HIV prevalence among persons suspected of tuberculosis: policy implications for India.

BACKGROUND: HIV testing of persons referred for tuberculosis diagnosis (TB suspects) is recommended by World Health Organization but is not a policy in India, where HIV prevalence among TB suspects has never been reported. The current Indian policy of offering HIV testing only to TB cases may limit opportunities for early HIV diagnosis and treatment. METHODS: All adult TB suspects examined for diagnostic sputum microscopy in Mandya district (2 million population), in December 2010, were offered voluntary HIV counseling and testing. Participants were assessed for subsequent TB diagnosis. RESULTS: Of 1668 eligible TB suspects, HIV status was ascertained for 1539 (92%). Among these, 108 (7%) were HIV positive. Of the 108, 43 (40%) were newly diagnosed as HIV (ie, not previously known to have HIV infection). To detect a new case of HIV infection, the number needed to screen among TB patients was 13, as compared to an number needed to screen of 37 among "TB suspects not diagnosed as TB". Applied annually in 2010, HIV testing of TB suspects in 2010 could have identified approximately 534 newly diagnosed HIV cases, a 51% increase in district HIV case finding. CONCLUSIONS: Routine HIV testing of TB suspects was feasible and yielded a large number of HIV cases in absolute terms and would increase district HIV case finding by 51%. The number of patients needed to be HIV tested to find a previously undetected HIV case among TB suspects was greater than for TB cases but was potentially acceptable. Given heterogeneity of HIV epidemic in India, broader surveillance is required before national policy decision.

Will adoption of the 2010 WHO ART guidelines for HIV-infected TB patients increase the demand for ART services in India?

BACKGROUND: In 2010, WHO expanded previously-recommended indications for anti-retroviral treatment to include all HIV-infected TB patients irrespective of CD4 count. India, however, still limits ART to those TB patients with CD4 counts <350/mm(3) or with extrapulmonary TB manifestations. We sought to evaluate the additional number of patients that would be initiated on ART if India adopted the current 2010 WHO ART guidelines for HIV-infected TB patients. METHODS: We evaluated all TB patients recorded in treatment registers of the Revised National TB Control Programme in June 2010 in the high-HIV prevalence state of Karnataka, and cross-matched HIV-infected TB patients with ART programme records. RESULTS: Of 6182 TB patients registered, HIV status was ascertained for 5761(93%) and 710(12%) were HIV-infected. 146(21%) HIV-infected TB patients were on ART prior to TB diagnosis. Of the remaining 564, 497(88%) were assessed for ART eligibility; of these, 436(88%) were eligible for ART according to 2006 WHO ART guidelines. Altogether, 487(69%) HIV-infected TB patients received ART during TB treatment. About 80% started ART within 8 weeks of TB treatment and 95% received an efavirenz based regimen. CONCLUSION: In Karnataka, India, about nine out of ten HIV-infected TB patients were eligible for ART according to 2006 WHO ART guidelines. The efficiency of HIV case finding, ART evaluation, and ART initiation was relatively high, with 78% of eligible HIV-infected patients actually initiated on ART, and 80% within 8 weeks of diagnosis. ART could be extended to all HIV-infected TB patients irrespective of CD4 count with relatively little additional burden on the national ART programme.