DR TB with HIV Co-infection

Drug-resistant TB (DR-TB) can affect people living with HIV (PLHIV) and cause a co-infection of both DR-TB and HIV. Compared to HIV-negative persons, PLHIV have a 24% higher risk of contracting multidrug-resistant TB (MDR-TB). As per the Global TB Report 2021, India has a dual high burden of HIV and DR-TB. 

Multi/extensively drug-resistant (M/XDR)-TB may be associated with HIV due to:

1. Rapid progression of disease due to harbouring of drug-resistant strains, particularly in the immunocompromised state as compared to the immunocompetent state
2. Drug malabsorption of anti-TB drugs, such as Rifampicin (R) and Ethambutol (E), leading to drug resistance and treatment failure 
3. Early reactivation of infection due to increased vulnerability in an immunocompromised state acquired from community or institutional transmission
4. Direct contact with DR-TB cases, suggesting primary or transmitted resistance
5. Confounding common risk factors, such as intravenous drug abuse, imprisonment, low socioeconomic status, alcoholism, and frequent hospitalisations
6. Repeated exposure to drug resistant isolates
7. Poor adherence to treatment 

Importance of addressing DR-TB and HIV Co-infection
Drug-resistant tuberculosis (DR-TB), including multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), is considered a potential obstacle for elimination of TB globally. HIV coinfection with M/XDR-TB further complicates the scenario and is a potential threat with challenging management.

PMDT Interventions to reduce the burden of DR-TB HIV coinfection
• All DR-TB cases must be offered HIV test
• Upfront culture and drug sensitivity testing to HIV/TB patients for early detection and prompt treatment 
• Early initiation of ART among HIV infected DR-TB cases 
• Early detection of HIV/TB among children by strengthening provider-initiated HIV testing and counselling (PITC) among children suffering from TB and intensified TB case finding among HIV-infected children
 

Programmatic Challenges in DRTB-HIV Co-infection
HIV co-infection with M/XDR-TB is a significant threat to the success of the TB programme due to the following reasons:

1. High pill burden --> poor adherence
2. Drug-drug interactions and risk of severe ADR --> poor adherence
3. High risk of complications due to fast progression of the disease
4. Requires costly diagnostics
5. Poor social support, stigma and reduced patient morale
 

Early and rapid diagnosis with genotypic tests, prompt treatment with appropriate regimens based on DST, preference for shorter regimens fortified with newer drugs, a patient-centric approach, and strong infection-control measures are all essential components in the management of M/XDR-TB in people living with HIV.
 

References

• Drug-Resistant Tuberculosis and HIV Infection: Current Perspectives, HIV AIDS (Auckl), 2020.  
• Alarming Levels of Drug-Resistant Tuberculosis in HIV-Infected Patients in Metropolitan Mumbai, India, Plos One, 2014.

Assessment