Saturday, March 2, 2013

FAQ: TB/HIV Co-infection

What is a co-infection?

Co-infection means infection with more than one disease at the same time. Some co-infections commonly seen in people infected with HIV include:
• HIV/hepatitis B virus (HBV) co-infection
• HIV/hepatitis C virus (HCV) co-infection
• HIV/tuberculosis (TB) co-infection
People infected with HIV should be tested for HBV, HCV, and TB.

Why risk of Tuberculosis is higher among people living with HIV than someone without HIV?

TB germs are available in the air. When we inhale air, TB germs enter in our body through air. In all likelihood, many of us may be carrying the TB germ inside our body in inactive state. We don’t get the Tuberculosis as long as our body immune system which protects us from diseases remains strong.  When HIV damages the body immune system, the TB germ in the body becomes active and causes Tuberculosis.

Why is the risk of tuberculosis/TB higher among people with HIV?

TB germs are released in air when a TB patient coughs or sneezes. When we inhale air, TB germs enter in our body through air. In all likelihood, many of us may be carrying the TB germs inside our body.  Our body’s immune system, which protects us from the diseases keeps the TB germs inactive and prevents Tuberculosis.HIV damages body’s immune system and weakens it.  The weak immune system cannot keep theTB germs inactive any more. The TB germs become active and cause Tuberculosis.
The chance of getting TB in lifetime is around 10% in a person not infected by HIV. The chance of getting TB increases up to 50 – 60% after one is infected with HIV.

If I have HIV, when I should suspect that I may have Tuberculosis?

If one has HIV and develops any one of the symptoms of any duration like cough, fever, loss of weight, loss of appetite or sweats at night, Tuberculosis should be suspected.

How do I protect myself from Tuberculosis, if I have HIV?

a.       Know about the Tuberculosis symptoms; if you have any one of the symptoms, please visit to the TB clinic of the local public hospital or health centre. Similarly know in details where in your locality free services of TB diagnosis and treatment available in the public health system.
b.      It is advised to take Isoniazid (INH) tablet daily.This is known as INH Prophylactic Treatment (IPT). IPT prevents Tuberculosis in people living with HIV.
c.       If you are already taking Antiretroviral Treatment (ART), you should adhere to the treatment. ART reduces the chances of Tuberculosis in people living with HIV by protecting the immune system which prevents the already existing TB germ in the body from causing Tuberculosis.
d.      Always cover your mouth whenever you cough or sneeze to stop shedding TB germs into the environment and advise your friends and relatives to do the same.

If I am infected by HIV and suspect to have TB symptoms what should I do?

Please visit immediately to the near-by DMC (Designated Microscopy Centre) and get yourself evaluated for TB by the Medical Officer of DMC. Don’t waste any time by visiting private doctors or pharmacists and avoid self-medication.

Why TB patients are advised to go for HIV counseling and testing?

Almost 5% of the TB cases of India are infected by TB, which means for every 20 TB cases 1 person is infected by HIV. The death rate among HIV-infected TB cases is as high as 14% in India when the same in HIV-uninfected TB cases is 2-3%. But early diagnosis of HIV in TB cases will help the person to seek HIV care and treatment on time which will decrease chances of relapse of TB and premature death by TB in people living with HIV.
This is why all the newly diagnosed TB cases are advised to go for HIV counseling & testing.

How HIV care on time can reduce chances of relapse of TB and death by TB in people living with HIV?

TB is the commonest opportunistic infections and also the major killer of people living with HIV. In India, a person living with HIV has chance of having TB disease 50 – 60% in his life time while the same is only 10% for a HIV-negative individual. TB is estimated to cause one in four deaths among PLHIV in India.
 WHO has recommended to initiative Anti Retro-Viral Treatment (ART)[1] to all HIV-infected TB cases even without evaluating the CD4 count[2]. ART improves the CD4 count in the body which further decreases occurrence of opportunistic infections[3] in the person living with HIV including TB.

Can a person infected by HIV and affected by TB take both ART and ATT (Anti-TB Treatment) together?

Yes, the person can take both ART & ATT together under strict medical supervision. The Medical Officer of ART centre is the best person to guide you in this regards.

If a person is infected by HIV and affected by TB and not on ART, which medications should start first?

The TB medications should be started as soon as the diagnosis of TB is confirmed. Once ATT is well-tolerated by the person, ART should be initiated (generally 2-4 weeks after ATT).

What else a person who is infected by HIV and affected by TB should take other than ATT & ART?

The person should also take CPT (Co-trimoxazole Prophylactic Therapy) to prevent pneumonia caused by other opportunistic organisms.

Can DOTS be equally effective for treating TB in persons living with HIV and affected by TB?

Scientific evidences prove that DOT is equally effective to treat and cure TB in people living with HIV if treatment adherence is strictly followed.

How TB disease enhances progress of HIV in the body?

In a TB/HIV co-infected person, the immune response to TB bacilli increases HIV replication. As a result of the increase in number of viruses in the body, there is rapid progression of HIV infection. The viral load can increase by 6-7 folds. As a result, there is a rapid decline in CD4 count and patient starts developing symptoms of various opportunistic infections. Thus the health of the patient who has dual infection deteriorates much more rapidly than with a single infection. Amongst the AIDS cases, TB is the most common opportunistic infection. The mortality due to TB in AIDS cases is also high.

What are the differences of manifestation of TB in different stages of HIV infection?

Early stage (when CD4 count is normal): TB is mostly Pulmonary Sputum Smear Positive TB
Late stage (when CD4 count is below normal): Pulmonary Sputum Smear Negative TB and Extra-Pulmonary TB.

Why TB services should be integrated with HIV prevention program? (Collaboration between Targeted Intervention and RNTCP)

HIV prevention programs (known as Targeted Intervention) aims to prevention of HIV transmission in HIV high risk groups namely sex workers, IDUs, migrants and truckers. Different studies revealed that these groups are equally vulnerable to TB not only because of co-infection with HIV but also due to socio-economic factors like poverty, unhealthy life-style in crowded and poorly-ventilated places, effects of drugs, malnutrition and migration. This is why the HIV prevention programs covering these groups should be integrated with TB services to provide them TB/HIV service packages within the same strategy and intervention cost-effectively.

Universal Health

[1] Antiretroviral medicines prevent multiplication and spread of HIV in the body. After antiretroviral treatment is started, HIV can’t destroy CD4 cells like before and the CD4 count gradually rises. Usually, the CD4 test is used to determine when a person living with HIV should start the antiretroviral treatment. After antiretroviral treatment is started CD4 count is repeated time to time to know the progress achieved after the treatment.  The CD4 count is measured by a simple blood test and is reported as the number of CD4 cells per cubic millimetre of blood. People those are not infected by HIV have CD4 counts between 600 and 1200 CD4 cells per cubic millimetre of blood. People living with HIV have CD4 counts less than 500, and people who have developed AIDS can have CD4 count 200 cells per cubic millimetre or fewer.

[2] CD4 are cells in the body that protect from disease producing germs such as bacteria and viruses and prevent occurrence of diseases. CD4 count is a measurement of how many CD4-cells is circulating in the blood. Once a person is infected by HIV, HIV destroys the CD4 cells in the body and his/her CD4 count gradually falls. As CD4 count falls, the immune system of the body starts losing the power to fight against the disease producing germs. The lowering of CD4 count indicates weakening of the immune system. Improving the CD4 count and strengthening the immune system of the HIV infected person is of critical importance; otherwise he/she may be affected by life-threatening condition of AIDS.

[3] There are disease-producing germs which remain within our environment and also inside our body. In normal condition they cannot produce any diseases because our healthy immune system easily fights them off.  These germs produce diseases when the immune system is damaged and weakened by HIV. We call these diseases ‘Opportunistic Infections’ as these germs find the weak immune system the opportunity to cause diseases.

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