HIV/Tuberculosis co-infection
'We cannot win the battle against AIDS if we do not also fight Tuberculosis. Tuberculosis is too often a death sentence for people with AIDS'. Nelson Mandela.
HIV/AIDS and Tuberculosis (TB) co-infection is when an individual has both been diagnosed as having HIV/AIDS and Tuberculosis simultaneously.
It must be noted that even though there are days when these major diseases are focussed on December 1 and May 24 for HIV/AIDS and tuberculosis respectively), a few unfortunate individuals who have been infected have special remembrance for both days.
UNAIDS reports that at the end of 2006, 39.5 million adults and 2.3 million children were living with HIV. During 2006, 4.3 million people acquired HIV; 530,000 of them being children and 2.9 million people died of AIDS-related illness; 380,000 as children. Ninety-five per cent of people living with HIV live in the developing world. There are 13,800 new HIV infections a day, 1,500 new infections are due to maternal-infant transmission.
Currently, two billion people have been infected with Mycobacterium tuberculosis. There are nine million new cases of TB each year with two million deaths each year.
A third of HIV deaths in Africa is attributable to active TB.
HIV will add approximately one million new cases of tuberculosis each year. Globally, nine per cent of all new TB cases in adults are attributed to HIV (31 per cent in Africa). Of the 1.8 million TB deaths, 12 per cent is attributable to HIV.
In sub-Saharan Africa HIV seroprevalence rate among patients with TB are high, ranging from 24- 67 per cent. In children, with TB seroprevalence of HIV ranges from 10-60 per cent. In developing countries TB is the most common life-threatening opportunistic infection in patients with HIV/AIDS, with about 25 to 65 per cent of patients with HIV/AIDS having TB of any organ.
The HIV pandemic has caused a resurgence of TB, resulting in increased morbidity and mortality world-wide. HIV and Mycobacterium TB have a synergistic interaction: Each accentuates progression of the other.
HIV directly attacks the critical immune mechanism involved in protection against infection, including tuberculosis. TB can appear at any stage of HIV infection but its presentation varies with the stage.
When cellular mediated immunity is only partially compromised, pulmonary tuberculosis presents as a typical pattern of upper lobe infiltrate and cavitations without significant lymphadenopathy (swollen lymph nodes) or pleural effusion (an accumulation of fluid between layers covering the lungs).
At the late stages of HIV infection, a primary TB-like pattern with diffuse interstitial or miliary infiltrates with little or no cavitations, and intrathoracic lymphadenopathy is more common.
Overall, sputum smear may be less positive among TB patients with HIV infection than among those without: thus the diagnosis of TB may be unusually difficult, especially in view of the variety of HIV-related pulmonary conditions mimicking tuberculosis. Extra pulmonary TB is more common in HIV than Pulmonary TB.
TB is a leading cause of morbidity and mortality in patients with HIV/AIDS. HIV and TB are also intricately linked to malnutrition, unemployment, alcoholism, poverty and homelessness. The direct and indirect costs of illness due to TB and HIV are enormous, estimated to be more than 30 per cent of annual household income in developing countries and has a catastrophic impact on the economy in the developing world. Thus co-infection with HIV and TB is not only a medical malady, but a social and an economic disaster and is aptly described as the 'cursed duet'.
Management of HIV-TB co-infection can be a big challenge and very difficult. Some patients may be on only anti-TB, others may be on both anti-retroviral and anti-TB. The type of regimen is influenced by the stage of the disease, CD4 count or viral load.
The preferred anti-retroviral therapy is the HAART (Highly Active Anti-retroviral Therapy) and that of anti-TB is the DOTS (Direct Observed Therapy Short-course).
Treatment of TB in HIV –infected individuals is most likely to be successful when it is begun early. Recent evidence also suggests that the presence of TB in HIV-infected individuals may hasten the progression of AIDS. It is therefore essential for a person who is HIV-positive or who has AIDS to be alert for respiratory symptoms such as coughing or shortness of breath, as well as other symptoms, such as fever, weight loss and night sweats that may suggest active TB infection.
Some of the challenges in managing HIV-TB co-infection include drug-drug interaction. Because of the interaction between protease inhibitors (antiretroviral) and rifampicin (anti-TB) there is sometimes the need to modify treatment in patients who are co-infected.
There is also the issue of overlapping drug toxicity. For instance, Nevirapine (antiretroviral) causes acute hepatitis,and so does rifampicin. Thus the adverse effects on the patient increases.
Moreover, the complexity of therapy can also be a big barrier to effective treatment. HAART has a minimum of three drugs and DOTS can have up to four drugs during the intensive phase. This cocktail of drugs makes compliance very poor. This is compounded by the long duration of therapy.
Multidrug-resistant TB (MDR-TB) is dangerous for all people but it's especially dangerous for individuals who are HIV infected. MDR-TB can develop when a patient with TB does not complete his or her full drug therapy.
One other problem that may come up with HAART is IRIS (Immune Reconstitution Inflammatory Syndrome). It is defined as a paradoxical clinical deterioration after starting HAART, resulting from improving immune system- system interaction with organisms that have colonised the body during the early stages of HIV infection. Some of the pathogens that cause IRIS include Mycobacterium tuberculosis, Mycobacterium avium complex, Cryptococcus neoformans, Candida albicans and Hepatitis B.
Non-pharmacological management includes adherence counselling for good compliance and also counselling through the stages of either acute or anticipatory grief which are denial, anger, bargaining, despair and acceptance.
The healthcare provider must show compassion to people co-infected. They must see them as having chronic diseases like hypertension and diabetic mellitus. Family members and care takers must support patients through difficult moments and show genuine love to them.
The public should not discriminate against those having the co-infection. So far as there is no cure for HIV and tuberculosis remains endemic in Ghana, we all remain at risk.
Even though the main mode of transmission of HIV is through heterosexual relationship (70 per cent), there are other modes of infection including blood transfusion, use of contaminated instruments like shaving blades, needles and equipment for manicure and pedicure. Drug addiction and homosexual relationships are risk factors as well.
HIV can largely be prevented by abstinence, being faithful to one's partner and the use of condoms. Also public use of unsterilised instruments such as those used for barbering, shaving, manicure and pedicure should stop. Contaminated needles, blades and blood products should also be avoided.
Tuberculosis, which is airborne, can be prevented by avoiding inhalation of infected droplets from an infected individual.
WORLD AIDS DAY has been celebrated and is now history but HIV/TB co-infection is real. Even though management may be difficult, we need to show sympathy to infected individuals and make informed effort to protect ourselves.