Mortality rate HIV-TB co-infected patients remains high; Out of 1,804, 458 lost lives: MDACS study

Representation image

Out of the 1,804 HIV-TB co-infected patients between 2018 to 2021 in Mumbai, a total of 325 died during their treatment, with 133 succumbing to the illness in the post-treatment period, revealed a study published in the European journal 'Tropical Medicine and International Health' this month. These findings are part of a study conducted by the Mumbai District AIDS Control Society (MDACS).

"The overall mortality remains high," the study suggests, examining the factors associated with death in HIV-TB co-infected patients in the city. The study relied on secondary medical data of the cohort of 1,804 patients, collected from 16 antiretroviral therapy (ART) centers affiliated with MDACS. The published study is authored by Dr Srikala Acharya, Dr Vijaykumar Karanjkar, Dr Sunil P Bhamre, Dr Amol Palkar, Dr Dhirubhai Rathod and Dr Maninder Singh Setia.

Dr Srikala, the lead author said, "It is important to understand that the results of the study are limited to this cohort, and many conclusions cannot be drawn for all HIV-TB coinfected patients. However, there is one thing that we can be certain about is that early diagnosis of both diseases and their treatment plays a crucial role in determining mortality."

The study also sheds light upon is our understanding of the post-TB treatment phase in HIV-TB coinfection patients. "For advanced HIV disease or advanced TB disease, there could be so much irreversible damage that could be happening inside the body. Even after the treatment was over, the clinical condition of many patients in this cohort did not improve, and they continued to have some symptoms with eventual demise," Dr Srikala said.

Most out of the 1,804 people in the study were in the age range of 19-39 (43%) and 40-59 (48%). The majority were men (62%) and lived in Mumbai. 54% of the cohort had pulmonary tuberculosis, and about 41% also reported tuberculosis in the past. Meanwhile, 221 individuals in the study were recorded as lost to follow-up.

Ganesh Acharya, a city-based HIV-TB activist and a survivor, said, "The tests for HIV and TB need to be included as routine tests. If a person is diagnosed with diabetes or undergoing any surgery, they can be asked get tested for TB or HIV."

While we do not know how many of the total 1,804 individuals in the study fell into the 'high-risk' category of contracting HIV, according to Acharya, there is a need to move beyond traditional diagnostic strategies. "We are not moving beyond traditional strategies of early diagnosis; beyond focusing on high-risk people. We now need to include everybody in HIV testing," he said.

However, Dr Srikala said that getting tested is an individual's responsibility and is also a very personal choice. "HIV testing or testing for other sexually transmitted diseases needs to be normalised in the society, which even after so many years is lacking to a certain degree. Our outreach programs and awareness programs continue to be carried out," she said.

The study also noted that age was also another factor that decided the fate of an individual. "Of the total 1,258 individuals for whom we had data after the completion of anti-tuberculosis treatment, 133 (10.6%) died during the follow-up period. The proportion of deaths was high in patients aged 60 years and above (28.0%); age was significantly associated with mortality in the post-treatment completion period," it mentions.

There were limitations to this study, one of which is, we do not know if there were any other infections that contributed to mortality in the cohort. This is more important because the time frame of this study includes the years of the pandemic; when COVID-19 was at its all-time high. The authors stressed the importance of monitoring the post-treatment condition of the patients, which they said should be considered in determining the success of TB control programs.

"Early identification of TB and HIV disease, and the use of rapid point-of-care tests for the diagnosis of TB are needed across all healthcare facilities," the study concluded.

Leading factors for death:

- People with lower CD4 counts, which are T-cells, also known as immune cells, had a higher risk of mortality. A serious drop in CD4 count is common among advanced HIV patients. Additionally, delays in diagnosis and treatment also contributed to a person's death.

- A significant death rate was also observed in ART-naive patients with TB. This refers to patients who are HIV positive, but their status is only known after they are diagnosed with TB later; once a patient tests positive for TB, guidelines recommend authorities to check their HIV status.

- The delayed diagnosis also means delayed antiretroviral therapy for HIV treatment. It is not uncommon for this to occur as TB presents itself with symptoms early on, while that is not the case with HIV.