Introduction.The basic places of tuberculosis treatment in Russian public health services are the divisions of phthisatric service. At the same time some chronic diseases having independent etiology, accompany tuberculosis, promoting its aggravation. In out-patient – polyclinics of general network, medical aid is provided by local general practitioner, for all therapeutic problems of the tuberculosis patients not connected with the basic disease.
The rapid increase of HIV infection in many parts of the world is causing great problems in the diagnosis and treatment of tuberculosis. It is also causing great problems in tuberculosis control. AIDS (Acquired immunodeficiency syndrome) is due to the HIV (Human Immunodeficiency Virus). In countries with high prevalence of tuberculosis, 30-60 per cent of adults have been infected with ТВ. Most people’s defenses prevent the ТВ causing disease. But if their defenses have been damaged by HIV the ТВ may no longer be kept under control. They may multiply and cause disease. In the same way, people with HIV infection, even if not yet ill, may not be able to resist new infection with ТВ from other patients with positive sputum. So there are likely to be many more cases of tuberculosis in countries where there is increasing HIV infection.
Mortality.
Nevertheless there is a higher mortality in HTV infected patients. Much of this is due to other complications of HIV infection. But some deaths seem directly due to tuberculosis.
HIV (Human Immunodeficiency Virus).
The HIV virus can be spread in different ways:
- By heterosexual activity.
- By homosexual activity.
- Through blood by:
- Blood transfusion with HIV contaminated blood. (In countries where many people are becoming infected with HIV, even screened blood can be dangerous. There may be virus in the blood before antibodies can be detected.)
- Use of needles which have not been properly sterilised. This is common in drug abusers.
- From mother to child: congenital transmission. Also by breast feeding, About one-third of children born to HIV-infected mothers are also HIV-infected.
It is NOT DANGEROUS to care for AIDS or HIV-infected patients as long as you are careful about needles and blood. However health staff who are known to be HIV-infected, even if healthy, should not care for patients with ТВ. They have a much greater risk than normal people of being infected with ТВ and later developing disease. There is a long period, often several years, between infection with the HIV virus and developing AIDS. This period is shorter in children under five and in patients aged over forty. During this ‘incubation period’ the patient may feel quite well (though he/she remains infectious). The development of tuberculosis is often the first sign that he/she has HIV infection. In about 50 per cent of patients with HIV and tuberculosis there is no other evidence of HIV infection. The only way to make the diagnosis is to do an HIV test.
Diagnosis and testing.
The HIV antibody test is the only certain way of making the diagnosis.
Effect of HIV on control programmes.
Disease prevalence.
Among people already infected with ТВ (as shown by being tuberculin positive) their lifetime risk of clinical ТВ is about 50 per cent if they have been infected with HIV. This compares with a 5-10 per cent risk if they are HIV negative. The result is a great increase of ТВ cases where and when the HIV rate becomes high.
Drug reactions.
Drug reactions are much more common in TB/HIV. This may increase the default rate from treatment.
Separation of patients.
In hospitals definite ТВ patients and those who might prove to have ТВ must be kept separate from HIV patients as these are so easily infected. And if infected they are more likely to develop ТВ disease.
Needles.
Great care must be taken in using needles. For this reason streptomycin is no longer used for tuberculosis in many countries with high HIV prevalence.
How tuberculosis with HIV infection shows clinically.
The following are differences from the usual ways tuberculosis shows in patients without HIV infection:
- Extra-pulmonary disease, especially in the lymph nodes, is more common. There is often general lymph node enlargement, which is rare in other forms of tuberculosis.
- Miliary disease is common. ТВ may be isolated from blood culture (which never occurs in ordinary tuberculosis).
- X-ray. In the early stages of HIV infection with pulmonary ТВ there is often little difference in the X-ray from the usual appearances. In the later stages there are often large mediastinal lymph node masses. Cavitation may be less frequent. Pleural and pericardial effusions are more common. The shadows in the lung may change rapidly.
- Tuberculosis may occur at unusual sites, e.g. tuberculomas of the brain, abcesses of the chest wall or elsewhere.
- Sputum smears may be negative despite considerable changes in the chest X-ray.
- The tuberculin test is often negative.
- Fever and weight loss are more common in HIV-positive tuberculosis than in HIV-negative.
In a patient with tuberculosis, suspect the possibility of accompanying HIV infection if there is:
- General lymph node enlargement. In late stages of HIV the nodes may be tender and painful, as in acute infection.
- Candida infection (painful white patches of fungus in the mouth).
- Chronic diarrhea for more than a month.
- Herpes zoster (shingles).
- Kaposi’s sarcoma: small red vascular nodules on the skin, and particularly on the palate
- Generalised itchy dermatitis.
- Burning feeling in the feet (due to neuropathy).
- Persistent painful ulceration of genitalia.
Treatment of tuberculosis.
Standardized course treatment.
Modern standardized treatment of tuberculosis in an HIV-positive patient is as effective as in HIV-negative patients. The sputum becomes negative just as quickly. Relapse rates are no higher. Weight gain may be somewhat less than in HIV-negative patients. But with former long term ‘standard’ treatment, not including rifampicin, treatment was less successful and relapse much commoner. Some of the relapse may have been due to reinfection because of the patient’s lowered defenses from HIV.
Prognosis.
The long term prognosis is therefore poor, as in all HIV patients. But treatment of the patient’s tuberculosis does usually give him/her a longer period of improved health and is well worth doing. Moreover treatment stops the spread of tuberculosis to others.
Side-effects.
Side-effects of drugs are commoner in HIV-positive patients. In particular thioacetazone is liable to cause severe skin reactions. These may be fatal in up to 25 per cent of cases. If a patient develops a reaction to thiaoacetazone never use it again. Some countries with high prevalence of HIV no longer use thioacetazone.
Streptomycin.
Streptomycin has to be given by injection. This carries a risk of spreading HIV from blood contamination. In countries with a high prevalence of HIV and which cannot afford a disposable syringe for each patient it is better to use ethambutol instead of streptomycin. Preventive treatment with isoniazid is used in HIV patients with no evidence of clinical tuberculosis.
Conclusions.
- With modern short-term treatment it is possible cure tuberculosis in HIV patients. On average it gives the patient an extra 2 years of life.
- Effective treatment to TB/HIV prevents the spread of ТВ infection. This is particularly important when there are many HIV positive people having poor immunity against the disease.
- Tuberculosis speeds up the progress of HIV disease. Therefore your TB/HIV patients may develop other common complications of HIV.
Protection of health staff from infection by HIV.
- If taking blood wear gloves. Afterwards put needle and syringe into special ‘Sharp Box’. Put gloves and swabs into leak-proof plastic bag.
- If doing anything which will bring you in contact with blood (e.g. surgery or delivering a baby) wear gloves and apron. Protect your eyes with glasses.
- If blood or other bodily fluid is spilled, clean up as soon as possible. Use an antiseptic, e.g. phenol or sodium hypochlorite.
- If doing resuscitation don’t do mouth-to-mouth breathing. Use a bag and mask.