|Year : 2015 | Volume
| Issue : 4 | Page : 496-502
Human immunodeficiency virus and hepatitis B virus co-infections among tuberculosis patients attending a Model Rural Health Research Unit in Ghatampur, North India
T Hussain1, KK Kulshreshtha2, VS Yadav3, K Katoch4
1 Regional Medical Reasearch Centre, Bhubaneswar, Odisha-751 023; Clinical Division-I, National JALMA Institute for Leprosy and Other Mycobacterial Diseases (ICMR), Tajganj, Agra-282 001, Uttar pradesh, India
2 HIV/AIDS UNIT; Clinical Division-I, National JALMA Institute for Leprosy and Other Mycobacterial Diseases (ICMR), Tajganj, Agra-282 001, Uttar pradesh, India
3 Division of Biostatistics, National JALMA Institute for Leprosy and Other Mycobacterial Diseases (ICMR), Tajganj, Agra-282 001, Uttar pradesh, India
4 Clinical Division-I, National JALMA Institute for Leprosy and Other Mycobacterial Diseases (ICMR), Tajganj, Agra-282 001, Uttar pradesh, India
|Date of Submission||28-Oct-2014|
|Date of Acceptance||24-Apr-2015|
|Date of Web Publication||16-Oct-2015|
Regional Medical Reasearch Centre, Bhubaneswar, Odisha-751 023; Clinical Division-I, National JALMA Institute for Leprosy and Other Mycobacterial Diseases (ICMR), Tajganj, Agra-282 001, Uttar pradesh
Source of Support: None, Conflict of Interest: None
Introduction: This prospective cross-sectional hospital-based study was carried out in order to assess the prevalence of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infections among patients with active tuberculosis (TB) disease attending an Outpatient Department (OPD) at the Model Rural Health Research Unit in Ghatampur, a rural village in Kanpur district. Materials and Methods: The socio-demographic features and clinical profile of the TB patients were analysed in the context of symptoms at the time of testing. The HIV and HBV status were determined and correlated with clinical features at the time of testing. Results: In our study, the prevalence of HIV infection among TB patients is 1.48% (18/1215) and that of HBsAg reactivity was found to be 2.96% (36/1215). During 2007–2010, the HIV-positivity varied between 1.5% and 1.45% whereas HBV reactivity ranged between 2.4% and 3.63%.A substantial percentage of the TB patients attending the OPD in Ghatampur harbour HIV and HBV infections, which otherwise would remain undiagnosed without serological screening. Conclusion: Co infection with HBV among TB patients potentiate the risk of anti-tuberculous therapy-induced hepatotoxicity, therefore, exercising caution and carefully monitoring the patients for drugs associated hepatotoxicity is essential. There is an urgent need to perform population-based surveys of HIV and hepatitis infections among TB patients to assess the true extent of the problem. Efforts should be made to make physicians aware of the peculiarities and manage these patients effectively.
Keywords: Ghatampur, hepatitis B virus, human immunodeficiency virus, North India, prevalence, rural area, tuberculosis
|How to cite this article:|
Hussain T, Kulshreshtha K K, Yadav V S, Katoch K. Human immunodeficiency virus and hepatitis B virus co-infections among tuberculosis patients attending a Model Rural Health Research Unit in Ghatampur, North India. Indian J Med Microbiol 2015;33:496-502
|How to cite this URL:|
Hussain T, Kulshreshtha K K, Yadav V S, Katoch K. Human immunodeficiency virus and hepatitis B virus co-infections among tuberculosis patients attending a Model Rural Health Research Unit in Ghatampur, North India. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 12];33:496-502. Available from: http://www.ijmm.org/text.asp?2015/33/4/496/167344
| ~ Introduction|| |
Human immunodeficiency virus (HIV) and hepatitis B virus (HBV) co-infections have emerged as a leading cause of morbidity due to liver disease throughout the world in the last two decades.,
Among the HIV-infected patients, HBV co-infection is more prevalent due to overlapping transmission routes. The introduction of highly-active antiretroviral therapy has led to a marked reduction in the morbidity and mortality and has resulted in increased survival in HIV-infected patients., Consequently, the importance of co-morbidities such as chronic liver disease due to HBV infection is being recognised as a significant problem. In co-infection, the presence of one virus impacts the natural history of the other virus. HIV accelerates the natural course of HBV infection and facilitates the faster progression of liver disease to cirrhosis and hepatocellular carcinoma. Disease progression to cirrhosis in HIV-positive patients is almost 3-times faster as compared to HIV negative patients. Most of the studies in HIV-HBV co-infected patients have been conducted among western patient populations. Understanding HBV co-infection with HIV is particularly important in Asian countries due to high background prevalence of HBV.
The present study was undertaken to estimate the prevalence of HIV and HBV co-infections among patients with active tuberculosis (TB) disease attending an Outpatient Department (OPD) at the Model Rural Health Research Unit (MRHRU) in Ghatampur, a rural village in Kanpur district of Uttar Pradesh. MRHRU in Ghatampur is an ICMR research field unit of the National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Agra for research in TB and leprosy and serves the population of adjoining rural areas of Kanpur district. The socio-demographic features and clinical profile of the TB patients were analysed in the context of symptoms at the time of testing. Many risk behaviours as well as the routes of transmission for HIV and HBV are identical. This was precisely the reason for which the TB and HIV-infected sera samples were tested for HBV. This is the first report of the HIV and HBV screening among TB patients in a rural area in this region of the country.
| ~ Materials and Methods|| |
The detailed plan of study was submitted to the Ethical Committee as well as the Scientific Advisory Committee of the Institute, which approved the assumptions for human research.
This was a prospective cross-sectional hospital-based study.
The present study was carried over a period of 4 years, from 2007 to 2010. A total of 1215 TB patients were included in the study and screened for HIV-1/2 and HBV antibodies.
Tuberculosis patients attending an OPD of MRHRU at Ghatampur, Kanpur were included in the study. They came for treatment of TB and various investigations like HIV and HBV were done. The inclusion criterion was adult TB patients between the age group of 15 and 65 years, with active TB disease. Children and old patients were excluded from the study assuming they were not likely to be sexually active. In order to ensure that the patients were not screened, over and over again, their OPD cards were marked, "HIV-HBV screened". This helped in excluding the repeat testing of the patients. The socio-demographic data namely, age, gender, marital status, residential background, education, occupation/profession, symptoms at the time of testing, type of disease, status of initial infection/disease and history of earlier treatment, etc., were recorded and patients were given pre-test counselling. They were interviewed using a standard questionnaire of the National AIDS Control Organisation (NACO). The Counsellors elicited the information regarding their complaints during pre-test counselling session and as well as after handing over the test result (post-test counselling session). The questionnaire elicited detailed information about their condition. The diagnosis of active TB disease was confirmed based on the signs, symptoms, clinical, radiological and bacteriological findings.
Blood samples, 3 ml were collected aseptically by ante-cubital venipuncture from clients, after obtaining pre-informed consent in the NACO format. Socio-demographic data like age, gender, marital status, education, occupation, complaints at the time of testing, etc., were recorded. Pre-test, post-test and follow-up counselling were provided to the patients. The sera samples collected after centrifugation at 2500 g were stored at −20°C until the assays were performed. Sera samples were tested by 2 ERS (ELISA, rapid and simple assays as is the strategy of NACO to assess the HIV status.
ELISA was done using MICROLISA kit (J. Mitra and Co. Pvt. Ltd., A 180–181, Okhla Ind. Area, Ph-1, NewDelhi). Those found positive were confirmed by rapid and simple assays, namely Capillus HIV-1/HIV-2 latex aggregation assay (Trinity Biotech PLC, Ireland) and/or Instachk HIV 1 + 2 (One Step Anti-HIV [1 and 2] Tri-Line Test (Intec Products, Inc. P.R.C., Transasia Bio-Medicals Ltd., Mumbai) and/or, Diagnos HIV Bi-dot (J. Mitra and Co. Pvt. Ltd., A 180–181, Okhla Indl. Area, Ph-1, New Delhi). Sera samples of the TB patients were also screened for HBV using immunochromatography (ACON HBsAg-One step HBsAg test device [serum/plasma] marketed by Rapid Diagnostics Pvt. Ltd., India-manufactured by Acon Biotech [Hangzhou] Co. Ltd., China).
Tuberculosis patients, irrespective of their HIV status were referred to the nearest DOTS centre, Kanpur. HIV-positive TB patients were referred to anti-retroviral treatment Centre, G.S.V.M. Medical College, Kanpur after post-test counselling, for further treatment, care, and management.
The demographic and clinical data were statistically analysed using the SPSS software version 15.0, and Chi-square and Fisher's exact test with 5% level of significance were used to measure the association between the variables and infection rates. Normal t-test was applied to test the equality of proportion.
| ~ Results|| |
In this hospital-based study, which was carried over a period of 4 years, from 2007 to 2010, 1215 TB patients were screened for HIV-1/2 antibodies and HBV. Of 1215 patients, 18 were found to be HIV-positive. Therefore, the prevalence of HIV infection among TB patients in Ghatampur is 1.48% (18/1215) and HBV reactivity was found to be 2.96% (36/1215). [Table 1] depicts the trend of HIV-positivity and HBV reactivity among the TB patients. During 2007–2010, the HIV-positivity varied between 1.5% and 1.45% whereas HBV reactivity ranged between 2.4% and 3.63%.
|Table 1: Depicts the trend of HIV and HBV-positivity among TB patients from year 2007 to 2010|
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[Table 2] shows the socio-demographic profile of the TB patients. There is a clear gender bias in TB patients attending the OPD that is, 77.71% males attended the OPD compared to 22.28% females. About 1.5% of the males and 1.1% females were HIV-positive whereas 2.7% males and 3.7% females were reactive for HBV. There is statistically no significant difference in gender in HIV-positive clients. Among the age groups, which were divided into <20, 21–30, 31–40, 41–50 and 51–60 years, HIV-positivity of 2% was observed in the age group, 21–30 years and 1.2% in the age group, 31–40 years. HBV reactivity was high among the 3 age groups, 2.2% in 21–30, 2.4% in 31–40 and 5.2% in 41–50 years. This shows that it is prevalent among the most productive years of the life.
|Table 2: Depicts the socio-demographic profile of HIV-positive/HIV-negative TB patients and HBV-reactive/non-reactive TB patients|
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With regard to marital status, among 59% of married clients, 38% of unmarried and 3% of single clients, maximum HIV-positivity of 1.3% and HBV reactivity of 2.6% was observed among the clients who were married. This emphasises the fact that being sexually active could be one of the factors for acquiring the infections. The observed difference in HIV-positivity among the married as well as the bereaved clients when compared with unmarried clients is statistically significant (P < 0.000l).
About 62% of the TB patients were illiterate, and 33.3% had studied up to primary school but 1.1% and 2.6% of the illiterate patients were HIV-positive and HBV-reactive, respectively. Literacy status had a statistically significant (P < 0.001) impact on HIV and HBV-positivity. About 78% of labourers that is, migrant workers (who have stayed away from their families for sometime due to work or other responsibilities). Of these, 1.2% of the labourers and 8.5% having no specific job were HIV-positive whereas 2.5% of the labourers and 5.7% having no specific job were HBV-reactive. Occupation of the TB patients had a statistically significant (P < 0.001) impact on HIV-positivity. [Table 3] shows the clinical profile, viz., type of TB, category of TB, Mantoux test, Sputum Examination and history of the contact of the HIV-positive, HIV-negative, HBV-reactive and HBV non-reactive TB patients.
|Table 3: Depicts the clinical profile of HIV-positive and HIV-negative TB patients and HBV-reactive and non-reactive TB patients|
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Among HIV-positive TB patients, 72.2% (13/18) were of pulmonary and 27.7% were of extra-pulmonary type. About 1.2% of pulmonary TB patients and 3.2% of extra-pulmonary type TB patients were HIV-positive. This appeared to be marginally significant (P < 0.056).
About 50% each were Cat-I and Cat-II type of TB patients. Further, 1.2% of Cat-I and 1.7% of Cat-II patients were HIV-positive. About 2.2% of HIV-positive TB patients were purified protein derivative (PPD) positive and 1.1% were PPD negative. The bacillary examination from sputum revealed that bacillary positivity was 2.3% and bacillary negativity was 0.38% among the HIV-positive TB patients. Bacillary positive status was statistically significant factor of HIV-positivity (P < 0.005). About 1% of TB patients had a history of positive contact, that is, spouse or one of the family members was HIV-infected. About 4% of the TB patients had no contact with HIV-positive individuals. History of positive contact played a significant role in HIV-positivity (P < 0.003).
About 2.2% of pulmonary TB patients and 7.6% of the extra-pulmonary type of TB patients were HBV-reactive. This appeared to be significant (P < 0.001). Further, 2.7% of Cat-I and 3.3% of Cat-II patients were HBV-reactive. About 3.5% of HBV-reactive TB patients were PPD positive and 2.7% were PPD negative. The bacillary examination from sputum revealed that bacillary positivity was 3.0% and bacillary negativity was 2.8% among the HBV-reactive TB patients. About 1% of TB patients had a history of positive contact, that is, spouse or one of the family members was HBV-reactive. About 9% of the TB patients had no contact with HBV-reactive individuals. History of positive contact played a significant role in HBV-reactivity (P < 0.001). Statistical analysis showed that age group, category (Cat-I and Cat-II), Mantoux test and bacillary index were not significantly different amongst the groups.
The major signs and symptoms among these TB patients were fever, cough, anorexia, loss of weight, lethargy, diarrhoea, pallor, lymphadenitis, and hepatosplenomegaly along with correlative positive chest radiography and respiratory findings. Among the HIV-positive TB patients, fever, loss of weight, cough, anorexia, lethargy, pallor and positive chest radiography were more common than those patients having TB only. The difference in the above symptoms among the HIV-positive and HIV negative TB patients was found to be statistically significant as analysed by the Chi square test, (P < 0.0001 for all the 5 parameters). HIV-positive patients are more likely to suffer from fever and weight loss while HIV negative are more likely to suffer from cough. Therefore, HIV-positive TB patients are less infectious.
In this study, only 25% (9) of the patients presented with features of hepatitis, that is, jaundice. The others presented with other HIV-related co-morbidities such as diarrhoea and weight loss. This shows that most of these infections (HBV) are clinically asymptomatic and likely to be chronic. They might be missed unless actively sought for. Pulmonary TB may be a risk factor for the clinical expression of chronic HBV infection because of the hepatotoxic effects of potent anti-TB drugs used in its treatment.
The mode of transmission of HIV and HBV infections among TB patients was heterosexual as revealed during the post-test counselling session. None of the HIV-positive and HBV-reactive cases admitted of having a homosexual relationship.
| ~ Discussion|| |
Tuberculosis, which is a major public health problem in most of the developing world, is posing a big threat with the worldwide epidemic of HIV infection. Globally, there are more than 14 million persons dually infected with TB and HIV ,, and India accounts for more than 1 million of them.,, HIV-TB co-infections have been reported from other parts of India by several authors. [Table 4] depicts the comparative figures of HIV seropositivity in TB patients in India. Although these periodic studies indicated that the rates of HIV-positivity are rapidly increasing among these patients,,,,,,,,,,,,,,,,,,, India continues to be in the category of low prevalence countries with overall prevalence rates ranging from 0.5% to 20%. Awareness about HIV/AIDS and HBV infections among these TB patients is lower despite various IEC programs with a wide coverage in print and electronic media.
|Table 4: Depicts a comparison of HIV - seropositivity in TB patients in India|
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In our study, the prevalence rate of HIV infection among TB patients is 1.48% (18/1215) and HBV reactivity was found to be 2.96% (36/1215). A substantial percentage of the TB patients attending the OPD in Ghatampur harbour HIV and viral hepatitis infections, mainly HBV which otherwise would remain undiagnosed without serological screening. Co infection with HBV among TB patients potentiate the risk of anti-tuberculous therapy-induced hepatotoxicity, therefore, exercising caution and carefully monitoring the patients for drugs associated hepatotoxicity is essential. Hepatitis B infections among TB patients have been reported in different studies.,,,,, These studies found a stronger association (P < 0.001) between the presence of HBsAg and TB suggesting that HBV carriers might be at a higher risk of contracting TB. There are only a few reports from our country on the prevalence of HBV/hepatitis C virus in HIV patients, and the observations have been highly variable. Co-infection observed in these studies was 30.4% from Nagpur, 2.25% from Lucknow, 7.7% from Chennai and 3.5% from Mumbai.,,,, In India, HIV testing and counselling services are offered free of cost to all the clients attending the Integrated Counselling and Testing Centre (ICTCs). Mushrooming of ICTCs in every district of the states of India has helped in the early detection of the infection but still a lot needs to be done.
| ~ Conclusion|| |
A low prevalence of HBV is associated with HIV infection among TB patients attending the MRHRU in Ghatampur, North India. Interventions to prevent HIV and HBV transmission among TB patients include counselling for patients and preventive intervention programs that attempt to change high-risk behaviour. Cost-effective drug treatment and HIV prevention programs for TB patients are needed in all areas of the country in order to reduce morbidities and mortalities from liver diseases amongst HIV-positive patients. HIV infection may predispose to many infections like TB and HBV. There is, however, serious implications of co-infection with both organisms especially in resource poor rural centres like the one in which our study was done. Efforts should be made to make physicians aware of the peculiarities and manage these patients effectively.
Co-infections in HIV-positive patients are of great importance, both as a public health concern and in the provision of appropriate antiviral and antibacterial treatments. There is an urgent need to perform population-based surveys of HIV and Hepatitis infections among TB patients in India to assess the true extent of the problem. We, therefore, feel that screening the patients with active TB disease, irrespective of the pulmonary or extra-pulmonary involvement, for HIV and HBV infections would go a long way in early detection of co-infections. An early treatment, if initiated, would help in preventing further spread of both the infections. There is a need, therefore, to support an approach of targeted screening, integrate HIV testing, counselling and referral services into the existing system for HIV/hepatistis/TB prevention and/or treatment services.
Hepatitis B virus DNA detection by polymerase chain reaction was not done due to unavailability of the technology. This may have increased the prevalence of HBV in our study as it would allow early diagnosis of these infections before surface antigen of HBV were detectable in serum. Limited availability of funds prevented viral load studies as well as measurement of other serologic viral markers among the co-infected patients.
| ~ Acknowledgments|| |
The authors thankfully acknowledge the Counsellors of the ICTC, Mr. Mohd Arif, Ms. Bharti Devi and Ms. Bharti Verma for eliciting the information from clients and Mr. Sushil Prasad, Lab. Technician, ICTC for assistance in the study.
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[Table 1], [Table 2], [Table 3], [Table 4]