Tuberculosis is the most common HIV-related opportunistic infectionin India, and caring for patients with both diseases is a majorpublic health challenge. India has about 1.8 million new casesof tuberculosis annually, accounting for a fifth of new casesin the world — a greater number than in any other country(see pie chart).1 Patients with latent Mycobacterium tuberculosisinfection are at higher risk for progression if they are coinfectedwith HIV. Patients with HIV infection have a similar bacteriologicresponse to tuberculosis treatment as those who are not infectedbut have higher risks of recurrence and death. The influenceof tuberculosis coinfection on the progression of HIV diseaseis controversial.2
Data are from the World Health Organization. The other high-burden countries, in descending order of number of cases, are the Philippines, Kenya, the Democratic Republic of Congo, Russia, Vietnam, Tanzania, Uganda, Brazil, Afghanistan, Thailand, Mozambique, Zimbabwe, Myanmar, and Cambodia.
In 2004, about 330,000 people in India died from tuberculosis.1Two of every five persons — more than 400 million —have latent tuberculosis infection.3 Tuberculosis can be expectedto develop in more than half of those who are also infectedwith HIV. At present, however, only about 5% of new tuberculosiscases in India occur in people with HIV coinfection. The situationdiffers from that in sub-Saharan Africa, where the incidenceof tuberculosis in many countries is higher than in India andas many as 80% of patients with tuberculosis are coinfectedwith HIV. In Africa, HIV has reversed gains in tuberculosiscontrol that were achieved a quarter-century ago.1,2 Such areversal is unlikely to occur in India.4
India began its Revised National Tuberculosis Control Programin 1993.5 Its mainstay is the strategy of directly observedtreatment, short course (DOTS). Typically, during the initial2 to 3 months of treatment, medication is administered threetimes a week under direct observation. During the subsequent4 to 5 months, at least one of the three weekly administrationsis directly supervised.3
After pilot testing, rapid expansion of DOTS began in the late1990s, and in March 2006, India achieved nationwide coverage(see line graph). Each month, more than 100,000 Indian patients— about two fifths of them persons with a new positivesputum smear — begin treatment. The success rate of treatment— the percentage of new smear-positive patients who arecured (i.e., whose sputum smear is negative) plus the percentagewho complete treatment without bacteriologic confirmation ofcure — is about 86%.1 In about 2% of patients, treatmentfails; in 7% treatment is interrupted for 2 consecutive monthsor more; and 4% die despite treatment.3 The estimated incidenceof multidrug-resistant tuberculosis is 2.4% among patients withnew cases and 15% among those who have previously received treatment.In 2006, the national budget for treatment was $57 million andthe total cost of tuberculosis control was $100 million.1
Population with Access to DOTS, for Tuberculosis, and Patients Receiving DOTS.
Data are from the Revised National Tuberculosis Control Program, India.
India's national tuberculosis-control program provides care,diagnosis, and treatment on a huge scale3,5 — offeringan example that the National AIDS Control Program may be ableto learn from as it expands. Of course, HIV treatment is oftenmore complex and expensive than tuberculosis treatment and mustcontinue indefinitely. When patients with HIV infection aretreated at the same facility as those with tuberculosis, effectiveinfection-control measures are essential, given the high riskof nosocomial transmission of tuberculosis. When caring forcoinfected patients, physicians must consider many clinicalissues, such as those related to the prevention of disease;the timing of treatment; the choice of medications; drug interactions,side effects, and resistance; and potential reinfection withother mycobacterium strains. Antiretroviral therapy is essentialfor reducing the number of deaths from tuberculosis that arerelated to HIV infection.4
In India, tuberculosis care and HIV care are increasingly beingcoordinated, but the full benefits have yet to be realized.An example of successful coordination is the referral of peoplewith suspected tuberculosis from voluntary counseling and testingcenters for HIV to tuberculosis-control facilities. BetweenJanuary and September 2006, a total of 15,000 people with suspectedtuberculosis who were HIV-positive and 16,420 who were HIV-negativewere referred to such facilities by centers in the six Indianstates with the highest HIV prevalence (Andhra Pradesh, Karnataka,Maharashtra, Manipur, Nagaland, and Tamil Nadu); tuberculosiswas diagnosed in 22.3% and 23.9% of patients in these groups,respectively. DOTS was begun in many of these patients. Thecontrol of both tuberculosis and HIV is likely to be most successfulif programs collaborate whenever possible and are closely integratedwith the rest of medical care.2
Source Information
Dr. Steinbrook (rsteinbrook{at}attglobal.net) is a national correspondent for the Journal.
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