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HIV, TB coinfection often increased in low-income countries

Epidemic overview provides alarming morbidity and mortality, impact on resource-limited countries with high HIV burdens.

Issue: August 2007

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TORONTO — HIV and tuberculosis epidemics are coexistent in many areas in low- and middle-income countries, including South Africa’s KwaZulu-Natal province, an endemic area and epicenter for coinfection studies.

The infections exacerbate disease progression in coinfected patients and further confound treatment programs and funding.

“Many people think HIV is the most important epidemic, but TB actually eclipses it,” said Sandra N. Lehrman, MD, director of the NIH/National Institute of Allergy and Infectious Diseases/Division of Acquired Immunodeficiency Syndrome therapeutics research program. Lehrman spoke at the American Society for Microbiology meeting, held here.

“There are 2 billion people worldwide affected by TB, and some believe there are 8 to 9 million new active cases of TB a year,” Lehrman said.

Ninety-eight percent of the new cases occur in low- and middle-income countries, according to Lehrman. More than 2 million people die each year of TB. Layered on this epidemic are 40 million people with HIV and an additional 5 million new cases of HIV each year. More than 90% of people with HIV also populate these resource-limited regions. HIV infections are estimated to cause 3 million deaths a year.

“When you superimpose the epidemics, you find that 12 to 14 million people have HIV and TB coinfection,” Lehrman said.

TB outbreaks considered

Worldwide instances of TB were decreasing until the 1980s but began a steady increase between 1982 and 1983 — at the beginning of the uptake of HIV/AIDS epidemic.

Rates skyrocketed in South Africa, whereas in the United States, urban outbreaks were quickly quelled. TB notification rates in New York City decreased steadily after 1920 to a point where many people believed TB was nearly gone from the United States. When HIV rates began to climb in New York City in the 1980s, however, TB rates rose concurrently.

“This coinfection outbreak was a harbinger of what we would see later worldwide,” Lehrman said.

KwaZulu-Natal as epicenter

South Africa’s national TB incidence is 500 per population of 100,000. Greater than 200 per population of 100,000 is considered an epidemic.

In KwaZulu-Natal, the incident rate is more than 1,000 per population of 100,000 and an estimated 80% to 90% of people with TB are HIV coinfected. The case mortality rate was 40% before the introduction of antiretroviral therapy, but cause of death was not well characterized. Sixty percent of women in the region have HIV by age 25. In a Yale intervention and study of integrated care for TB and HIV coinfection, patients were successful with antiretroviral treatment and TB treatment. – by Kirsten H. Ellis

For more information:

• Lehrman SN. XDR-TB and HIV infection: Challenges for low- and middle-income countries. Symposium 335. Presented at: The American Society for Microbiology 107th General Meeting; May 21-25, 2007; Toronto.