TB/HIV collaboration at the community level

We wholeheartedly welcome GeneXpert that will make TB diagnosis easier in coming future. But we should not also perceive the current non-availability of GeneXpert as an absolute hindrance to the collaborative program of TB/HIV.

We should remember few points in TB/HIV.

Pulmonary TB is the most common form of TB disease among PLHIV which generally manifest similar clinical features, namely cough, fever, night sweats, coughing out blood and weight loss like an HIV uninfected person. The presentation may sometimes vary with the degree of immune suppression. In PLHIV with mild immune suppression the clinical picture of TB resembles usual adult post-primary pulmonary TB; that is sputum smear is frequently positive for TB bacilli, and the chest X-ray typically may show unilateral or bilateral upper lobe infiltrates, cavitations, pulmonary fibrotic changes and volume loss.

In the advanced form of immune suppression, the clinical picture becomes complex due to involvement of organs other than lungs (extra-pulmonary TB) with disseminated nature of the disease. The clinical picture of pulmonary TB also shows more atypical pattern with sputum smear result showing frequently negative result. Diagnosis, and especially management of TB becomes extremely challenging during this phase.

It is very important to suspect and detect TB among the PLHIV in the early stage when the diagnosis of sputum smear positive pulmonary TB can be easily conducted through sputum smear microscopy available at RNTCP and the affected person can be treated and cured by DOTS strategy without major difficulties.

Efforts to detect TB early should be intensified in all the home based care programs of PLHIV. TB should be suspected on the appearance of any early warning symptoms (a person infected by HIV and with cough of any duration is a TB suspect) like cough, evening rise of temp, night sweats, loss of appetite, loss of weight etc. and the person should immediately report to the local RNTCP services. The HIV infected persons should be thoroughly educated on TB and RNTCP in the home based care programs. They should be continuously motivated to seek the services of RNTCP on the slightest doubt of TB. This is extremely important, especially for those people who generally don’t visit ART centres or other HIV service points either due to relatively ok health or lack of knowledge about those services. It is estimated that about 80% of the PLHIV don’t visit the healthcare outlets and making those clinic absentees aware on TB, TB symptoms and RNTCP services is hugely critical to protect their lives from the menace of TB.

The PLHIV networks at national and state level should take the primary and key steps to reach the HIV infected people located at the peripheries with the necessary TB messages through a strong collaboration with National AIDS Control and TB Control Programs.

Those national and state PLHIV networks should ensure that,

1)   TB screening, referral to RNTCP and awareness generation is regularly happening in the home based care programs of the PLHIV

2)   There is representation from the PLHIV members in the District TB/HIV coordination Committees

3)  The local PLHIV groups are regularly advocating for quality TB/HIV collaboration in the districts

4)      TB patients are regularly reaching ICTC for HIV counseling and testing

5)  TB patients infected by HIV are receiving Co-trimoxazole Prophylactic Therapy and also accessing the services of ART centers

TB transmission through droplet nuclei can be minimized by adopting appropriate measures of airborne infection control like maintaining strict cough etiquette and cough disposal, personal hygiene both at home, healthcare facilities and outside places. The PLHIV networks once again can take key role to sensitize the members of infected communities on airborne infection control and ensure their safety from possible TB transmission. The necessary technical support can be always sought from the National Programs.

TB is preventable and completely curable. Let’s respond to the need of the people living with HIV promptly to make their lives well protected from TB.  I am confident this can be largely achieved with the services we currently have in our National Programs.

The discussions and advocacy activities for GeneExpert can always go side by side.

Sugata Mukhopadhyay

UNIVERSAL Health

FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

                                          No condom No sex 

Part Three

1.11 How STI management can help

Treatment and cure from STIs decrease -

• Susceptibility to HIV
• Concentration of viral load in genital secretion
• Shedding of HIV in genital secretion
• STIs & HIV both associated with unprotected sex with multiple partners. So same measure that prevent STIs can also prevent sexual transmission of HIV
• Spread of HIV infection in the community
• Reduces serious complications of mothers & children like cervical cancer, ectopic pregnancy, infertility, still birth

1.12 Objectives of STI Management and control:

·        To prevent new infections

·        To treat those who are symptomatic & seeking treatment

·        To treat those who are symptomatic but not seeking treatment

·        To treat those who are symptomatic, seeking treatment without success due to lack of quality STI services

·        To identify and treat those who are asymptomatic

·        To treat the partners of the cases

1.13 Basic approaches of prevention and control of STIs

There are three basic approaches to prevent and control STIs: -

1. Reduction of STI load/burden of the community (prevalence)
2. Reduction of  new STI cases (incidence)
3. Strengthening STI reporting and surveillance

Table 1: Reduction of STI prevalence

Major activities •         Quality STI services •         Early diagnosis and treatment of STIs among high risk groups •         Presumptive treatment of STIs •         Simultaneous treatment of the partners of the STI cases •         Promotion of STI services and health seeking

Table 2: Reduction of STI incidence

Major activities •         STI prevention by correct and consistent use of condom •         Creating sufficient awareness on STIs and HIV through strategic communication •         Prevention of STI relapse/re-infection after treatment by consistent safe sex •         Creating enabling environment of safe sex •         Practice of non-penetrative sexual acts •         Practice of abstinence, fidelity, delayed sexual debut •         This is applicable to prevention of sexual route of HIV transmission as well

Table 3: Comprehensive package of STI Services

Syndromic management of STIs Etiologic management of STIs Presumptive Treatment for asymptomatic infections Treatment of the partners STI Screening through risk assessment & screening tests Condom promotion Information Education Communication Promotion of services and health seeking

            (Peer Educators of STI clinic of Sanur, Bali, Indonesia)

FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

Part Two

1.5 STI Transmission Dynamics

Many of the STIs, especially those among female are asymptomatic. They create serious reproductive health complications if remain untreated or incompletely treated. Infertility, still birth, ectopic pregnancy, repeated abortions and cervical carcinoma are some of the grave complications of STIs in females. Asymptomatic STIs take a major share of the STI load of the community. Moreover, poor decision making and lack of access to appropriate services affects treatment outcome among females.

Many STIs remain hidden due to stigma. People seek medical care in places such as unqualified practitioners, pharmacists of the medical shops, street ‘doctors’ and receive improper and ineffective treatment. Recurrence is common among STIs such as genital herpes, genital warts. In general viral STIs are difficult to treat.

Asymptomatic, hidden, maltreated and recurrent STIs are responsible for the STI load of the community (STI prevalence). This STI load acts as the potential reservoir of the sexually transmitted diseases and infections.

New STI cases (STI incidence) appear due to continuing unprotected sexual activities, especially, among those who have multiple sexual partners. The new cases of STIs add on the existing STI load of the community. Unprotected sexual acts with many partners help to spread STIs and consolidate the community burden of STIs.  This is a vicious cycle.

1.6 Flow of STI & HIV Transmission through sexual and perinatal routes

Transmission of STIs is common among high risk groups because of sexual acts with multiple partners either as a profession (sex workers) or as a preference (MSM, Transgender). Clients and partners of the sex workers act as the bridge because they carry the infections back to the relatively low risk groups (house wives, spouses of the clients of the sex workers). STIs like HIV, syphilis and gonorrhoea are also transmitted from infected mother to the child.

1.7 Factors facilitating STI in HIV positive individuals

• Poor immune status
• Lack of awareness on STIs
• Low risk perception specially those on HAART
• Desperateness in sexual expression and behavior
• Absence of proper counseling system

1.8 Non STI genital conditions which increase vulnerability to HIV

• Poor genital hygiene
• Anal intercourse as it is more likely to injure tissues of receptive partner
• Exposed adolescent girls as cervix is less effective barrier to HIV and less production of mucus in the genital tract
• Post menopausal period due to thinning of genital mucosa and less production of mucus in the genital tract
• Unprotected sex during menstruation due to abrasions of the skin or mucus membrane
• Sexual violence like rape resulting in genital injury

1.9 Complications of STI

• Cervical cancer
• Ectopic Pregnancy, Infertility
• Miscarriage & stillbirth
• Foetal transmission
• CVS & CNS complications
• HIV infection

1.10 Challenges of STI management in women

• Asymptomatic infection more frequent (chlamydial/gonorrhoeal cervicitis)
• Delay in treatment seeking
• Complications more serious than men

FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

Part One

1. Sexually Transmitted Infections

1.1 Reproductive Tract Infections

Reproductive Tract Infections/RTIs are infections which affect the reproductive tract in males and Females.

RTIs can be caused by organisms which are normally present in/near the reproductive tract or they can be introduced by outside, (Sexual route or medical procedures).

RTIs are basically of three types,

1. Iatrogenic infections: Infections caused by medical procedures in women like unclean delivery, unsafe abortion, IUCD insertion. Example: Staphylococcus aureus, Pseudomonas

2. Endogenous Infections: Infections caused by overgrowth of organisms in the reproductive tract of women in conditions like diabetes, immune deficiency.  Example: Candida albicans and bacterial vaginosis

3. Sexually Transmitted Infections (STI): Infections caused by unprotected sexual act with multiple partners or with partner or spouse who has multiple partners.

STIs are basically of two types

Viral (Difficult to treat)

* Ulcerative: Genital herpes

* Non ulcerative: HIV, Genital Warts, HPV

Non viral (Treatable & curable)

* Ulcerative: Syphilis, Chancroid

* Non ulcerative: Gonorrhoea, Chlamydia, Trichomoniasis

1.2 STI increases vulnerability to HIV

A randomized control trial was done to evaluate the impact of improved STI case management at primary health care level on the incidence of HIV infection in a rural region of Tanzania. HIV incidence, or numbers of new HIV infections, was compared in intervention communities and control communities where no intervention was conducted.

The improved STI services were designed to be feasible for resource-poor settings and were integrated with the Tanzanian primary health care system. Patients in the intervention community were treated according to WHO recommended syndromic STI case management guidelines. As part of the intervention, an STD reference clinic was established in each community, staffs were trained, a regular supply of effective STI drugs was provided, regular supervisory visits to health facilities were conducted, and health education about STIs was delivered.

Over a two-year period, the trial demonstrated a 42% reduction in new sexually transmitted HIV infection in the intervention communities compared with the control communities. This study provides strong evidence of the impact of improved treatment of symptomatic STIs.

1.3 HIV-positive individuals who have other Reproductive Tract Infections are more likely to transmit HIV to others

Studies have shown that when HIV-positive individuals are also infected with other STIs and reproductive tract infections, their bodies are more likely to shed or release HIV cells in both ulcerative and inflammatory genital secretions. They are also more likely to shed more numbers of HIV infected cells compared to people with HIV infection alone.

A study conducted recently in Malawi measured the concentration of HIV-1 RNA (the genetic material of HIV virus) in cell free seminal plasma from HIV-1-seropositive men with urethritis before and after antibiotic therapy. The results were compared with those seen in HIV-1 seropositive men who had no clinical evidence of urethritis. Results showed that HIV-1 positive men with urethritis had HIV-1 concentrations in seminal plasma eight times higher than those in seropositive men without urethritis. After the urethritis patients were treated for their STI, the concentration of HIV-1 RNA in semen decreased significantly.

 
These results suggest that urethritis increases the infectiousness of men with HIV-1 infection and that programmes which include detection and treatment of STDs in patients already infected with HIV-1 may help to curb the HIV epidemic.

1.4 STIs and HIV – biological relationships

a)  Increased Susceptibility

• 10 fold increased risk of HIV transmission in presence of Ulcerative STIs

      and 4 fold increased risk of HIV transmission in presence of Inflammatory

      STIs/RTIs

• Ulcerative STIs results in breaks in genital tract lining or skin and create a portal of entry for HIV. Micro erosions caused by STIs also facilitate HIV entry.
• Both Ulcerative & Non ulcerative STIs & RTIs increase the concentration of T-cells in the genital secretions and genital linings that can serve as target of HIV.

b) Increased infectiousness

• HIV positive individuals who are also infected by STIs have shown increased concentration of HIV (viral load) in the genital  lesions.
• Both ulcerative & Non Ulcerative STIs and RTI increase HIV shedding in the genital secretions of HIV positive individual. Bleeding from the genital ulcer is another contributory factor.
• There is mounting evidence that some STI pathogens become more virulent in presence of HIV related immune deficiency.