Dr Jalal Mohsin Uddin MBBS DTCD FCPS (Pulmonology) Dr Jalal Mohsin Uddin MBBS DTCD FCPS (Pulmonology)

Why TB-HIV co-infection is important ? TB is the most common opportunistic infection affecting HIV-seropositive individuals, and it remains the most common cause of death in patients with AIDS. Worldwide, 14.8% of TB patients have HIV co- infection. TB is the most common cause of death among patients with AIDS, killing 1 of 3 patients. TB is the most common opportunistic infection affecting HIV-seropositive individuals, and it remains the most common cause of death in patients with AIDS. Worldwide, 14.8% of TB patients have HIV co- infection. TB is the most common cause of death among patients with AIDS, killing 1 of 3 patients.

Why TB HIV co-infection is special ? HIV alters the pathogenesis of TB, greatly increasing the risk of disease from TB in HIV co infected individuals and leading to more frequent extra pulmonary involvement. Atypical radiographic manifestations, and paucibacillary disease, which can delay timely diagnosis. HIV alters the pathogenesis of TB, greatly increasing the risk of disease from TB in HIV co infected individuals and leading to more frequent extra pulmonary involvement. Atypical radiographic manifestations, and paucibacillary disease, which can delay timely diagnosis.

Clinical Presentation of TB in HIV Infection Features of PTBStage of HIV Infection EarlyLate Clinical PictureOften resembles post-primary TB Often resembles primary TB Sputum smear results Often positive more likely to be negative Chest X-ray appearance Upper lobe infiltrates, Often with cavitations Often infiltrates in any lung zone No cavitation Miliary/ No abnormalities South African National Tuberculosis Control Programme Practical Guidelines 2004

CxR Findings in TB Patients with HIV Infection Early HIV Sputum smear positive Late HIV Sputum smear often negative

Role of HTC centre in NIDCH TB in high risks group HTC centre Pre-test counseling HIV screening test Post test counseling HTC centre Pre-test counseling HIV screening test Post test counseling HIV test positive HIV test negative Managed in NIDCH ART is provided by Ashar Alo and other NGOs.

Steps for HIV Counseling & Testing

Patient selection for HIV screening : It is ideal to sent all the patients of tuberculosis to HCT center, but due to low prevalence of HIV infection we choose the patients with high risks. The prevalence of HIV remains very low (<0.1%) in the general population and low (<1%) in most at-risk populations (MARPs). It is ideal to sent all the patients of tuberculosis to HCT center, but due to low prevalence of HIV infection we choose the patients with high risks. The prevalence of HIV remains very low (<0.1%) in the general population and low (<1%) in most at-risk populations (MARPs).

Links between HIV & TB o Generally the lifetime risk of developing active TB is around 10% o While for TB/HIV co-infection the risk may be upto 60%

Which patients of tuberculosis are in possible risk of HIV infection ? o 1 ) TB or TB suspects with history of high risk behavior (IDU, unsafe blood transfusion, SW, migrant workers, H/O STI, MSM, transgender/hijra). o 2) MDR-TB o 3) Relapse and treatment failure TB cases o 4) Complicated extra-pulmonary TB o 5) Clinical suspects of HIV infection o 6) Children of mother known to be HIV-positive o 1 ) TB or TB suspects with history of high risk behavior (IDU, unsafe blood transfusion, SW, migrant workers, H/O STI, MSM, transgender/hijra). o 2) MDR-TB o 3) Relapse and treatment failure TB cases o 4) Complicated extra-pulmonary TB o 5) Clinical suspects of HIV infection o 6) Children of mother known to be HIV-positive

HCT center of NIDCH Previously it was known as VCT (Voluntary Counseling and Testing) center, now it is known as HCT ( HIV Counseling and testing ) center and its activities are conducted by NTP. Set up: HTC centre situated in Asthma OPD, NIDCH HTC Strength Counselor -1 Lab Technician – 1 Starts functioning : September 10, 2009 Previously it was known as VCT (Voluntary Counseling and Testing) center, now it is known as HCT ( HIV Counseling and testing ) center and its activities are conducted by NTP. Set up: HTC centre situated in Asthma OPD, NIDCH HTC Strength Counselor -1 Lab Technician – 1 Starts functioning : September 10, 2009

Test Procedure o A ) Informed consent of patients o obtained o B ) Consent forms filled up o A ) Informed consent of patients o obtained o B ) Consent forms filled up

Pre-test counseling form filled up. It includes : 1.1. Regular or, multiple partner 2.2. Occupational exposure 3.3. IVU 4. Drug addict 5.4. Tattooing 6.5. SW 7.6 Pregnancy status 1.6. Using contraception including condom etc H/O STD 3.8. Mental status 4.9. Psychiatric disorder 5. Suicidal tendency 6. Intent to harm another etc.

o A ) Full confidentiality is maintained. o - No names should be recorded in the form o - In special situations names of contact details to be stored in a separate location o - Only ID no. is used. o B ) The client can review, cancel his/her consent even before the test. o A ) Full confidentiality is maintained. o - No names should be recorded in the form o - In special situations names of contact details to be stored in a separate location o - Only ID no. is used. o B ) The client can review, cancel his/her consent even before the test. Test Procedure

HIV screening test in HCT center by rapid test kits 1)1) Determine method 2)2) Uni-gold method 3)3) Fast Response 1)1) Determine method 2)2) Uni-gold method 3)3) Fast Response

Diagnosis of HIV in TB patient There are many tests at different stages of HIV In NIDCH, Rapid HIV test kits are used 1 st test is performed by- Determine kits There are many tests at different stages of HIV In NIDCH, Rapid HIV test kits are used 1 st test is performed by- Determine kits

If it is ( + ), 2 nd test is by Unigold kits If 2 nd test is ( + ), 3 rd test is by Fast Response kits A person is HIV ( + ) if all 3 tests are ( + ) If it is ( + ), 2 nd test is by Unigold kits If 2 nd test is ( + ), 3 rd test is by Fast Response kits A person is HIV ( + ) if all 3 tests are ( + ) Diagnosis of HIV in TB patient

WHO Recommendation If the result remains inconclusive following the initial and confirmatory tests, it is repeated two weeks laterIf the result remains inconclusive following the initial and confirmatory tests, it is repeated two weeks later

WHO Recommendation….  If it is still inconclusive But person is at high risk, consider retesting at 6 and 12 months But person is at high risk, consider retesting at 6 and 12 months If the results remain inconclusive after 1 year, the person is considered HIV negative If the results remain inconclusive after 1 year, the person is considered HIV negative  If it is still inconclusive But person is at high risk, consider retesting at 6 and 12 months But person is at high risk, consider retesting at 6 and 12 months If the results remain inconclusive after 1 year, the person is considered HIV negative If the results remain inconclusive after 1 year, the person is considered HIV negative

If HIV negative – counseling for risk reduction If HIV positive – 1 ) appropriate measure taken 2 ) proper counseling 3 ) Suicidal risk / psychiatric disorder assessed 4 ) Referred to IDH/ Ashar Alo Society If HIV negative – counseling for risk reduction If HIV positive – 1 ) appropriate measure taken 2 ) proper counseling 3 ) Suicidal risk / psychiatric disorder assessed 4 ) Referred to IDH/ Ashar Alo Society Post-test measures :

HIV screening in 2122 TB patients. Smear (+ve) PTB 774 Smear (-ve) PTB 181 MDR TB : 1004 EPTB : 76 Treatment failure 22 Defaulter 21 Relapse 43

HIV screening in 2122 TB patients. HIV positive 21 ( % ) HIV positive 21 ( % )

TB/HIV co-infection Situation in Bangladesh High TB prevalence in HIV patients: As per Ashar Alo Society : TB-HIV Co- infection is 18.5%

HIV positive cases : 21 HIV 1 15 HIV 1 15 HIV 1&2 06 HIV 1&2 06

HIV + ve 21 HIV + ve 21 Smear +ve PTB 9 Smear - ve PTB 6 MDR 2EPTB 2 Tuberc ular mening itis 2

HIV Positive 21 HIV Positive 21 Immigrants 08 Immigrants 08 Spouse 01 Spouse 01 Drivers 02 Drivers 02 Garments worker 06 Garments worker 06 Day labourer 04 Day labourer 04 Occupations

Age groups (Years) HIV Positive Total21 Age Distribution of HIV Positive Cases (n 21) Maximum number of cases lie in the 31 – 40 age group

Organizations for PLHIV care and treatment in Bangladesh AAS : Lead organization for care and treatment of PLHIV  Ashar Alo Society ( AAS) has 3 centers: Dhaka, Chittagong and Sylhet  Confidential Approach to AIDS Prevention (CAAP) only in Dhaka  Mukto Akash Bangladesh (MAB) has 3 centers: Dhaka 2 and Khulna AAS : Lead organization for care and treatment of PLHIV  Ashar Alo Society ( AAS) has 3 centers: Dhaka, Chittagong and Sylhet  Confidential Approach to AIDS Prevention (CAAP) only in Dhaka  Mukto Akash Bangladesh (MAB) has 3 centers: Dhaka 2 and Khulna

Ashar Alo Society and other NGOs follow some rules regarding starting ART : Early initiation of ART is preferable. ambulatory HIV-infected patients with TB and CD4 counts <500 cells/mm 3 integrated with ART either during the first 4 weeks of TB therapy or after the first 8 weeks of TB treatment (i.e., during the continuation phase of TB therapy). Initiation of ART within the first 2 weeks of TB treatment in patients with CD4 cell counts <50 cells/cumm. Early initiation of ART is preferable. ambulatory HIV-infected patients with TB and CD4 counts <500 cells/mm 3 integrated with ART either during the first 4 weeks of TB therapy or after the first 8 weeks of TB treatment (i.e., during the continuation phase of TB therapy). Initiation of ART within the first 2 weeks of TB treatment in patients with CD4 cell counts <50 cells/cumm.

Management flow chart by AAS : Initial assessment and detection of CD4 cell count. Critical patients are managed in Infectious Disease Hospital 15 to 30 days. Ambulatory patients receive ART from AAS Available drugs are Tenofovir Lamivudine Zidovudine Efavirenz etc. Patients come for follow up visit at 15 days interval to respective doctor and counselor

 Everyone infected with HIV should be tested for TB  Everyone infected with TB /MDR TB & complications should be tested for HIV  Everyone infected with HIV should be tested for TB  Everyone infected with TB /MDR TB & complications should be tested for HIV Future Program Focus

Conclusion  Globally HIV/AIDS pandemic is threatening to destabilize the control of TB  Treatment of HIV-TB co-infection requires strong commitment and a focused approach  A strong co-ordination between the national TB and the AIDS control programme is required for effective management of HIV-TB patients  Globally HIV/AIDS pandemic is threatening to destabilize the control of TB  Treatment of HIV-TB co-infection requires strong commitment and a focused approach  A strong co-ordination between the national TB and the AIDS control programme is required for effective management of HIV-TB patients

Let us work together to have TB/HIV free Bangladesh

Courtesy : Dr. Md. Khairul Hassan Jessy, Associate Professor,Respiratory Medicine,Co-ordinator HIV/AIDS,NIDCH. Atia, councilor, HTC center, NIDCH. Ashar Alo Society Dr. Md. Khairul Hassan Jessy, Associate Professor,Respiratory Medicine,Co-ordinator HIV/AIDS,NIDCH. Atia, councilor, HTC center, NIDCH. Ashar Alo Society