Trend of HIV infection in patients with pulmonary tuberculosis in South India

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Title: Trend of HIV infection in patients with pulmonary tuberculosis in South India
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Tubercle and
Lung Disease

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Trend of HIV infection in patients with pulmonary tuberculosis in South India
S. Solomon*. S. Anuradha,* S. Rajasekaran'
Inslitute of Microbiology, Madras Medical College, Madras. ‘Institute of Thoracic Medicine. Madras, India

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S U M MARY. Setting: Tuberculosis is life threatening, transmissible and pandemic especially among millions
of HIV infected persons. In developing countries like India where HIV infection is becoming prevalent and
where tuberculosis infection has long been endemic, its incidence is increasing.
Objective: The aim of the study was to find out the trend of HIV infection in patients with pulmonary tuber
culosis in south India.
Design: HIV seropositivity was assessed in_1430 radiologically and/or bacteriologically confirmed pulmonary
tuberculosis patients attending major tuberculosis institutions in Madras by the AIDS Cell, Institute of Microbiology, Madras Medical College, Madras from January 1991 to May 1993.
Results: HIV ^eropositivity was found to rise significantly from 0.77% in 1991 to 3.4% in 1993 (P<0.05). 22
(91.67%) of a total olf24 HIV Wropositive pulmonary tuberculosis patients had pulmonary cavities and 21
patients (87.5% ) had bacteriological confirmation of tuberculosis.
Conclusion: The findings of this prospective study suggest that pulmonary tuberculosis patients with HIV
infection are an in early phase of immunosuppression. This study reveals the rising trend of HIV infection; all
persons with tuberculosis should therefore be questioned about the risk factors for HIV infection and urged to
have an HIV test.
R E S U M E. Cadre: La tuberculose met en danger la vie des malades, est transmissible et pandemique, surtout
parmi les millions de personnes infectees par le VIH. Dans les pays en developpement comme 1’Inde ou
Pinfection VIH a une prevalence croissante et oil la tuberculose est endemique depuis longtemps, 1’incidence de
la tuberculose s’intensifie.
Objet: L’objet de I’etude etait de decouvrir la tendance de (’infection VIH chez des malades atteints d’une
tuberculose pulmonaire en Inde du sud.
Schema: La seropositivite VIH a ete analysee par la cellule SIDA, Institut de Microbiologie, Madras Medical
College, chez 1430 malades atteints d’une tuberculose pulmonaire confirmee par radiologic et/ou bacteriologie,
consultant les services principaux de tuberculose a Madras de janvier 1991 a mai 1993.
Resultats: II a etc observe que la seropositivite VIH a augmente de fa(;on significative : de 0,77% en 1991 a
3.4% en 1993 (P < 0,05). Sur un total de 24 malades atteints d’une tuberculose pulmonaire et VIH-positifs, 22
(91.67%) avaient des cavites pulmonaires et 21 (87,5%) ont montre une confirmation bacteriologique de
tuberculose.
Conclusion: Les resultats de cette etude prospective suggerent que les malades atteints d’un tuberculose
pulmonaire et seropositifs sont dans une phase precoce d’immunosuppression. Cette etude montre la tendance
croissante de I’infection VIH et la necessite que toute personne atteinte d’une tuberculose soil interrogee sur les
facteurs de risque de I’infection VIH et incitee a avoir un test VIH.
R E S U M E N. Marco de referenda: La tuberculosis es una enfermedad que amenaza la vida, es transmisible y

pandemics, especialmente entre los millones de personas infectadas con VIH. En los paises en desarrollo como
India, donde la infeccidn VIH se esta haciendo prevalente y donde la infeccion tuberculosa ha sido endemica
desde hace mucho tiempo, la incidencia esta en aumento.
Objetivo: Poner en evidencia la tendencia de la infeccidn VIH en pacientes con tuberculosis puimonar en el sur
de la India.

Correspondence to: Dr Suniti Solomon, AIDS Cell. Institute of
Microbiology. Madras Medical College. Madras 600 003. India.
Paper received 16 July IWJ. Final version accepted I February 1994.

17

18

fubercle and Lung Disease

Metodo: Se evaluo la serologia VIH en 1 430 pacientes con tuberculosis puimonar confirmada bacterioldgica y/
o radiologicamente, atendidos en los principales centros antituberculosos de Madras por la Celula SIDA del
Institute de Microbiologia, Madras Medical College, de enero de 1991 a mayo de 1993.
Resultados: Se encontro que la seropositividad VIH habia aumentado de 0,77% en 1991 a 3,4% en 1993
(P < 0,05). De un total de de 24 pacientes con tuberculosis puimonar VIH-positivos, 22 (91,67%) tenian
cavidades puimonares y 21 (87,5 %) tuvieron una confirmacion bacterioldgica de tuberculosis.
( onclusion: Los resultados de este estudio prospectivo sugieren que los pacientes con tuberculosis puimonar
infectados con el V IH se encuentran en la primera fase de la inmunosupresion. Este estudio revela la tendencia
al aumento de la infeccion VIH y por consiguiente, todas las personas con tuberculosis deben ser interrogadas
sobre los factores de riesgo para la infeccion V IH y deben ser instados a someterse a un test de serologia VIH.

INTRODUCTION

take of female patients, from 25.77% in 1991 to 32.3%
in 1993 (Table).
HIV infection was detected in 24 (1.68%) of the 1430
pulmonary tuberculosis patients screened (Table). There
was a significant rise of HIV infection among pulmo
nary tuberculosis patients, from 0.77% in 1991 to 3.35%
in 1993 (P <0.05). During 1992 the HIV infection rate
was 1.32%.
20 (83.33%) of the 24 HIV seropositive patients were
in the =£40 year age group. In 1993 the number of
young seroposilives (^ 20 years) was a great deal higher
than in the previous years (Table). The HIV detection
rate was high (7.14%) during 1993 among female pa
tients, as against the figures of 0.99% and 0.5% obtained
during 1991 and 1992 respectively.
Pulmonary cavitary lesions were seen in 22 (91.67%)
ot total 24 patients and bacteriological confirmation
(sputum smear and/or culture positivity for M. tuber
culosis) was obtained in 21 patients (87.5%).
Heterosexual intercourse was the major risk factor
among 16 pulmonary tuberculosis patients with HIV in
fection. While many patients gave a history of previous
administration of intraveinous medication, as advised by
their physicians for various other ailments, none of them
was found to be a drug addict.

HIV infection is making rapid in-roads among tubercu
losis patients in India; this association has been reported
from Pondicherry,1 Bombay,2 and Madras.3

MATERIALS AND METHODS

Bacteriologically and/or radiologically confirmed pul
monary tuberculosis patients were screened for the pos
sible association of HIV infection at 4 major centres
ot Thoracic Medicine in Madras by the AIDS cell of
the Institute of Microbiology. Madras Medical College.
Madras from January 1991 to May 1993.
Routine history was taken and a detailed clinical
examination was done. All the patients were subjected
to chest roentgenography and their sputa were examined
tor the presence of Mycobacterium tuberculosis by
smear and culture methods. Blood samples were taken
and the serum was separated and tested for HIV anti
bodies by ELISA technique (Wellcozyme kit). The
blood samples, which were proved seropositive twice by
ELISA, were also confirmed by Western Blot method.

RESULTS

DISCUSSION
1430 pulmonary tuberculosis patients were selected for
this study from January 1991 to May 1993. There is a
definite rising trend in the selection of patients over the
succeeding years. Whilst there is no significant differ
ence in the pattern of age groups selected during 1991.
1992 and 1993, there is a noticeable increase in the in-

Persons with latent tuberculosis infection may be more
likely to develop overt tuberculosis if they are infected
with HIV.4- Reactivation of tuberculosis infection tends
to occur relatively early (often as a sentinel disease)
in the course of HIV immunosuppression, before the

Table. Trend of HIV infection among pulmonary tuberculosis patients

Age and sex
distribution
Age (in years)
« 20
21-40
41 -60
Sex
Male
Female
Total

1991
Total

HIV+ %
%
HIV+

1992
Total

HIV+
HIV+ %
%

1993 (Up to May)
Total HIV+ %

Total

Total

HIV+

%

31
231
130

0
0
0

0
1.30
0

51
396
233

0
6
3

0
1.52
1.29

29
213
1 16

4
7
1

13.79
3.29
9.86

111
840
479

4
16
4

3.60
1.90
0.84

291
101

1

0.69
0.99

478
202

8
1

1.67
0.50

246
112

4
8

1.63
7.14

1015
415

14
10

1.38
2.41

392

3

0.77

680

9

1.32

358

12

3.35

1430

24

1 68

Trend in HIV infection in patients with pulmonary tuberculosis in South India

i bacterioldgica y/
t Celula SIDA del

a 3,4% en 1993
(91,67%) tem'an
.is.
rculosis pulmonar
evela la tendencia
n ser interrogadas
de serologia VIH.

in 1991 lo 32.3%
1.68%) of the 1430
med (Table). There
ion among pulmo7c in 1991 to 3.35%
HIV infection rale

sitive patients were
>93 the number of
; a great deal higher
The HIV detection
among female paand 0.5% obtained

een in 22 (91.67% I
igical confirmation
ivity for M. tuber;87.5%).
major risk factor
tients with HIV in
history of previous
ilion. as advised bj
nents, none of them

ction may be more
if they are infected
osis infection tends
a sentinel disease)
ression. before the

iv+
4
5
4

3.60
1.90
0.84

4

)

1.38
2.41

1

1.68

invasion of other opportunistic infections and other overt
mam testations of AIDS and AIDS-related complex
(ARC).'’ Allhough reactivation of perviously acquired
tuberculosis is mainly responsible for tuberculosis in
HIV-infected individuals, the disease may also develop
from recent primary infection and possibly from
e \ogcnous rei n feetion.
Classical tuberculosis upper lobe infiltrates and cavitarv lesions are more frequently seen among patients
who ha\e contracted tuberculosis in the earlier stages
ol HIV infection/“ 91.67% of 24 patients in this
stud\. 50% of 6 patients in the Pondicherry series1 and
52.63% of 57 patients in the Bombay study2 had cavitary
tuberculosis. Demonstration of tubercle bacilli in the
sputum specimens obtained from 21 (87.5%) HIV seropositbe pulmonary tuberculosis patients is another
important pointer in this study. Prospective studies such
as the present one. undertaken in developing countries
like India on the spectrum of tuberculosis among
HIX infected patients, include more HIV associated
cases of tuberculosis occurring earlier in the course of
immunosuppression.1"
Hie most significant finding of this study was the
using trend of HIV seropositivity in pulmonary tuber
culosis patients, from 0.77% in 1991 to 3.35% in 1993
t/’ <0.05). This trend was also observed in Bombay,2
where HIV infection among patients with respiratory
disease (<89% of them with tuberculosis) increased to
3 43% in 1990-91 from 2.32%> in 1988-89.
In India, an estimated 1 753 000 people were infected
with HIV during 1993 and 87 650 new cases of tubercu
losis with HIV are likely to emerge." The present study
rcxeals the rising trend of HIV infection among pulmo
nary tuberculosis patients in India and therefore, as
recommended by the Centers for Disease Control.12 all
persons with tuberculosis should be questioned about
risk factors for HIV infection and. whether or not risk
factors are elicited, urged to have an HIV test.

19

Acknowledgement
The authors gratefully acknowledge the kind cooperation extended by
the Superintendent of the Government Hospital of Thoracic Medicine,
Tambaram. the Director of the Institute of Thoracic Medicine, Chetput
and the Superintendent. Government Thiruvotteeswarar Hospital of
Thoracic Medicine. Otteri, Madras. India.

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