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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 475-479  

HIV positivity in presumptive tuberculosis cases in a tertiary respiratory care institute in New Delhi, India


1 Department of Tuberculosis and Respiratory Diseases, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
2 Department of Microbiology, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India

Date of Submission09-Dec-2019
Date of Decision04-Apr-2020
Date of Acceptance25-Jun-2020
Date of Web Publication7-Sep-2020

Correspondence Address:
Amartya Chakraborti
Room Number 6, Doctors Hostel, National Institute of Tuberculosis and Respiratory Diseases, Sri Aurobindo Marg, New Delhi - 110 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_337_19

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  Abstract 


Background: Routine screening of presumptive tuberculosis (TB) patients for HIV was advised by the Treatment and Operational Guidelines of TB in India in 2016. This was in contrast to the earlier policy in which only diagnosed TB cases underwent HIV screening. Keeping this in mind, our study was carried to look at the prevalence of HIV in presumptive TB cases in a tertiary respiratory disease hospital in New Delhi, India. Materials and Methods: This prospective observational study was carried out from 2015 to 2017 in which patients (>18 years of age) attending the outpatient department diagnosed as presumptive TB were enrolled. They underwent sputum examination in Revised National TB Control Programme Designated Microscopy Centre by fluorescence microscopy/Ziehl–Neelsen staining technique for the diagnosis of PTB, and they were taken to Integrated Counselling and Testing Centre in our hospital. Fine-needle aspiration cytology from lymph nodes and pleural or ascitic fluid studies were also done as per requirement for the diagnosis of extrapulmonary tuberculosis. Pretest counseling and HIV test were performed after informed consent. Results: Forty out of 1020 enrolled patients were HIV positive (3.9%). Fifteen out of 617 patients who were not suffering from TB came out to be HIV positive (2.4%). Our strategy led to an enhanced case finding of 15/25 (60%) new HIV-positive patients. Conclusion: Routine HIV screening in presumptive TB patients is a viable model to increase the case finding of HIV patients.

Keywords: HIV, presumptive pulmonary tuberculosis, pulmonary tuberculosis


How to cite this article:
Munjal SK, Mudavath V, Chakraborti A, Arora P, Bhall M. HIV positivity in presumptive tuberculosis cases in a tertiary respiratory care institute in New Delhi, India. Med J DY Patil Vidyapeeth 2020;13:475-9

How to cite this URL:
Munjal SK, Mudavath V, Chakraborti A, Arora P, Bhall M. HIV positivity in presumptive tuberculosis cases in a tertiary respiratory care institute in New Delhi, India. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Sep 29];13:475-9. Available from: http://www.mjdrdypv.org/text.asp?2020/13/5/475/294363




  Introduction Top


Globally and in India, tuberculosis (TB) is the most common opportunistic infection and the most common cause of death among HIV-infected individuals.[1],[2],[3],[4] Unless HIV-infected TB patients are initiated on cotrimoxazole preventive therapy and antiretroviral therapy (ART) in addition to TB treatment, mortality may remain high.[5] The first step in this process is early identification of HIV-infected persons. Globally, less than half of those living with HIV know their HIV status.[6] To facilitate early HIV case finding, the World Health Organization and International Standards for TB Care recommend Integrated Counselling and Testing Centre (ICTC) for people suspected and/or diagnosed to be having TB.[7],[8] India has adopted the policy of ICTC for TB patients.[9] The policy of offering HIV testing only to TB cases may limit opportunities of early HIV diagnosis and treatment. Moving HIV testing upstream to include all persons suspected of having presumptive TB and referred for diagnostic evaluation, though recommended internationally, HIV prevalence in this population has limited reports. Previous studies on this topic are mostly from African countries where HIV epidemic is generalized; the findings from these studies cannot be generalized to Indian situation with a concentrated HIV epidemic.[10],[11] Indian policy-makers seek evidence of the value of HIV testing of presumptive TB for HIV case finding.[12] Keeping this in mind, our study was carried out in National Institute of Tuberculosis and Respiratory Diseases (NITRD) to look into the HIV prevalence in presumptive TB coming to our outpatient department (OPD).

Objectives

  • Primary objective: To determine the HIV positivity among presumptive TB cases.
  • Secondary objective:


    1. To determine the number of newly diagnosed HIV-seropositive cases by testing all presumptive TB cases
    2. To assess the number needed to screen (NNS) to find an additional case of HIV-infected person among presumptive TB cases in comparison to diagnosed TB patients.



  Materials and Methods Top


The present study was cross sectional and observational conducted at NITRD with the aim to study HIV seropositivity in presumptive TB. Adult patients (≥18 years) attending NITRD OPD with suspicion of TB were enrolled. Presumptive TB patients were defined as per the Treatment and operational Guidelines of Revised National TB Control Programme (RNTCP) (2016) as a person with any of the symptoms and signs suggestive of TB including cough >2 weeks, fever >2 weeks, significant weight loss, hemoptysis, or any abnormality in the chest radiograph.

Presumptive TB patients underwent sputum examination in RNTCP Designated Microscopy Centre by fluorescence microscopy/Ziehl–Neelsen staining technique for the diagnosis of TB. Other diagnostic tests such as fine-needle aspiration cytology of cervical lymph node and diagnostic thoracocentesis and abdominocentesis were carried out as per clinical judgment for the diagnosis of extrapulmonary tuberculosis (EPTB). Subsequently, patients were taken to the ICTC in our hospital. Pretest counseling and HIV test were performed after informed consent. The sera were tested by 3E/R/S (ELISA/RAPID/SIMPLE) tests as per the National AIDS Control Organization guidelines (India).

The study was approved by the Ethics Committee of the NITRD, New Delhi (Letter number NITRD/PGEC/2015/7280 dated December 2, 2015).

Study area

The present study was conducted at NITRD, a tertiary care center, located in South Delhi.

Study population

This study included adult (≥18 years) males and females attending OPD among patients of presumptive TB cases with unknown HIV status.

Sample size and sample technique

A number of patients getting enrolled during the study period October 2015–May 2017 or sample size of 1020 patients whichever is earlier, fulfilling the inclusion–exclusion criteria, were included in the study. Sample size was calculated using the formula: m = Z2(1−α/2)P (1 − P)/(EP)2 where m = sample size, P = expected prevalence, EP = error in the estimation of P, α = level of significance, and Z(1−α/2)= 1.96 (for 95% confidence interval). As per the most recent data in NITRD, total population of presumptive TB diagnosed by one unit in the year 2014–2015 is 5102. Hence, total population was taken to be 5000. As per Naik B. et al.,[9] expected prevalence is 7%. It is to be estimated with 20% of P or 20% of 7% (expected relative precision). Here, P = 7%. Hence, EP = 20% of 7% = 0.014. Applying the abovementioned formula, the sample size comes out to be 1274.5 (m). However, since the population is finite, we have to apply correction, and the final sample size would be:



where N = population size, i.e., 5000.

After applying the values in the above formula, the minimum sample size required was 1016 ≈ 1020.

These had to be included randomly. Systematic sampling was adopted; since the population size was 5000, therefore, every fifth patient was included in the study to cover the sample size.

Data collection technique and tools

This study was a cross-sectional and observational study with an aim to study HIV seropositivity with presumptive TB. Patient pro forma was made, and all data were entered after informed consent. HIV testing and designated sputum smear microscopy were done simultaneously, and reports were recorded. Patients were further managed by respective chest physicians, and the final diagnosis of the patients was taken from the hospital OPD records. For example, some patients who were initially diagnosed as presumptive TB suspects with cough were later found out to have pleural effusion and their final diagnosis changed to EPTB as given in the OPD records.

Data analysis

Descriptive statistics was calculated for both types of the patients (TB and non-TB). Proportions were calculated for HIV cases in the two groups. Data were presented with the help of different types of tables, pie charts, line diagrams, etc.


  Results Top


The total study population was 1020 with a mean age (± standard deviation) of 37.03 ± 15.76. As given in [Table 1], the demographic characteristics of presumptive TB patients were analyzed, and it was found that male: female ratio was 1.7:1 (males were 63.13% and females were 36.8%). Out of 1020 patients, 40 (3.9%) patients were HIV seropositive and 980 (96.07%) were HIV seronegative. Totally forty patients were newly diagnosed cases of HIV. The ratio of HIV seropositivity percentages among males and females was 1:1. HIV seropositivity among different age groups was calculated with a range of around 10 years. The highest number of HIV-seropositive cases were found in the age group of 25–34 years (7.06%) and the lowest was found in the age group of >60 years. When the various age brackets were clubbed to encompass all patients belonging to 18–44 years, it was found that 34/40 (85%) patients who were HIV seropositive belonged to this group. Among 1020 patients, 403 (40%) were TB patients (PTB and EPTB) diagnosed by sputum microscopy and on clinicoradiological basis and 617 (60%) patients were non-TB which included respiratory diseases other than TB. Of these 403 TB patients, 306 (76%) were finally diagnosed as PTB and 97 (24%) diagnosed as EPTB. 271/306 (88.55%) finally diagnosed PTB patients were sputum positive, whereas the rest 35/306 (11.43%) were sputum negative. Out of total 25 HIV-seropositive cases of TB patients, 22 (88%) cases were PTB and 3 (12%) were EPTB. Conversely, out of the 306 diagnosed PTB patients, 22 (7.1%) were HIV positive, whereas out of the 97 diagnosed EPTB cases, 3 (3.1%) were HIV positive. 15/617 (2.4%) patients in whom TB was ruled out were found to be HIV positive.
Table 1: HIV positive rates across various patient groups

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Forty patients were diagnosed to be suffering from HIV on testing all presumptive TB patients, whereas the number dropped to 25 when only testing diagnosed TB cases. We see that our strategy of routine HIV screening in all presumptive TB led to a 15/25 (60%) increase in HIV diagnosis rates across all age groups. Similarly, in the age group of 18–44 years, our strategy led to diagnosis of 34 patients with HIV. This is in comparison to twenty patients that would have been detected on HIV testing of only diagnosed TB patients in the same age group. Hence, we see that there is an increased yield of 14/20 (70%). NNS was calculated for various hypothetical strategies, as shown in [Table 2]. It was found that 26 presumptive TB patients should be screened to diagnose an extra case of HIV among all age groups. On considering the age group of 18–44 years, it was again found that 21 presumptive TB of this age group should be screened to diagnose an extra case of HIV.
Table 2: Number needed to screen across various strategies and patient groups

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  Discussion Top


Our study has shown that there is an increase in HIV detection rates (60%) when we take into account presumptive TB among all age groups while it goes up higher to 70% if we consider population belonging to the age group of 18–44 years. Presumptive TB can easily be found out by a simple clinical history, and they can be found at all of our health facilities, starting from a primary health care to a tertiary institute like ours. With the help of our strategy, HIV detection rates can be increased to a great extent, keeping in mind that most of our health facilities now have HIV testing co-located with sputum microscopy. We have taken into account the age group of 18–44 years since they are in the productive age group and have the greatest potential of contracting and spreading HIV and once infected bring the biggest socioeconomic burden on the community. In the study done by Naik et al.,[9] they predicted that there would be a 51% increase in HIV detection rates with respect to the current rates if presumptive TB was sent for routine screening.

There are a handful of studies done in India which look into the prevalence rates of HIV in presumptive TB. In the study done by Naik et al.,[9] it was found that HIV prevalence in TB suspects was 7%, in TB patients, was 15%, and in TB suspects without TB, was 6.5%. In another study done by Kumar et al.,[13] HIV prevalence rate in presumptive TB was 5.7%. In our study, the prevalence rate in presumptive TB was 3.9%, whereas in diagnosed TB cases, it was 6.2%. This difference may be attributed to the lower HIV prevalence rates in Delhi with respect to Karnataka where these two studies were conducted[14] (0.47% vs. 0.30% respectively). However, the HIV-TB co-infection rate in our study is higher than the national average of 3.9% owing to the fact we are a tertiary referral institute for TB management.[15] Rajaram et al. did a study similar to ours in a tertiary care center in Puducherry in which they carried out HIV testing in all presumptive TB cases presenting to the pulmonary medicine OPD of the institute.[16] They found that of the 964 presumptive TB cases, 879 gave consent for HIV testing, and 33 (3.7%) turned out to be HIV positive. 5.5% of the patients who were sputum positive turned out be HIV positive in the study. The number needed to screen was 27 among presumptive TB cases and 18 among TB patients. In another study done by Palanivel et al. in Puducherry in 2013, the prevalence of HIV in presumptive TB cases was 3.3%.[17]

It can be accepted that HIV screening in TB patients is a good option in a resource-strapped nation like India. However, since the past 5 years, government spending in combating HIV-TB cohabitation has increased and so has the resources. Hence, routine screening of presumptive TB does not seem like a nonviable option any more, especially since it has potential to generate high HIV detection rates. The NNS to detect a case of HIV in the presumptive TB pool was 26, and the NNS for presumptive TB cases not subsequently diagnosed with TB was 41. However, these numbers dropped to 21 and 31, respectively, when we looked at the 18–44 age brackets. This shows that carefully picking out the correct population to screen also can increase the detection rates and reduce resource waste. Furthermore, 18–44 years is the most vital energetic working strata of our society, and hence, early detection of HIV in this age group can markedly decrease future socioeconomic losses. In the study by Naik et al.,[9] NNS in presumptive TB was 23, which increased to 37 in presumptive TB without TB, and it was 20 in presumptive PTB of the age group of 25–54 years. Again, we see that in the study done by Kumar et al.,[13] it was found that the NNS for HIV in presumptive TB was 18, whereas it dropped to 11 when considering suspects in the 25–54 age bracket. A somewhat higher NNS found in our study may be due to the difference in our methodologies, whereby we included people who satisfied criteria of presumptive TB, and the other studies included criteria for all TB suspects. Furthermore, the lower values may be explained by the fact that our institute being a tertiary respiratory institute, we received a skewed distribution of PTB, EPTB, and non-TB cases. Our institute receives lower percentages of EPTB cases such as spinal TB/Pott's spine, abdominal TB, cutaneous TB, and genitourinary TB which usually get referred to their respective specialties in other institutes. In RNTCP, the Technical and Operational Guidelines for TB Control in India 2016,[18] in diagnostic algorithm of TB, it has been clearly mentioned that all presumptive TB cases should be offered HIV counseling and testing. From this reference, it clearly shows that the policy-making for HIV testing in presumptive TB will help in early detection of HIV cases for early identification and further management of opportunistic infections such as TB and other infections. An important challenge in this regard would be to maintain the functionality of HIV testing centers by ensuring uninterrupted supply of HIV testing kits and availability of trained and motivated staffs – this requires continuous collaboration between the TB and HIV programs.

HIV-TB co-infection leads to extremely high rates of mortality and risk of drug resistance; if HIV is left untreated, it is advisable to do HIV testing in cases of presumptive TB to actively diagnose new cases. A lot of patients coming to our OPD are from the low socioeconomic strata; hence, there is decreased awareness, and patients may not turn up for further follow-up. Hence, an initial workup at the first point of contact in the OPD including a HIV blood test will help us to actively diagnose cases. In addition, even if the sputum for acid-fast bacteria comes out to be negative, a reactive HIV report will guide us to resend sputum for cartridge-based nucleic acid amplification test or further search for opportunistic infections. These cases could be initiated on isoniazid prophylactic therapy, which would go a long way in decreasing the occurrence of TB infection in HIV-positive cases.


  Conclusion Top


The WHO and the Joint United Nations Programme on HIV/AIDS have a vision of 90-90-90 strategy which emphasizes the need to detect 90% of all HIV-infected patients in the community, treat 90% of those detected with ART, and achieve viral suppression in 90% of those treated.[19] Screening of presumptive TB cases for HIV would definitely help us in achieving this vision.

Limitations

NNS estimations require exhaustive and advanced analysis, and we realize that further studies with much larger representative population samples are required in the future. As ours is a tertiary care center for tuberculosis, there is an obvious bias to get more TB patients in our hospital OPD. Hence, it is not a proper representative model of the general population for prevalence studies. Finally, CD4 counts of the patients who tested positive for HIV were not incorporated in our study which could have led us into further insights into the opportunistic infections plaguing the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Sharma SK, Kadhiravan T, Banga A, Goyal T, Bhatia I, Saha PK. Spectrum of clinical disease in a series of 135 hospitalised HIV-infected patients from north India. BMC Infect Dis 2004;4:52.  Back to cited text no. 3
    
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Harries AD, Zachariah R, Corbett EL, Lawn SD, Santos-Filho ET, Chimzizi R, et al. The HIV-associated tuberculosis epidemic – When will we act? Lancet 2010;375:1906-19.  Back to cited text no. 5
    
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Kumar AM, Gupta D, Kumar A, Gupta RS, Kanchar A, Rao R, et al. HIV testing among patients with presumptive tuberculosis: How do we implement in a routine programmatic setting? Results of a large operational research from India. PLoS One 2016;11:e0156487.  Back to cited text no. 13
    
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Rajaram M, Ravindra AG, Dwivedi DP, Ramakrishnan J, Chinnakali P, Mohapatra MM. HIV status among presumptive tuberculosis cases attending tertiary Care Centre in South India. Adv Respir Med 2018;86:211-4.  Back to cited text no. 16
    
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Palanivel C, Kumar AM, Mahalakshmi T, Govindarajan S, Claassens M, Satyanarayana S, et al. Uptake of HIV testing and HIV positivity among presumptive tuberculosis patients at Puducherry, South India. Public Health Action 2013;3:220-3.  Back to cited text no. 17
    
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    Tables

  [Table 1], [Table 2]



 

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