illness and family history. Further, a thorough physical examination of the patients was done by the investigator to detect any opportunistic infections, the presence of lymphadenopathy and then all the clients were tested for HIV infection as per the guidelines laid under HIV Testing Policy of Government of India. Both HIV-positive and HIV-negative cases irrespective to their serostatus were referred to DOTS center located in the same institution for the screening of TB as per standard RNTCP guidelines, during the study period. Sputum smear-negative patients were further subjected to a chest radiography (PA view), and the patients who had symptoms of extra-pulmonary TB were also screened by microbiological investigations, fine needle aspiration and cytology (FNAC) of enlarged and clinically palpable lymph nodes, pleural or ascitic fluid examination and abdominal ultrasonography (USG) in order to locate the site of the EPTB. Data analysis: The data collected was analyzed using SPSS software version 11.
| Results|| |
The study revealed that a total of 525 clients who participated had the following characteristics: 198 tested positive for HIV and the rest 327 were seronegatives. Of the 198 seropositive cases, 93 (47%) were males and 105 (53%) were females. Within the group, 146 (73.8%) seropositives were predominantly married. The highest number, 85.8% of HIV infection was found in the age group of 25-44 in both the sexes. The seropositivity rate was highest among the housewives, 72 (36.4%). The second highest positivity was found among the drivers, 59 (29.8%) and these were all males as shown in [Table 1]. None of them were found to be homosexuals and intravenous drug users (IDUs), and the most common mode of transmission was unprotected heterosexual contact, 59 (29.8%) with multiple sexual partners; 40 (43%) of those who had sex with multiple sexual partners accepted to have had sex with commercial sex workers.
The commonest presenting symptom of PTB was cough for more than 3 weeks duration in 40.4% of seropositives as compared to 25.4% in seronegatives, followed by production of purulent sputum, 33.8% and 23.9% in seropositives and seronegatives, respectively. Fever for >3 weeks was present more, 23.2% in HIV seropositives as compared to 12.8% in seronegatives and involuntary weight loss of more than 10% in the past 6 months was a commoner, 3.5% in the seropositive group. The most useful diagnostic tool to detect TB is chest X-ray and USG abdomen. Chest X-ray detected pleural effusion and lesions suggestive of PTB such as infiltrates almost equally, 8% among both the groups, seropositives and seronegatives, followed by fibrosis, which is slightly more than double, 7.6% in seropositives in comparison to seronegatives 3.7% (P < 0.029). Additionally, cavitary TB, which is an equally common finding, 0.5% in HIV positive; 0.3% in HIV negative patients as shown in [Table 2].
USG abdomen revealed lesions suggestive of abdominal TB in 1.5% of the seropositive cases. Thus, all HIV cases should be screened for TB with the additional usage of USG, irrespective of the initial clinical symptoms. AFB culture and sensitivity tests were not done because of non-availability of the facilities in the institute. Among seropositives, sputum for AFB was positive in only 6.6% of patients. Out of 35 cases with clinically palpable lymph nodes, FNA of lymph nodes (along with H and E and ZN staining) detected TB lymphadenitis in all 35 cases. Cerebral spinal fluid (CSF) sampling detected TB meningitis in 4.5% cases. Moreover, 0.5% had caries spine, which also responded to a therapeutic trial of ATT.
The majority of seropositives had double the proportion of EPTB, 24.2%, than seronegatives, wherein, 12% had EPTB, followed by PTB, 17.7% of seropositives; however, 10.1% of seronegatives had PTB as shown in [Table 3].
Clinically, palpable lymph nodes were the most frequent site of involvement among EPTB cases - 17.7% in seropositives; 4.9% in seronegatives, followed by meningeal involvement in 4.5% seropositives; 2.8% in seronegatives, pleural effusion was more common, 4.9% in seronegatives than 3% in seropositives.
Abdominal lymphadenopathy was the most common finding observed in 1.5% cases of abdominal TB, presented with abdominal pain, fever and occasional diarrhea.
| Discussion|| |
In this study out of a total 525 subjects, 198 (37.7%) were seropositives and the rest 327 (62.3%) were seronegatives. The sexually active age group of 25-44 years is the most commonly affected in 85.8% of seropositives, which is lesser than the national figures (90%) and other studies (88.7%).  Whereas, 67.3% of the seronegatives were in the age group of 25-44 years. The HIV infection was highest among the housewives, 72 (36.4) followed by drivers, 59 (29.8) among laborers and cultivators 53 (26.7) indicating the penetration of HIV infection in the general population and is a matter of concern. These results were not consistent with the other study where the seropositivity was more among the manual laborers, followed by truck drivers. 
In the present study, majority (46.5%) had the risk from their infected spouses, followed by unprotected heterosexual contact with multiple partners (29.8%) and only 1.5% had received a blood transfusion whereas among seronegatives, the most common risk factor to visit the ICTC was unprotected heterosexual contact with multiple partners in 17.7%, followed by 6.1% who had a spouse infected with HIV and 3.4% had received a blood transfusion (P < 0.00001). This finding is more than half of what was reported by WHO where more than 90% of infected women acquire the infection from their husbands.  But our findings were not consistent with the study conducted at Manipur where IDU among the unemployed youths sharing the needles was the most common risk factor (87%). 
In this study, 17.7% of seropositives were suffering from PTB infection as compared to HIV seronegatives where PTB was found in only 10.1% and the results were significant statistically (P < 0.006). These findings were much lesser than the findings from the other studies in India, conducted in BHU, Banaras and Kolkata where the PTB among seropositives was 38.8% and 27.7%, respectively. , Higher rates of HIV-TB co-infection, as high as 47% were also reported from Ethiopia. 
The findings differed from what NACO, Govt. of India has reported, where PTB was the commonest opportunistic infection (62.3%) observed in the HIV-infected persons.  In another study conducted in Vadodara, Gujarat, in 85.8% of the co-infected cases, TB was detected through active screening and PTB, which is a more common presentation in HIV-negative cases was present in only 55% of these seronegative patients. 
In the present study, the rate of EPTB infection was the commonest opportunistic infection (24.2%), exactly double in the seropositive patients in comparison to 12% in seronegatives. Similarly, the results of the study conducted by Ragini Ghiya reported EPTB to be the commonest infection, almost (68%) of seropositives had EPTB manifestations.  On the contrary, the results of another study conducted in Delhi reported PTB to be the commonest opportunistic infection followed by EPTB manifestation found to be (45.6%) in HIV positive cases.  Another author also observed EPTB to be present in (60%) of their HIV/TB patients.  In our study, the most common site of EPTB involvement were lymph nodes in 17.7%, followed by pleural cavity in 3%. Similarly, the study conducted in Nepal which revealed the lymph nodes to be the most commonly occurring site of EPTB.  Another author from India has also reported that the most common form of EPTB is mediastinal lymphadenopathy followed by pleural effusion and extra-thoracic adenopathy. The overall involvement of the lymphatic system was seen in 42% of patients.  Our findings differed from the findings of the study conducted in other countries, where the most common site of EPTB occurrence was the pleura.  It also differed from another Indian study, wherein among seropositives, abdominal tuberculosis was the most common site observed (74%), followed by clinically palpable lymph nodes (22%) and pleural effusion (17%). 
The commonest clinical presentations were low-grade fever, cough, weight loss and lymphadenopathy in both seropositives and seronegatives, which were consistent with the findings of studies by Nunn et al. and by Putong et al. where fever, cough and weight loss were found to be equally common in both HIV-positive and HIV-negative patients. ,
In the present study, seropositives were most commonly suffering from cough >3 weeks in 40.4%, followed by cough with purulent sputum in 33.8%, fever >3 weeks in 23.2%, and hemoptysis were seen in 3% as compared to seronegatives, where cough was the most common symptom present in 25.4%. These findings of clinical symptoms of PTB differed from other studies where among seropositives, cough was the most common symptom (94%), followed by fever, weight loss and loss of appetite present in 86%, 78% and 62% of the patients, respectively, while hemoptysis was seen in 14% of the patients.  Moreover, it did not also corroborate with the findings of another author, Dey et al. where low incidence of cough (43.5%) was reported, along with a marked weight loss (100%) and fever (100%), which were the cardinal clinical features in seropositive patients. However, it remained consistent with the symptom of cough being the most common symptom of TB in seronegative subjects.  In our study, positive sputum for AFB was observed in 6.6% and infiltrative lesions in chest skiagram were seen in 8.6% of the seropositive patients, however this finding is very less in comparison to the results of another study conducted by Anand K. Patel, where 25.6% of their patients had a sputum smear positive for AFB positive.  It has been shown that sputum smear is often positive in the early stage of HIV infection. 
This is very different from the situation in HIV uninfected TB patients and indicates that smear microscopy is not a sensitive diagnostic tool in the presence of HIV infection.  With this we conclude that Himachal Pradesh is not an exception; the dual burden has captured it, worsening each other; however, simultaneous utilization of ICTC service has increased in the recent times, benefitting the people with HIV infection and subsequently improving their conditions. We would also emphasize on the fact that the link between DOTS and ICTC needs to be strengthened in Himachal Pradesh.
| Acknowledgments|| |
We acknowledge cooperation of all the individuals who participated in the study.
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[Table 1], [Table 2], [Table 3]