ORIGINAL ARTICLE
* Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur.
 HIV and TB Co-infection
(A Study from RIMS Hospital, Manipur)
S Bhagyabati Devi*, Santa Naorem*, T Jeetenkumar Singh*, Ksh Birendra Singh*,
Lallan Prasad*, Th Shanti Devi*
Abstract
Background and objectives: Human immunodeficiency virus (HIV) and Tuberculosis (TB) co-infection is emerging as a serious threa
globally. This study was done in Manipur, which has the highest HIV seropositivity rate in India, in an attempt to document the
vulnerability of the HIV infected persons to tuberculosis in this State.
Methods: 100 HIV positive patients of 30.27 ± 5.5 years of age and 100 HIV negative patients of 31.13 ± 8.54 years of age who
willingly consented to participate in the study were selected after proper counselling. Confirmation of HIV status was done acc
to NACO guidelines, and diagnosis of TB as per the RNTCP guidelines. Their mode of clinical presentation, site of TB, CD4 cell count,
etc., were studied.
Results: TB was found in 55% of HIV infected patients compared to 25% in seronegative patients, which was significant statistic
(p < 0.001). Combined pulmonary and extrapulmonary form of TB were significantly more common in HIV seropositive patients (p
< 0.02) in whom the CD4 cell count was also low (less than 100/cmm).
Interpretation and conclusion: The result of this study showed the increased vulnerability of the HIV infected persons to TB in
as seen in other studies in India and abroad. Disseminated TB with lower CD4 cell count is also shown. Further strengthening of the
joint action plan on HIV and TB is suggested.
Key words: AIDS, HIV, Tuberculosis, NACO, RNTCP.
Introduction
The emergence of human immunodeficiency virus (HIV)
has paved the way for the resurgence of Mycobacterium
tuberculosis infection – pulmonary as well as
extrapulmonary. Multidrug resistant  (MDR) and other
rarer forms of TB have also become more prevalent. As a
result, HIV and TB co-infection is on the rise, more so in
the developing countries like India.
HIV is the most powerful risk factor for progression from
M. tuberculosis infection to TB disease. The risk of
development of TB in HIV infected patients in India is 6.9/
100 person years as compared to 10% lifetime risk of
developing TB in HIV negative persons. This is especially
important in India where 40% of adult population is
latently infected with M. tuberculosis1. TB, in turn,
accelerates the progression of HIV infection to AIDS
defining stage and shortens the survival of such patients
and is the leading cause of death, accounting for one-third
of deaths due to AIDS worldwide2. Despite the existence
of effective drugs, TB continues to be a major health
problem and kills more than a million people every year.
The World Health Organisation (WHO) declared TB a
global emergency in 1993 and Govt of India has launched
a Revised National Tuberculosis Control Programme
(RNTCP) with directly observed therapy, short course
(DOTS) as a solution for its control3.
The magnitude of HIV infection is alarming in Manipur, a
small state with a population of about 25 lakhs. In 1989
October, out of 828 blood samples screened, only 6
persons were found to be seropositive, but at present it is
disturbing to note that Manipur has the highest
seropositive rate of 157.92 per 1,000 blood samples
screened4 as against the national figure of 40.63. The
present study was undertaken to document the
vulnerability of the HIV infected patients in Manipur to
TB, and to study the present status of this common co-
infection.
Materials and methods
The regional Institute of Medical Sciences Hospital (RIMS)
JIACM 2005; 6(3): 220-3
is a referral teaching hospital in the North-Eastern part
of India. This cross sectional study was conducted on the
patients admitted to the Medicine ward of RIMS hospital
from January, 2002 to January, 2003, mostly for the
evaluation of fever. Patients who were earlier treated or
were continuing treatment for TB were excluded from
the study.
Patients with high risk behaviour for HIV exposure like
intravenous drug abuse, multipartner sex, transfusion of
blood or blood products, sharing of razor blades, having
tattoo mark, etc., were given proper counselling and their
blood samples were tested for HIV serology. 240 patients
were found to be seropositive out of 1,100 such cases
(21.8%). Out of these, 100 patients who consented to
participate in the study were randomly selected. Another
100 patients of comparable age with no history of high
risk behaviour for HIV exposure were also selected. After
proper counselling and due consent, they were subjected
to HIV serology testing and were also investigated for
tuberculosis.
Screening and confirmation for HIV status were done in
Voluntary Counselling and Testing Centre (VCTC) in the
Dept of Microbiology, RIMS, as per NACO guidelines4. The
centre is also a recognised National Reference Centre
where CD4 lymphocyte count is also done by using Becton
Dickinson FAC Scan. Diagnosis of TB was made according
to the RNTCP guidelines5 by positive sputum AFB smear
for pulmonary TB and by fine needle aspiration cytology
or biopsy showing caseating granuloma, positive chest x-
ray, pleural or ascitic fluid examination, etc., for
extrapulmonary tuberculosis.
Statistical Evaluation
Mean and standard deviations were worked out for all
numerical variables. Statistical association between
variables was established by applying the chi-square test
on a 2 x 2 table. Degree of freedom and significance of
statistical association were calculated from standard
probability (p-value) chart.
Results
Of the 100 seropositive cases, 94 (94%) were males and
6 (6%) were females. 87 (87%) patients including one
female were intravenous drug users (IDUs), the
remaining consisted of 10 male heterosexuals with
multiple sexual partners and 3 homosexuals.
The age range for seropositive patients was from 16 - 46
years with a mean and SD of 30.27 ± 5.5 years. For the
seronegative patients it was from 15 to 48 years with mean
± SD of 31.13 ± 8.54 years. The highest number of HIV
infection was found in the age group of 21 - 30 years (63%)
as shown in Table I.
Table I: Showing age distribution of the patients.
Age (years) HIV Status
(+ve) (-ve)
n = 100 n = 100
Below 20 3 8
21 – 30 63 40
31 – 40 30 30
Above 40 4 22
The seropositivity rate was highest among those who
were unemployed (40%); they were all IDUs (including 1
female). The second highest positivity was found among
the business professionals (35%) among whom 30 were
also IDUs.
Tuberculosis was found in 55 patients (55%) in the
seropositive group (age ranged from 21 - 36 years) and
25 (25%) patients in the seronegative group (age ranged
from 22 - 46 years). Combined (pulmonary and
extrapulmonary) lesions were more commonly seen in the
HIV infected patients as shown in Table II.
Table II: Showing distribution of TB among the
patients (numbers in brackets denote percentage of
the total TB cases detected).
Koch’s No. of Patients Significance
Lesion with TB in
HIV (+) HIV (-)
Patients Patients
n = 55 n = 25
Pulmonary 18 (32.70) 11 (44) P > 0.05
Extra-pulmonary 12 (21.82) 09 (36) P > 0.05
Combined 25 (45.46) 05 (20) P < 0.02
The commonest extrapulmonary lesion in the HIV
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222 Journal, Indian Academy of Clinical Medicine  circle6  Vol. 6, No. 3  circle6  July-September, 2005
seropositive patients was in the lymph nodes (n = 15;
27.27%), followed by pleural effusion (n = 11; 20%),
abdominal (n = 7; 12.72%) and CNS involvement (n = 4;
7.27%). AFB culture and sensitivity tests were not done
because of non-availability of the facilities in our Institute.
Sputum for AFB was positive in 16 (29%) of the
seropositive cases and AFB was present in plenty in the
lymph gland aspiration cytology in 12 (21.81%)
seropositive cases. CD4 cell count was done in the
seropositive patients with TB. It was lowest (less than 100/
cmm) in those patients with combined (pulmonary and
extrapulmonary) lesions, less than 200/cmm in
extrapulmonary lesions, and less than 300/cmm in
pulmonary TB.
Fever was present in all the patients of TB in both the study
groups, cough of more than 3 weeks duration was present
more in the seronegative group (80%) and involuntary
weight loss of more than 10% in the past 6 months was
commoner in the seropositive group (38.18%) as shown
in Table III. Pulmonary infiltrates in the chest x-ray were
found in 38 (69%) cases in the seropositive and in 17 (68%)
cases in the seronegative patients. In 12 (21.81%) patients
of the seropositive group, lower zone involvement was
seen in the chest skiagram, a feature not present among
the seronegative patients.
Table III: Showing frequency of symptoms of TB
(numbers in brackets denote the percentage value).
Symptoms HIV Status
(+ve) (-ve)
n = 55 n = 25
Fever > 3 weeks 55 (100) 25 (100)
Cough > 3 weeks 26 (47.27) 20 (80)
Weight loss > 10% 21 (38.18) 4 (16)
Haemoptysis 10 (18.18) 12 (48)
Chest pain 10 (18.18) 11 (44)
Shortness of breath 8 (114.54) 9 (36)
Lymphadenopathy 15 (27.27) 4 (16)
Discussion
HIV seropositivity rate is on the rise in the State of
Manipur6 as in rest of India and world. The sexually active
age group of 20 - 40 years (93%) is the most commonly
affected with the mean age of 30.27 ± 5.5 years. This is
consistent with the findings of other studies8. For the
seronegative controls also, the mean age was a
comparable one of 31.13 ± 8.54 years. The incidence of
HIV infection was highest among the unemployed youth
(49%) and business personnel (35%). In other studies in
India9 it was highest among the manual labourers,
followed by truck drivers. IDU was the most common risk
factor in the present study (87%) and it was most
commonly found among the unemployed youths
sharing the needless.
In this study, TB was found in 55 % of the HIV positive
patients and in 25% of the HIV negative patients which
was significant statistically (p < 0.001). This is consistent
with the findings in another study7, but higher than that
of a Kolkata study with 27.7% only9. Our study was based
on the patients admitted in the hospital for evaluation
of fever. This may explain the higher incidence of TB in
those seronegative patients.
NACO, Govt. of India also has reported TB as the
commonest opportunistic infection (62.3%) in the HIV
infected persons4. The incidence of combined pulmonary
and extrapulmonary TB infection was significantly higher
(P<0.02) in the seropositive patients, a finding that is
consistent with a study by Jones et al10. This shows that in
immunocompromised patients TB may get disseminated
early in comparison to their immunocompetent
counterparts.
The commonest clinical presentations were low grade
fever, weight loss, cough, and lymphadenopathy which
were consistent with studies by Kumar et al11 and by
Putong et al12. But Dey et al9 found rapid weight loss was
most common prsentation in seropositive patients, and
cough was the most common symptom of TB in
immunocompetent subjects. In our study, sputum for AFB
was positive in 16 (29%) of seropositive patients and
infiltrative lesions in chest skiagram were seen in 32 (58%)
of seropositive patients which were 30.4% and 95.6%
respectively in another study9. The CD4 cell count vis-à-vis
the HIV – TB lesion in its different forms in this study is in
tune with the findings in other studies10, 13, 14. Thus TB and
HIV infection have a common interaction. HIV infection
increases the individuals’ susceptibility to TB by impairing
the immune response to mycobacterial infection15. Forte
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et al16 have documented the declining proliferative and
cytolytic T-cell mediated responses in HIV patients with
progression of immunodeficiency.
Recognising this serious threat, a joint action plan on HIV-
TB was developed by the Government of India in
November, 2001 between the National AIDS Control
Organisation (NACO) and the Central TB Division8. The
initial focus of the plan was on the six high HIV burden
States of India which includes Manipur, a focus of HIV
infection with the highest percentage of seropositivity
where the present work was undertaken to study the
current status of HIV and TB co-infection in this state. We
humbly suggest the need for strengthening the joint
action plan on HIV and TB, and also the ART (anti-retroviral
treatment) services.
Acknowledgement
We are indebted to the Medical Superintendent and
Microbiology Deptt. of Regional Institute of Medical
Sciences and Hospital, Imphal for their guidance and kind
permission to publish this study.
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ANNOUNCEMENT
13th Annual Conference of
the Indian Association of
Clinical Medicine
October 15 - 16, 2005
Patna (Bihar)
Dr. Arun Tiwary
Chairman, Organising Committee
Dr. Ajay Kumar
Organising Secretary
Dr. R. P. Srivastava
Chairman, Reception Committee
Conference Secrerariat:
Dr. Ajay Kumar
22, Nehru Nagar, Patna - 800 013 (Bihar)
Phone: 0621-2265715/2350434
Mobile: 09431020510, Fax: 0612-2278945
E-mail: drajaykr@yahoo.com