|Year : 2011 | Volume
| Issue : 4 | Page : 329-331
Pulmonary tuberculosis among HIV seropositives attending a counseling center in Kolkata
Mihir K Bhattacharya1, Trailokya N Naik2, Mrinmoy Ghosh3, Sarojit Jana4, Phalguni Dutta5
1 Deputy Director, National Institute of Cholera and Enteric Diseases, Kolkata, India
2 Emeritus Scientist, National Institute of Cholera and Enteric Diseases, Kolkata, India
3 Professor, Infectious Diseases Hospital, Kolkata, India
4 Mamata Care and Treatment Centre, Kolkata, India
5 Emeritus Medical Scientist (ICMR), National Institute of Cholera and Enteric Diseases, Kolkata, India
|Date of Web Publication||30-Jan-2012|
Mihir K Bhattacharya
National Institute of Cholera and Enteric Diseases, P-33, CIT Road Scheme XM, Beliaghata, Kolkata - 700 010, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The study was carried out to detect the prevalence of pulmonary tuberculosis among HIV-seropositive individuals (HIV/TB co-infection) who attended counseling center of National Institute of Cholera and Enteric Diseases, Kolkata. A total of 109 HIV-seropositive individuals were screened. Of them, 36 (33%) had HIV/TB co-infection diagnosed by chest X-ray and presence of acid fast bacillus (AFB) detected by repeated microscopic examination of sputum. Blood samples were examined for CD4 and CD8 counts and ratio. Findings of blood examination showed that low CD4 count (<50/μl) had statistically significant association (P = 0.007) with HIV/TB co-infection as compared to HIV infection only. However, no significant correlation with CD4:CD8 ratio in HIV/TB co-infection was observed.
Keywords: CD4 and CD8 count, HIV seropositive, HIV/TB co-infection
|How to cite this article:|
Bhattacharya MK, Naik TN, Ghosh M, Jana S, Dutta P. Pulmonary tuberculosis among HIV seropositives attending a counseling center in Kolkata. Indian J Public Health 2011;55:329-31
|How to cite this URL:|
Bhattacharya MK, Naik TN, Ghosh M, Jana S, Dutta P. Pulmonary tuberculosis among HIV seropositives attending a counseling center in Kolkata. Indian J Public Health [serial online] 2011 [cited 2020 May 31];55:329-31. Available from: http://www.ijph.in/text.asp?2011/55/4/329/92419
HIV/AIDS has recently been recognized as one of the major public health problems in developing countries. It has been estimated that about 4.9 million new infections and 3.1 million deaths occur annually due to HIV/AIDS largely in sub-Saharan Africa and South-East Asia.  Pulmonary tuberculosis (TB) is an age-old disease; however, recently the incidence of TB cases has increased to a great extent due to advent of HIV/AIDS pandemic throughout the world. 
An estimate showed that about 9% of all TB cases in adults were attributable to HIV/AIDS infection globally and 12% of the total of 1.8 million deaths from TB in the year 2000 was directly related to HIV/TB co-infection.  This situation has crippled the activities of health care personnel who are already overburdened in most of the developing countries. Increased incidence of TB infection by >6% per year has made the situation very serious.  About one-third of the world's population suffers from TB and more than half of them live in the countries where HIV infection is still prevalent and spreading rapidly.  According an estimate of World Health Organization (WHO), TB has become one of the leading causes of death among HIV-infected persons.  In India, the incidence of TB is around 40% in the general population; however, it has been estimated that around 25-30% more cases of TB may be added due to HIV infection.  This study was aimed to assess the occurrence of HIV-TB co-infection at a counseling center in Kolkata.
HIV reference center of National Institute of Cholera and Enteric Diseases (NICED), Kolkata, is one of the centers of National AIDS Control Organisation (NACO) of Ministry of Health and Family Welfare, Government of India. Major activity of this center is to conduct serosurveillance for HIV infection among the high-risk population in and around Kolkata. Subjects are mainly referred by different hospitals and non-governmental organizations (NGOs). Blood samples of these subjects are tested for HIV infection using highly specific enzyme-linked immunosorbent assay (ELISA) or Western Blot techniques.
Seropositive subjects, who were referred to the counseling center of NICED, were included in the study. Counseling was done by trained physicians and a counselor hired from Durbar Mahila Samannoy Committee (DMSC), one of the reputed NGOs of Kolkata, who has the expertise in taking care of the HIV cases. Blood samples were collected on the first visit and thereafter periodically to estimate CD4/CD8 counts and ratio. Repeated examination of blood helped in staging of HIV-related clinical conditions and to evaluate the response to antiretroviral therapy (ART). This also helped to take decision for initiation of chemoprophylaxis against opportunistic infection.
A total of 109 HIV-seropositive individuals, including 4 children aged between 2 and 5 years, were referred to the counseling center during the period February 2004-October 2006 and they served as the study population. All the subjects, irrespective of whether they had signs and symptoms of chest infection, were screened for pulmonary TB by chest X-ray, and subsequently by repeated microscopic examination of sputum for acid fast bacillus (AFB) using standard technique. Those individuals who were positive for AFB in their sputum received standard Directly Observed Therapy Short-course (DOTS) as per Revised National Tuberculosis Control Programme (RNTCP) of the Government of India. Personal data were collected through interviews conducted using pre-tested questionnaire by two trained counselors. The project was approved by the Institutional Ethics Committee (IEC). Blood samples were collected periodically after obtaining written informed consent as recommended by the IEC. Blood samples were processed for CD4 and CD8 counts and their ratio, which were calculated using FACS caliber (Becton Dickinson, USA) with the reagents supplied by the manufacturer.
The data were analyzed using Epi-info 2000 software (CDC, Atlanta, GA, USA). The associations between individual socio-demographic factor, CD4 and CD8 counts, and their ratio were assessed using the Chi-square test or Fisher's exact test (when the sample size of any cell was ≤5). The strength of association was determined by calculating odds ratio (OR) and 95% confidence intervals (95% CI).
A total of 109 HIV-seropositive individuals were initially included as the study population. Of them, 36 (33%) had pulmonary TB. Pulmonary TB infection was detected in 25/71 (35%) and 11/38 (28.9%) male and female study populations, respectively.
Occurrence of pulmonary TB was observed in 3/8 (37.5%) persons in the age group above 45 years, 32/97 (33.0%) in the age group of 15-45 years, and in only 1/4 (25%) children who were below 5 years of age. Personal data of the study population of HIV/TB co-infection showed that 5/14 (35.7%) were sex workers, 23/61 (37.7%) were clients, and 6/23 (26.1%) were spouses. One intravenous drug user had HIV/TB co-infection. Out of four HIV-positive children of HIV-positive mothers, one developed TB. On the contrary, five seropositives had history of multiple blood transfusions, but they were not infected with TB. One seropositive individual did not have any apparent risk factor for having HIV and did not suffer from TB either. Education level of the study population (except four children) indicated that 8/35 (22.8%) were illiterates and 14/23 (60.9%), 10/28 (35.7%), and 3/19 (15.8%) had education levels of primary, secondary, and above secondary, respectively.
Out of 109 HIV-seropositive individuals, 105 were included for the estimation of CD4 counts and CD4:CD8 ratio, as 4 persons refused to provide consent for collection of blood. [Figure 1] shows the CD4:CD8 ratio of seropositives who had pulmonary TB. Sensitivity and specificity of CD4 counts ≥475/μl were 77.78% and 77.88%, respectively, in HIV-infected Indian population, which correspond well with the recommended CDC cut-off values. The cut-off value of CD4:CD8 ratio was ≤1.4. There was no significant correlation of CD4:CD8 ratio with HIV/TB co infection. However, low CD4 count (<50/μl) had statistically significant correlation (P = 0.0007) with HIV/TB co-infection as compared to HIV infection only [Figure 2].
In developing countries, TB is one of the most common life-threatening infections among the persons living with HIV/AIDS.  An estimate shows that around 5.1 million people are infected with HIV and about half of these cases are co-infected with TB.  In India, approximately 200,000 of these HIV-infected persons develop active TB each year. 
Incidence of HIV/TB co-infection was reported to be very high (50%) in sub-Saharan Africa compared to that in Asia.  The rates of HIV/TB co-infection have been reported to vary in different regions of India. In North India, it was found to be between 0.4 and 20.1%.  However, in South India, the incidence was 3.2% in 1991, which increased to 20.1% in 1996.  The present study shows that prevalence of HIV/TB co-infection was 33% among clinic attendants in Kolkata. This prevalence of HIV/TB co-infection is different from the national figure (60.30%),  but almost similar (27.3%) to that of another study conducted in Kolkata. 
Low CD4 cells in HIV-infected persons indicates severely depressed immunity which makes them susceptible to fresh TB infection or reactivation of latent infection and rapid degradation of clinical condition. It has already been established that TB attributed to a sixfold to sevenfold increase of viral load in HIV-seropositive population.  However, no definite correlation of CD4:CD8 ratio was observed in relation to HIV/TB co-infection in this study.
This study emphasizes the urgent need for effective prevention and treatment of TB in HIV-infected population.
| Acknowledgments|| |
The authors wish to thank all the HIV-positive persons who participated in this study, and also Dr. Tapash Biswas for estimation of CD4 and CD8 counts using the FACS instrument. The study was supported by financial grant from Indian Council Medical Research (ICMR), Government of India.
| References|| |
|1.||Joint United Nations Programme on HIV/AIDS and WHO 2002. AIDS Epidemic updates 2004. UNAIDS/04.45E. Geneva: UNAIDS; 2004. |
|2.||Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, et al. The growing burden of tuberculosis: Global trends and interactions with HIV epidemic. Arch Intern Med 2003;163:1009-21. |
|3.||The global tuberculosis epidemic. Available from: http://www.theglobalfund.org/en/about/fighting/tuberculosis/default.asp. [Last Accessed on 2004 Dec 12]. |
|4.||World Health Organization. Tuberculosis facts 2007. PDF Icon Non-CDC Web Link. Available from: http://www.cdc.gov/hiv/resources/factsheets/hivtb.htm. [Last Accessed on 2008 Jan 14]. |
|5.||Ravigilione MC, Snider DE, Kochi A. Global epidemiology of tuberculosis morbidity and mortality of a worldwide epidemic. JAMA 1995;273:220-6. |
|6.||Narain JP, Pontali E, Tripathy S. Sentinel surveillance for HIV infection in tuberculosis patients in India. Indian J Tuberc 2002;49:17-20. |
|7.||Khatri GR, Frieden TR. Controlling tuberculosis in India. N Eng J Med 2003;347:1420-5. |
|8.||Kaiser Weekly TB/Malaria Report. HIV/TB co-epidemic rapidly is spreading in sub-Saharan Africa. Available from: http://www.globalhealth.kff.org/Daily-Reports/2007/02/dr00048620aspx. [Last Accessed on 2007 Nov 2]. |
|9.||Sharma SK, Agarwal G, Seth P, Saha PK. Increasing seropositivity among adult tuberculosis patients in Delhi. Indian J Med Res 2003;117:239-42. |
|10.||Paranjape RS, Tripathy SP, Menon PA, Mehendale SM, Khatavkar P, Joshi DR, et al. Increasing trend of HIV seroprevalence among pulmonary tuberculosis patients in Pune, India. Indian J Med Res 1997;106:207-11. |
|11.||Govt. of India, Ministry of Health and Family. Welfare, National AIDS Control Organisation. National guidelines for clinical management of HIV/. AIDS 2003. Available from: http://www.nacoindia.org. [Last Accessed on 2011 Nov 15]. |
|12.||Dey SK, Pal NK, Chakrabarty MS. Cases of immunodeficiency virus infection and Tuberculosis -Early experience of different aspects. J Indian Med Assoc 2003;101:291-2, 294, 296 passim. |
|13.||Nissapatorn V, Christopher L, Init I, Mun Yik F, Abdullah KA. Tuberculosis in AIDS Patients. Malays Med Sci 2003;10:60-4. |
[Figure 1], [Figure 2]
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