HIV-associated tuberculosis on the rise: India TB Report

Pediatric and drug-resistant TB major concerns for India

By Banjot Kaur
Published: Wednesday 25 September 2019

The number of HIV-infected people who go on to develop Tuberculosis (TB) is increasing in India, according to the India TB Report 2019, which was released by the government on September 25, 2019.

TB is the leading cause of morbidity and mortality among People Living with HIV (PLHIV). This group is 21 times more likely to develop TB than persons without the virus. TB-HIV co-infection results in higher mortality rates. Nearly 25 per cent of all deaths among PLHIV are estimated to be due to TB, the 2019 report says.

The figures for India are depressing. It is the third-highest HIV burden country in the world, with an adult prevalence of 0.22 per cent.

HIV co-infection or co-morbidity with TB in India was nearly 50,000 out of a total 2,155,894 cases, according to the 2019 report, amounting to a TB HIV confection rate of 3.4 per cent. In the 2018 report, this figure was 3 per cent, with 43,253 cases out of 1,444,175 notified ones being co-morbid.

India ranks second in the world as far as TB-related mortality is concerned. About nine per cent of the global burden of HIV-associated TB is borne by India. Every year, 11,000 Indians die of HIV-associated TB.  

The highest percentage of patients who tested positive for TB and were also infected with HIV came from Nagaland (15.6 per cent), followed by Karnataka (10 per cent), Chandigarh (9.1 per cent) and Manipur (8.9 per cent).

The treatment success rate of newly registered TB-HIV patients also dipped by 9 per cent points. The India TB Report 2018 said it was 79 per cent as compared to 70 per cent according to this year’s report.

The co-morbities of TB don’t come in form of HIV only. Diabetes and tobacco-related ailments too play a role.

The report says that more than 5 lakh cases of TB can be attributed to diabetes. “Diabetes increases the risk of developing TB by nearly two-three times. Moreover, diabetes can worsen the clinical course of TB, and TB can worsen glycemic control in people with diabetes. Also, diabetes worsens TB treatment outcomes in terms of increased deaths, failure and relapse rates,” the report noted.

Besides, nearly 8 per cent of TB cases can be attributable to tobacco usage.

Notification increases

Overall, the TB burden in India is highest in Uttar Pradesh. India’s largest state, accounting for 17 per cent the country’s population, contributed 20 per cent of total TB notified patients.

Around 4.2 lakh cases out of an all-India figure of 21.5 lakh came from Uttar Pradesh. The same state had shown the highest contribution in the last report too.

Uttar Pradesh, this year, is followed by Maharashtra (10 per cent) and Rajasthan (7 per cent). Madhya Pradesh and Gujarat reported the same proportion of cases as Rajasthan. Tamil Nadu, Bihar and West Bengal contributed 5 per cent cases each.

The report claims that the notification of TB cases has gone up by 16 per cent points as compared to the last report. The 2019 report said 21.5 lakh cases were notified, as compared to 18.3 lakh reflected in last year's cases.

The notification of TB cases is a challenge because of their being poorly reported to government data from the private sector, and therefore the notification going up is being touted as an achievement in the 2019 report. However, the 2019 report itself says that the estimated incidence of TB in India is 27 lakh out of which, about eight lakh cases are still out of the ambit of notification.

Against the success rate of 79 per cent of treatment of all TB cases notified in the public sector, it was only 35 per cent in the private sector, the report said.

The 2019 report also points out that the reporting from private sector had improved as compared to the previous year.  “Of the total notification, 25 per cent (5.4 lakh) cases were from the private sector; a 40 per cent increase from last year,” the report said.

Pediatric and drug-resistant TB

Another worrying aspect that has come out in this year’s report is the fact that the percentage of pediatric tuberculosis (TB among the population aged less than 15 years) cases have also slightly gone up. According to the 2019 report, as many as 133,059 pediatric TB patients were notified, thus amounting to 6.17 per cent of the total notified cases.

In the last report, the corresponding figure was only 6 per cent. Pediatric TB is among the 10 major causes of mortality among children globally. An estimated 10 lakh children became ill with TB and 2,50,000 children died of TB in 2017, the India TB Report 2019 said.

The highest number of pediatric TB cases have been reported from Uttar Pradesh, followed by Delhi and Maharashtra, in terms of absolute numbers.

One of the biggest concerns is drug resistant tuberculosis. There are 1,14,237 MDR-TB (multi-drug resistant TB) patients globally, of which, more than 8,000 are XDR-TB (extensive drug resistant TB), according to the 2018 World Health Organization TB update. India has 26,966 MDR-TB patients, the highest in the world, while there are 2,130 XDR-TB patients in the country.

According to the India TB Report 2019, the success rate of treatment of drug resistant TB patients has remained stagnant at 47 per cent, the same as in last year’s report. However, the government says it is doing its best to provide optimum care to drug resistant TB patients.

“On the occasion of World TB Day 2018, the programme introduced Shorter MDR TB regimen for country-wide implementation. According to the current programme guidelines, Shorter MDR TB Regimen (9-11 months duration) is the first choice of treatment for patients diagnosed with Rifampicin resistance that would be continued or switched to longer regimen, based on second line LPA results,” the report said.

It added: “In addition to pulmonary MDR/RR TB patients, extra pulmonary diseases like lymph node TB & plural TB are also eligible for Shorter MDR TB regimen. In 2018, more than 16,488 MDR/ RR TB patients were initiated on Shorter MDR regimen in India.”

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