High prevalence of multi drug resistant tuberculosis in people living with HIV in Western India

Abstract

Background Most studies assessing drug resistant tuberculosis (DRTB) in human immunodeficiency virus (HIV) co-infected patients in India have used conventional culture- based systems to diagnose DRTB that have a longer turnaround time leading to risk of amplification of resistance to an empirical regimen. We determined the prevalence of DRTB amongst people living with HIV (PLHIV) using the line probe assay and determined risk factors associated with the presence of multi drug resistant tuberculosis (MDRTB). Methods A Cross-sectional study was undertaken at Poona Hospital and Research Center (PHRC) and the Institute of Infectious Diseases, two tertiary level private care centers in Pune, India. Consenting PLHIV with confirmed Pulmonary TB (PTB) and/or extra-pulmonary TB (EPTB) diagnosed based on detection of Mycobacterium TB by line probe assay (Geno Type MTBDRplus version 2) on clinical specimens were included. Those with documented past history of DRTB were excluded. Resistance against anti-TB drugs was determined by the same assay. The prevalence of any form of drug resistant TB (DRTB), MDRTB, Rifampicin resistant TB (RRTB) and Isoniazid (INH) mono-resistant TB were determined as the proportion of these amongst all included PLHIV-TB. A multivariate analysis was conducted to determine risk factors that were statistically associated with MDRTB, DRTB, RRTB and INH mono-resistant TB. Results Two hundred PLHIV were recruited. The prevalence (95% CI) of MDRTB, INH mono- resistance and RR resistance was 12.5% (7.9–17.1%), 9% (6.9–11.2%) and 2.5% (1.4–3.6%), respectively. The prevalence (95% CI) of MDRTB among new and relapsed patients was 8.8% (6.5–11.1%) and 23.1% (17.2–28.9%), respectively. Tuberculosis relapse was the only factor significantly associated with MDRTB, DRTB and INH mono-resistant TB. Conclusion We document a high prevalence of drug resistance to anti-TB drugs including MDRTB among PLHIV in our setting using Geno Type MTBDRplus directly on clinical specimens. This validates the WHO recommendation of performing routine rapid molecular resistance testing prior to initiating anti-TB treatment among all PLHIV with presumptive TB. Using rapid molecular testing especially Geno Type MTBDRplus (that detects resistance to INH and Rifampicin simultaneously) reduces the turn-around time helping in optimizing treatment.

<p>Drug-Resistant Tuberculosis and HIV Infection: Current Perspectives</p>

“…The incidence of drug-susceptible TB (DS-TB) and HIV coinfection has increased over the past two decades, as both are strongly linked. It is estimated that PLHIV, especially with fewer than 200/cm 3 CD4 count, show a 19 (15)(16)(17)(18)(19)(20)(21)(22)-fold increased risk of developing active TB compared with those who are HIVnegative. 5 According to the WHO, 8.6% (7.4%-10%) of 10 million (range, 9-11.1 million) incident cases with active TB were alsocoinfected with HIV in 2018.…”

“…A few studies have estimated the burden of drug resistance among PLHIV ranging from 5.6% to 24% with genotypic tests, such as the cartridge-based nucleic acid-amplification test (CBNAAT), including automated GeneXpert MTB/RIF assays and polymerase chain reactionbased line-probe assays (LiPAs). [10][11][12][13][14][15] However, existing data remain sparse, as implementation of these tests remains suboptimal, particularly in resource-limited settings assumed to have a high burden of disease. Community-based surveillance at national level should be conducted for all regions worldwide to estimate the burden of coinfection in the near future.…”

Prevalence of multidrug resistance tuberculosis in adult patients in India: A systematic review and meta-analysis

“…To date, the rate of MDR-TB has been reported in various report and surveys from India. [1112] However, it is likely that surveys undertaken in India might underestimate the true burden of MDR-TB in India. The surveys conducted in India are mostly on smear positive TB thereby excluding smear negative and extra-pulmonary TB.…”

Prevalence of HIV among newly diagnosed tuberculosis patients in Erbil Governorate, Iraq

“…Drug malabsorption in HIV-infected patients, particularly rifampin and ethambutol, can produce drug resistance leading to treatment failure. 46 The linkage between HIV infection and MDR-TB may be discomposed by risk factors such as injection drug use, imprisonment, socioeconomic status, alcohol use, and hospitalization which are shared between both. HIV-infected patients and MDR-TB patients are more likely to be hospitalized compared to those who are HIV negative.…”

“…47 HIV-infected patients may thus be more likely to be exposed to patients with drug-resistant isolates, and thus be infected or re-infected with a resistant isolate as the associations between MDRTB and HIV infection observed in many North American studies, which included in part patients involved in institutional outbreaks in New York City, support this possibility. 46,47 It is of worthy to mention that Albujeer 48 had concluded in their study in Iraq that preventing the spread of HIV in conservative communities such as Middle Eastern communities requires a comprehensive strategy that includes effective, continued health education and health promotion programs at both community and health professional levels.…”