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.
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
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