by Jorien Breur
He was a young man, 33 years old. When I entered the emergency room, he was there, gravely ill and struggling to breathe. Although he was surrounded by family, he looked afraid. His family confided in me that they could barely recognize him as he had become so desperately thin in the past couple of weeks.
The Caribbean region, after sub-Saharan Africa, has the highest HIV prevalence in the world, with the Dominican Republic (DR) and Haiti accounting for nearly three-quarters of HIV cases in this area (1). Many of the estimated 800,000 Haitians living in DR, including about 280,000 undocumented Dominican-born persons of Haitian descent, are affected by the HIV epidemic (2). In the DR there are an estimated 62,000 HIV-positive individuals, a prevalence of 0.8% in the adult population (1). La Romana is located in one of the most affected regions due to the high number of disenfranchised Haitian immigrants, poverty, and the prolific tourism industry.
For the past year I have been working at Clínica de Familia La Romana, exploring the world of clinical research in the DR, with the support of the Doris Duke Clinical Research Fellowship. Clínica de Familia is a comprehensive community health services organization, which runs one of the largest HIV clinics in the country, in addition to primary care services, an adolescent reproductive health clinic, and a specialized clinic for sex workers, amongst other programs. The doctors, nurses, and support staff work tirelessly to improve the quality of life of nearly 1500 children, women, and men with HIV. Many of the employees themselves are affected by HIV and have personally benefited from the clinic’s services. The clinic fosters a genuinely caring and supportive environment for everyone present.
The HIV pandemic has also fueled a rise in TB incidence, with approximately a 40% increase in incident TB cases compared to 20 years ago (3). Worldwide, an estimated 1.37 million (14.8%) TB cases occur in HIV-positive persons, resulting in 456,000 TB-related deaths in this population. Tuberculosis is now the leading cause of mortality in people living with HIV and taken together, these two diseases make up the leading infectious causes of mortality worldwide.
HIV-TB co-infection is particularly prevalent in populations with limited resources and limited access to care, which is closely linked to poverty and discrimination. My research focuses on this dual epidemic. Lack of reliable HIV and TB surveillance and health care service data in the DR impairs our understanding of Hispaniola’s epidemic and trends in health care service utilization.
I conducted a retrospective chart analysis in three clinics providing varying levels of integrated HIV and TB care in La Romana. At the HIV clinic, assessments of TB-related variables, such as mycobacterial culture, acid fast bacilli (AFB) smear, chest X-ray, and clinical presentation were often incomplete. Similarly, HIV-related markers of disease, such as CD4 cell count and HIV viral load, were rarely available at the TB clinic. Clearly, integrated HIV and TB services within these clinics are lacking. Globally, TB is the most common cause of AIDS-related death, and this was proven to be true in our population as well. This highlights the fact that basic aspects of the management of these diseases are still not established.
Diagnosis of TB in an HIV-infected individual is difficult due to the high rate of extrapulmonary disease, the need to distinguish TB from other infectious and neoplastic complications of HIV, and the high rate of atypical clinical presentation. Many co-infected individuals have few symptoms of TB or less specific ones. HIV-positive patients with TB frequently present with “sub-clinical” TB, which often is not recognized as TB, and consequently there are delays in both TB diagnosis and TB treatment. In low resource settings TB is typically diagnosed with a combination of AFB smear, AFB culture, and chest X-ray. An AFB smear is used to determine if an infection may be due to one of the AFB, the most common of which is M. tuberculosis; however, HIV-associated TB is often AFB smear-negative which increases the likelihood of a missed diagnosis. In resource-rich areas, results of an AFB culture take a minimum of six weeks, but here in La Romana it takes an average of three months, rendering the results clinically irrelevant. In addition, up to a fifth of people with both pulmonary TB and HIV have normal chest x-rays.
As a researcher I have seen firsthand the challenge of diagnosing TB in an HIV-positive patient in a low resource setting. Due to this increased likelihood of atypical clinical presentation and the poor performance of standard diagnostic tools, HIV-positive patients with TB are being diagnosed largely by clinical presentation. I am currently conducting two studies in La Romana: one is focused on evaluating the role of vitamin D in the clinical course of co-infected patients, and the other exploring the feasibility of utilizing an immune-based whole blood IFN-γ release assay for the detection of TB among newly diagnosed HIV-positive individuals. Our goal is to improve the clinical algorithm currently used to diagnose HIV-associated TB at Clínica de Familia.
The young patient co-infected with HIV and TB whom I encountered in the emergency room died that weekend in the hospital. His death reminds us of the work that needs to be done. HIV-TB co-infection is a major concern worldwide. Unlike HIV, TB spreads by air. These smear-negative cases of TB remain infectious sources. With a delay in diagnosis, TB can spread easily among subjects infected with HIV and into the general community. The urgency of establishing optimal approaches to the diagnosis of TB and the co-treatment of HIV and TB cannot be overstated. Although complete integration of HIV and TB services may be difficult, it is clear that a greater awareness of the problem of TB for people with HIV has already resulted in significant benefits. The World Health Organization HIV-TB policy includes the provision of antiretroviral therapy for all HIV-positive TB patients regardless of their CD4 count. In 2011, 3.2 million people living with HIV were screened for TB and 2.46 million TB patients were tested for HIV. However, there remains an urgent need for a rapid and accurate diagnostic test for active TB in HIV-co-infected patients.
Of critical importance is the improvement of access to both life-saving HIV and TB medications to all those in need of such therapy. In low resource settings such as the DR, access is often a major barrier. Patients travel hours to arrive at the clinic for their monthly HIV check-up. As TB treatment requires the patient to come to the clinic on a daily basis, many patients are lost in the process.
I am running a marathon to raise money for this important cause. All donations will go directly to the patients I am working with, individuals who have truly impacted my life. In order to reach my fundraising goal, I need your support!
- Joint United Nations Programme on HIV/AIDS. Uniting the world against AIDS. 06. Fact sheet. Caribbean. Geneva: UNAIDS; 2006 [cited 2008 Jun 10]. Available from: http://data.unaids.org/pub/GlobalReport/2006/200605-FS_Caribbean_en.pdf.
- Roman-Poueriet, J., et al. “HIV infection and prevention of mother-to-child transmission in childbearing women: La Romana, Dominican Republic, 2002-2006.” Rev.Panam.Salud Publica 26.4 (2009): 315-23.
- Girardi E, Antonucci G, Vanacore P, Palmieri F, Matteelli A, Lemoli E, Carradori S, Salassa B, Pasticci MB, Raviglione MC, Ippolito G; GISTA-SIMIT Study Group. Tuberculosis in HIV-infected persons in the context of wide availability of highly active antiretroviral therapy.EurRespir J. 2004 Jul;24(1):11-7.
- Monkongdee P, McCarthy KD, Cain KP, Tasaneeyapan T, Dung NH, Lan NTN, Yen NTB, Teeratakulpisarn N, Udomsantisuk N, Heilig C, et al. Yield of acid-fast smear and mycobacterial culture for tuberculosis diagnosis in people with human immunodeficiency virus. Am J Respir Crit Care Med.2009;180:903–908.