Long term follow up of HIV-infected patients with tuberculosis treated with 6-month intermittent short course chemotherapy.

BACKGROUND: Tuberculosis occurs in 60%-70% of HIV-positive persons in India. The outcome of HIV-positive patients treated with 6-month intermittent short course antituberculosis regimens in India is not well described. METHODS: This was a prospective observational feasibility study of 71 patients with HIV and tuberculosis who were treated with category I regimen of the Revised National Tuberculosis Control Programme (ethambutol, isoniazid, rifampicin and pyrazinamide thrice weekly for the initial 2 months followed by rifampicin and isoniazid thrice weekly for the next 4 months). Sputum was examined by smear and culture for Mycobacterium tuberculosis every month up to 24 months. Chest X-ray, CD4 cell count and viral load were done prior to and at the end of treatment. None of the patients received antiretroviral therapy. RESULTS: We present here the treatment response of patients with sputum culture-positive pulmonary tuberculosis to category I regimen. By efficacy analysis, among 43 patients treated with category I regimen, sputum smear conversion was observed in 79% and culture conversion in 82% at the second month. A favourable response was seen in 72% of patients. The mean (SD) CD4% fell from 12.6 (5.9) to 8.9 (4.9) (p < 0.001) with no significant change in mean (SD) CD4 cell count (169 [126] to 174 [158]; ns) at the end of treatment. Viral load change from 1.8 x 10(5) at baseline to 1.3 x 10(5) at the end of treatment was not statistically significant. Thirty-one patients, who completed the full course of treatment, were declared cured and were followed up for 24 months. Twelve had recurrent tuberculosis (39%); 16 of 43 (37%) patients had died by the end of 24 months, two-thirds due to causes other than tuberculosis. CONCLUSION: Though the early bacteriological response to intermittent short course antituberculosis regimen was satisfactory, the overall outcome was adversely affected by the high mortality (during and after completion of treatment) and recurrence rate among HIV-infected patients with tuberculosis. Immune status deteriorated in spite of antituberculosis treatment, highlighting the need for antiretroviral treatment in addition to antituberculosis treatment to improve the long term outcome. The results of this pilot study need to be confirmed by larger studies.

Miliary tuberculosis in human immunodeficiency virus infected patients not on antiretroviral therapy: clinical profile and response to shortcourse chemotherapy.

BACKGROUND: An increase in tuberculosis (TB) incidence has been associated with human immunodeficiency virus (HIV). AIMS: To describe the clinical characteristics and treatment outcome of patients with HIV and miliary TB treated with short-course intermittent chemotherapy in the absence of access to highly active antiretroviral therapy (HAART). SETTINGS AND DESIGN: Prospective study of HIV infected adults referred to a TB clinic between July 1999 and July 2004. MATERIALS AND METHODS: On diagnosis of miliary TB, patients were treated with a standard regimen of two months of isoniazid, rifampicin, ethambutol and pyrazinamide followed by four months of isoniazid and rifampicin (2EHRZ 3 /4RH 3 ) thrice weekly and followed up for 24 months. Patients were reviewed clinically every month and two sputa were collected. Chest radiographs and blood investigations were done at two months, end of treatment and every six months thereafter. RESULTS: Of 498 patients with HIV and tuberculosis, 31 (6%) were diagnosed as miliary tuberculosis. At diagnosis, sputum smear was positive for acid-fast bacilli (AFB) in 14 patients (45%) and Mycobacterium tuberculosis was isolated in 21 (68%). The mean CD4 cell count was 129 +/- 125 cells/mm3 . Twenty-five patients were declared cured at the end of treatment (81%) while one (3%) died and five (16%) failed. The recurrence rate was 19.4/100 person-years and the median survival was 17 months (95% CI 14 to 20). None of the patients received antiretroviral therapy. CONCLUSIONS: Miliary TB tends to occur among HIV infected patients with severe immunosuppression. Though the initial response to short-course chemotherapy was encouraging, a high recurrence rate and mortality was observed indicating poor prognosis in HIV.

Prevalence of acquired MDR-TB and HIV co-infection.

BACKGROUND: Mounting prevalence of primary and acquired multidrug-resistant tuberculosis in India is a sorry reminder of all round failure in our fight against tuberculosis and also of the necessity for new effective strategies. OBJECTIVES: (1) To assess the prevalence and pattern of drug resistant pulmonary tuberculosis among treated patients or on those on treatment without adequate response and (2) to evaluate HIV seropositivity among MDR-TB patients. METHODS: Pulmonary TB patients, who had at least six months of unsuccessful anti-tuberculous treatment were selected for the study. Their sputum specimens were examined for M. tuberculosis culture and drug sensitivity pattern and serological examinations for HIV infection were carried out. RESULTS: Sputum specimens of 618 patients' (61.8%) of a total of 1000 examined had shown culturable M. tuberculosis. Four hundred ninty-five patients (49.5%) were found to expectorate tubercle bacilli resistant to one or more anti TB drugs. MDR-TB was detected in 339 patients (33.9%). HIV seropositivity among MDR-TB was 4.42%. Significantly, 245 patients (24.5%) had tubercle bacilli resistant to one or more reserve drugs too (ethionamide, kanamycin and/or ofloxacin). CONCLUSIONS: Prevalence of MDR-TB was high in the study population. It is essentially an acquired condition. Its association with HIV disease was at present on the lower side, an observation contrary to published western literature. Higher rates of resistance for reserve drugs (ethionamide, kanamycin and/or ofloxacin) in patients who never had these drugs in their earlier treatment schedules suggest the possibility of emerging spontaneous drug resistant mutants.