The Hindu : Opinion / Editorials : DEADLIER IN COMBINATION

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Wednesday, Apr 07, 2004

Opinion

Opinion - Editorials

DEADLIER IN COMBINATION

BAD ENOUGH THAT India has far more tuberculosis (TB) cases than any other country. Nearly two million people in India develop the disease every year and one person dies of it every minute, making tuberculosis the leading killer among infectious diseases in this country. But in addition, India is second only to South Africa in the number of people infected with the Human Immunodeficiency Virus (HIV) that causes the Acquired Immune Deficiency Syndrome (AIDS). It is estimated that there are already about four million HIV-infected people in India. The combination of TB and HIV makes for a lethal cocktail. Most people who get infected with Mycobacterium tuberculosis (which causes TB) do not develop the disease as their immune system is able to keep the bacterium in check. But once an HIV infection cripples the immune system, it paves the way for a dormant TB infection to become active. HIV infected people are also less able to withstand new TB infections. While a person with only a TB infection has just a 10 per cent lifetime risk of developing active tuberculosis, the risk is six times higher for those infected with both TB and HIV. There is also evidence that tuberculosis accelerates the progression of an HIV infection into full-blown AIDS. Not only is tuberculosis the most common opportunistic infection among HIV-positive people in India, but it also substantially increases the chances of death due to HIV.

The advent of HIV has also made diagnosis of tuberculosis more difficult, observes the Government's National AIDS Control Organisation (NACO) in its "Guidelines For Management of TB in HIV Infected." If TB occurs in the early stages of HIV infection when immunity is only partially compromised, it usually manifests as typical tuberculosis that affects the lung. But as the HIV infection advances, patients can develop other lung infections that resemble tuberculosis or forms of tuberculosis that affect other parts of the body (extra-pulmonary TB). "The definitive diagnosis of extra-pulmonary TB is often difficult because of the paucity of diagnostic facilities, and at times difficulty in accessing the affected tissue for intervention," say the NACO guidelines. As it is, the World Health Organisation is being criticised for relying too much on examination of patients' sputum under the microscope for diagnosis of tuberculosis in its "Directly Observed Treatment, Short-course (DOTS)" programme; India's Revised National Tuberculosis Control Programme (RNTCP), which already covers 76 per cent of the population and will be expanded to bring the rest within its ambit by 2005, is based on the DOTS methodology. On sputum smear microscopy, Rowan Gillies, president of Medecins Sans Frontieres, the Nobel Prize winning medical charity, has been quoted as saying, "We rely on a 19th century tool — it doesn't detect paediatric, extra pulmonary, or smear-negative tuberculosis."

With over half of India's adult population infected with Mycobacterium tuberculosis, there have been warnings that the spread of HIV could lead to "a potentially explosive increase" in tuberculosis. A study published recently by scientists at the Tuberculosis Research Centre in Chennai suggested that HIV infection is on the rise among TB patients in Tamil Nadu. Scientists at the All India Institute of Medical Sciences in Delhi have also drawn attention to the increasing prevalence of HIV among TB patients at their hospital. Meanwhile, health professionals worry that the country's separate TB and HIV control programmes are running in isolation. Only if the two control programmes work together for the early diagnosis and treatment of tuberculosis, and secure the cooperation of private health care providers for these efforts, is there a realistic chance of stemming the pestilence.

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