Perceptions and challenges among health care providers about HIV-TB co-infected children- A qualitative study

BACKGROUND

Human immunodeficiency virus - Tuberculosis (HIV-TB) co-infected patients have a greater risk of mortality, treatment failure, and recurrence. The significant morbidity and mortality rates associated with tuberculosis and human immunodeficiency virus infection in children cause concern. India aims to enhance the detection and treatment of HIV-TB cases in children and coordinate TB & HIV care.

OBJECTIVE

To explore the perceptions and challenges of health care providers regarding the diagnosis and treatment of Tuberculosis in HIV-TB co-infected children.

MATERIALS AND METHOD

In-depth interviews among 14 health care providers were conducted in ART centers of 5 talukas of Belagavi district to identify health care providers' perceptions and challenges regarding pediatric HIV-TB diagnosis and treatment. Interviews were conducted after receiving informed consent.

RESULTS

Challenges during HIV-TB diagnosis and treatment in children: difficult to get sputum sample for CBNAAT and child was unable to complain about symptoms, caregivers were not able to mention the signs/symptoms correctly, unavailability of a pediatrician in few Taluka ART centers, delay in receiving TB lab report, challenging to feed drugs to an infant, higher loss to follow-up, financial problem, distance from centers, low community awareness, poverty and illiteracy, stigma and death due to TB treatment default.

CONCLUSION

Efforts such as expanded health care providers, community education, and a constant supply of HIV rapid test kits are required to ensure successful diagnosis and treatment of HIV-TB co-infected children.

Performance of Xpert MTB/RIF Ultra for the Diagnosis of Pulmonary Tuberculosis Using Bronchoalveolar Lavage Samples in People Living with HIV/AIDS (PLWHA) in China: A Prospective Study

Background

Sputum is commonly used for the diagnostic testing of pulmonary tuberculosis (PTB), but people living with HIV/AIDS (PLWHA) usually have little sputum. Moreover, the automated molecular test, Xpert MTB/RIF assay (Xpert), has a low sensitivity in PLWHA. We aimed to estimate the performance of Xpert Ultra on the detection of Mycobacterium tuberculosis (MTB) using bronchoalveolar lavage (BAL).

Methods

From February 5, 2018 to March 30, 2019, a total of 99 PLWHA with suspected PTB at the Third People’s Hospital of Shenzhen, China, were recruited. The information on demographics and medical history, blood MTB antigen-specific interferon gamma enzyme-linked immunospot assay (T-SPOT.TB), T lymphocyte subsets, and plasma HIV RNA load were collected. Computed tomography (CT) and flexible bronchoscopy were performed, and BAL and blood samples were collected. Testing of acid-fast bacilli (AFB), tuberculosis real-time fluorescence quantitative PCR (TBDNA), Ultra, Xpert, and MTB culture were conducted.

Results

Compared to BAL MTB culture for tuberculosis diagnosis, Ultra, Xpert, T-SPOT.TB, TBDNA and AFB smear had the sensitivity of 0.96 (24/25), 0.80 (20/25), 0.84 (21/25), 0.44 (11/25), and 0.12 (3/25), respectively; and the specificity of 0.92 (68/74), 0.96 (71/74), 0.93 (69/74), 0.96 (71/74), and 0.99 (73/74), respectively. Our study found that the sensitivity of Ultra was higher than that of culture and Xpert (AUC 0.92, 0.86 and 0.84, respectively). The results also indicated that PLWHA with CD4 <200 cells/mm³ had reduced both sensitivity (from 1.00 and 0.86 to 0.94 and 0.78, respectively) and specificity (from 0.96 and 1.00 to 0.90 and 0.41, respectively) of Ultra and Xpert for the diagnosis of PTB.

Discussion

Our data supported an increased sensitivity of Ultra compared to that of Xpert on BAL samples of PLWHA, regardless of the CD4 counts and reference diagnosis standards.

3D host cell and pathogen-based bioassay development for testing anti-tuberculosis (TB) drug response and modeling immunodeficiency

Tuberculosis (TB) is a global health threat that affects 10 million people worldwide. Human Immunodeficiency Virus (HIV) remains one of the major contributors to the reactivation of asymptomatic latent tuberculosis (LTBI). Over the recent years, there has been a significant focus in developing in-vitro 3D models mimicking early events of Mycobacterium tuberculosis (Mtb) pathogenesis, especially formation of the granuloma. However, these models are low throughput and require extracellular matrix. In this article, we report the generation of a matrix-free 3D model, using THP-1 human monocyte/macrophage cells and mCherry-expressing Mycobacterium bovis BCG (Bacilli Camille Guérin), henceforth referred as 3D spheroids, to study the host cell-bacterial interactions. Using mCherry-intensity-based tracking, we monitored the kinetics of BCG growth in the 3D spheroids. We also demonstrate the application of the 3D spheroids for testing anti-TB compounds such as isoniazid (INH), rifampicin (RIF), as well as a host-directed drug, everolimus (EVR) as single and combinational treatments. We further established a dual infection 3D spheroid model by coinfecting THP-1 macrophages with BCG mCherry and pseudotype HIV. In this HIV-TB co-infection model, we found an increase in BCG mCherry growth within the 3D spheroids infected with HIV pseudotype. The degree of disruption of the granuloma was proportional to the virus titers used for co-infection. In summary, this 3D spheroid assay is an useful tool to screen anti-TB response of potential candidate drugs and can be adopted to model HIV-TB interactions.

Trehalose limits opportunistic mycobacterial survival during HIV co-infection by reversing HIV-mediated autophagy block

Opportunistic bacterial infections amongst HIV-infected individuals contribute significantly to HIV-associated mortality. The role of HIV-mediated modulation of innate mechanisms like autophagy in promoting opportunistic infections, however, remains obscure. Here we show, HIV reactivation in or infection of macrophages inhibits autophagy and helps the survival of pathogenic Mycobacterium tuberculosis (Mtb) and nonpathogenic non-tuberculous mycobacterial strains (NTMs). The HIV-mediated impairment of xenophagy flux facilitated bacterial survival. Activation of autophagy by trehalose could induce xenophagy flux and kill intracellular Mtb or NTMs either during single or co-infections. Trehalose, we delineate, activates PIKFYVE leading to TFEB nuclear translocation in MCOLN1-dependent manner to induce autophagy. Remarkably, trehalose significantly reduced HIV-p24 levels in ex-vivo-infected PBMCs or PBMCs from treatment-naive HIV patients and also controlled mycobacterial survival within Mtb-infected animals. To conclude, we report leveraging of HIV-mediated perturbed host innate-immunity by opportunistic bacterial pathogens and show an attractive therapeutic strategy for HIV and associated co-morbidities.Abbreviations: AIDS: acquired immune deficiency syndrome; AMPK: AMP-activated protein kinase; ATG5: autophagy related 5; BafA1: bafilomycin A1; CFU: colony forming unit; CTSD: cathepsin D; CD63: CD63 molecule; EGFP: enhanced green fluorescent protein; FRET: Förster resonance energy transfer; GABARAP: gamma-aminobutyric acid receptor-associated protein; GAPDH: glyceraldehyde 3-phosphate dehydrogenase; GLUT: glucose transporter; HIV: human immunodeficiency virus; hMDMs: human monocyte derived macrophages; IL2: interleukin 2; LAMP1: lysosomal-associated membrane protein 1; LC3B-II: lipidated microtubule-associated proteins 1A/1B light chain 3B; Mtb: Mycobacterium tuberculosis; MTOR: mechanistic target of rapamycin; mRFP: monomeric red fluorescent protein; M6PR: mannose-6-phosphate receptor; NAC: N- acetyl- L -cysteine; NTM's: non-tuberculous mycobacteria; PBMC: Peripheral Blood Mononuclear cells; PIKFYVE: phosphoinositide kinase; FYVE-Type Zinc Finger; PHA: phytohemagglutinin; PMA: phorbol 12-myristate 13-acetate; PtdIns(3,5)P2: Phosphatidylinositol 3,5-bisphosphate; ptfLC3: pEGFP-mRFP-LC3; ROS: reactive oxygen species; SQSTM1: sequestosome1; TFEB: transcription factor EB; MCOLN1/TRPML1: mucolipin 1; PIP4P1/TMEM55B: Human trans-membrane Protein 55B; UVRAG: UV Radiation Resistance Associate; VPS35: vacuolar protein sorting associated protein 35; WDR45: WD repeat domain 45; YCAM: Yellow Chameleon.

Defective Antigen Presentation Leads to Upregulation of PD1 and IL-10 in HIV-TB Co-Infection

Human immunodeficiency virus-tuberculosis (HIV-TB) co-infection poses a challenge to the immunologists in developing new diagnostic and therapeutic tools. Mechanisms behind the breakdown of the immune defense of the co-infected individual are poorly known. Numerous studies in HIV alone have revealed the role of PD1, TAP, and IL-10, but not in co-infection. The interaction of the 2 distinct bugs, which is resulting in domination over the host immune system, is still a lacuna. Hence, we aimed to portray functions of IL-10, TAP, and PD1 molecules in HIV-TB co-infection. Co-culture cells challenged with γ-irradiated M.Tb under various conditions resulted in high interleukin (IL)-10 secretion and high percentage of PD1 expression on CD8 T cells, which might be due to defective antigen presentation of TAP on dendritic cells and macrophages. Herein our observations provide an insight into the escape mechanisms by M.Tb in HIV-infected individuals from the host immune responses leading to TB co-infection.

The role of Mycobacterium tuberculosis antigen specific cytokines in determination of acid fast bacilli culture status in pulmonary tuberculosis patients co-infected with human immunodeficiency virus

Introduction

The interaction between Mycobacterium tuberculosis and HIV leads to rapid progression of tuberculosis (TB) and human immunodeficiency virus (HIV)-induced immunosuppression. Diagnosis of TB in these patients is more difficult due to its atypical presentations giving contradicting results. The overall aim of this study was to evaluate the ability of pro-inflammatory cytokine (Th1) and anti-inflammatory cytokine (Th2) to discriminate between culture-positive and -negative smear status in HIV-TB co-infected patients.

Methods

In a prospective cohort, a total of 86 study participants were recruited: 46 culture-negative and 40 culture-positive. Blood and sputum samples were collected from all participants. The blood was then analyzed using FACSCalibur flow cytometer to immunophenotype the cells and ELISA performed for cytokine profiles. Sputum samples were analyzed to determine smear status using direct microscopy and Lowenstein Jensen medium. Statistical analyses were performed using R software. Independent samples t-test was used to compare means between the two groups, while the medians were compared using two-sample Wilcoxon rank sum test. Pearson's Chi-square test was used to compare the proportion of male and female participants across the culture and AFB smear status. In order to determine the predictive power of Th1 and Th2 in discriminating Pulmonary Tuberculosis status (PTB) (culture status was used as a confirmatory test), binary logistic regression models were fitted for Th1 covariates [IFN-γ, TNF-α, IL-2 and IL-12(p70)] and Receiver Operating Characteristic (ROC) curves plotted.

Results

The overall mean age of the participants was 39 years (SD=12), 42% being male. Although, lymphocytes counts were higher in culture-positive relative to culture-negative, the CD8, CD19, and CD16/CD56 were comparable in the two groups. The CD4 counts differed between the two groups (P=0.012). The Th1 showed a better discrimination between culture-positive and -negative PTB individuals; IFN-γ (P=0.001), TNF-α (P=0.001), IL-2 (P=0.001) and IL-12(p70) (P=0.016). The Th2 cytokines (IL-4, IL-6 and IL-10) were comparable between the culture-positive and -negative groups. However, when the combination of Th1 cytokines [IFN-γ, TNF-α, IL-2 and IL-12(p70)] was fitted in binary logistic regression models, the predictive power was high with area under curve (AUC) being 89.7% in discriminating PTB.

Conclusion

This study provides evidence for the ability of a combination of Th1 cytokines in discriminating against culture-positive and culture-negative PTB.

Assessment of quality of antiretroviral therapy services in India, 2014-2015

Background

Following a decade of provision of free antiretroviral therapy (ART) in India, a nationwide assessment of ART services was conducted to review quality of care at ART centers. This paper presents the methods and defines replicable model of undertaking large scale assessments.

Methods

During the period January 2014-March 2015, 357 ART centers were reviewed under four domains, namely, operations, technical, monitoring and evaluation (M&E), and logistics. Mixed methods, comprising of desk review and on-site facility assessment; random sample of records, interviews with both health-care staff and people living with HIV (PLHIV) were used. Grading for each of the domain was done on a scale of 5, with 1 (Very poor) being the lowest and 5 (Excellent) as highest.

Results

1720 health-care staff and 1762 beneficiaries were interviewed; 34 600 patient cards were reviewed. Of the 357 centers assessed 60, 169 and 128 scored Excellent, Average and Poor, respectively, in operations domain; 147, 176, 34 in Technical domain; 215, 115, 27 in M&E domain; 263, 71, 23 centers in logistics domain scored Excellent, Average and Poor, respectively. About 95% (1698/1785) of PLHIV were satisfied with the care provided at ART centers.

Conclusion

The methodology used for the assessment of ART centers in India yielded insights on the different domains that impact implementation and quality of service delivery. The design of this exercise may inform other researchers and managers planning similar large-scale assessments.

Bevacizumab for paradoxical worsening treatment adjunct in HIV patient with choroidal tuberculoma

The use of anti-tubercular therapy (ATT) along with anti-retroviral therapy (ART) in human immunodeficiency virus-tuberculosis (HIV-TB) co-infected individuals could at times lead to paradoxical worsening due to an increase in the inflammatory activity due to immune reconstitution inflammatory syndrome (IRIS) in the eye. This is characterized by anterior and posterior segment inflammatory reactions which may occur in the form of serous retinal detachment. We describe a case where the use of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agent led to resolution of the serous retinal detachment, which had failed to respond to other common modalities of treatment.

An HIV-TB co-infected 18-year-old, male patient, who was started on ART and ATT developed IRIS in the form of worsening of serous retinal detachment around a pre-existent asymptomatic tuberculoma. The patient was initially treated with oral and topical steroids without a satisfactory response. Intravitreal bevacizumab was then tried for this patient. Serial fundus photos and optical coherence tomography (OCT) taken before and after treatment showed complete resolution of the serous retinal detachment with two doses of intravitreal bevacizumab.

Intravitreal anti-VEGF agents may have a role in the reversal of serous retinal detachment, which occurs as a part of IRIS in HIV-tuberculosis co-infected individuals who have been started on anti-tubercular and anti-retroviral therapies.

High levels of plasma interferon gamma and +874T/A gene polymorphism is associated with HIV-TB co-infection

OBJECTIVE

Tuberculosis (TB) is one of the most frequent opportunistic infections in HIV patients leading to increased morbidity and death rate. This study was carried out to investigate the role of the cytokines IFN-γ and TNF-α level and their single nucleotide polymorphisms (SNPs) in HIV-TB co-infection.

METHODS

247 HIV-TB (124 HIV-pulmonary TB, 123 HIV-extra pulmonary TB), 126 HIV positive individuals without tuberculosis and 129 healthy subjects (HS) were included to measure plasma levels of IFN-γ and TNF-α by sandwich ELISA and One way ANOVA statistical analysis was carried out among the groups. The SNPs of TNF-α-308 G/A, -238 G/A and IFN-γ+874 T/A were also investigated using amplification refractory mutation system polymerase chain reaction (ARMS-PCR). The frequencies between the groups were compared by Pearson's chi square statistical analysis.

RESULTS

Plasma IFN-γ and TNF-α were significantly elevated in HIV-TB and TB (p<0.05) as compared to those in HS group. There was significant association between IFN-γ+874 'A' allele and AA genotype in HIV-TB groups compared to HS and HIV (p<0.05) and no such association was found for TNF-α-308 and -238. The plasma cytokine levels of TNF-α and IFN-γ reveals no significant association with levels of IFN-γ+874 T/A, TNF-α -308 G/Aand-238 G/A genotypes in any of the study groups.

CONCLUSION

In conclusion, the present study revealed elevated plasma IFN-γ and its +874 'A' allele are associated with HIV-TB co-infection indicating 1.6 times increased risk for TB susceptibility. Elevated TNF-α levels in TB and HIV-TB suggest its involvement in TB pathogenesis.

Analysis of HLA association among North Indian HIV-positive individuals co-infected with Mycobacterium tuberculosis

BACKGROUND

Genetic variation in HLA genes influence the immune response and may thus contribute to differential development of tuberculosis (TB) in HIV-infected individuals. The study was designed to determine whether HLA polymorphisms influence the development of Mycobacterium tuberculosis infection in HIV-infected individuals.

MATERIALS AND METHODS

Fifty HIV-positive individuals without TB (HIV+TB-), 50 HIV patients co-infected with TB (HIV+TB+) and 50 control subjects (HIV-TB-) were analyzed for HLA Class I and II polymorphisms.

RESULTS

In HLA Class II, frequency of occurrence of DRB1*13 (OR 3.165, CI 1.176-8.518, P value 0.019), DRB5 (OR 2.253, CI 1.011-5.019, P value 0.045) and DQB1*06 (OR 2.705, CI 1.197-6.113, P value 0.016) were increased in HIV+TB+compared to HIV+TB-. HLA DQB1*02 (OR 0.436, CI 0.185-1.029, P value 0.05) on the other hand conferred a protective role. In HLA Class I, frequency of B*15 (OR 2.705, CI 1.040-7.036, P value 0.038) was increased, whereas B*51 (OR 0.148, CI 0.031-0.706, P value 0.007) was decreased in HIV+TB+group compared to HIV+TB-. These differences however were not significant when compared with healthy controls.

CONCLUSION

HLA polymorphisms independently did not account for the susceptibility to either of the disease mostly, although they seem to play a role once the infection(s) has established in a particular individual. Further studies are needed on a larger sample size to confirm these observations.

Clinical outcomes and mortality associated factors in patients infected with HIV receiving a presumptive anti-tuberculosis treatment in a tertiary level hospital in Burkina Faso

INTRODUCTION

Tuberculosis is the leading cause of death among people living with HIV/AIDS (PLHIV) in sub-Saharan Africa. In PLHIV, Smear-Negative Pulmonary Tuberculosis (SNPTB) and Extrapulmonary Tuberculosis (EPTB) are predominant. Presumptive anti-tuberculosis (anti-TB) treatment is often delayed leading to a high mortality rate.

OBJECTIVES

To investigate the clinical outcomes of presumptive anti-TB treatment in HIV patients suspected of having TB and to determine the factors associated with patients' death.

METHODS

We conducted a retrospective descriptive study from 1 January 2007 to 31 December 2008 in the Department of Internal Medicine of the Hospital Yalgado Ouédraogo on patients infected with HIV who received a presumptive anti-TB treatment. Defining patients with SNPTB or EPTB was based on the 2007 WHO's diagnostic algorithm of SNPTB and EPTB.

RESULTS

One hundred and sixteen patients of the 383 (30.2%) HIV patients hospitalized in this period were suspected of having TB. The average CD4 count was 86.1 cells/µl (SD = 42.3). A SNPTB was diagnosed in 67 patients (57.8%) and a EPTB in 49 patients (42.2%). The median length of hospitalization duration was 23.5 days. The average time of initiation of anti-TB treatment after admission was 22 days (SD = 9.2 days). Evolution during the hospital stay was favorable for 65 patients (56.0%), unfavorable for 48 patients (41.4% or 12.5% of all hospitalized patients), and 3 patients (2.6%) were treatment defaulters. In a multivariate analysis, hospitalization duration longer than 15 days and a delay of anti-TB treatment initiation of more than 30 days are independent factors associated with patients' deaths.

CONCLUSION

An urgent access to TB-diagnostic tools and a revision of the International algorithm for the diagnosis and treatment of SNPTB and EPTB in the context of HIV could help to reduce the delay of anti-TB treatment initiation and the mortality rate of PLHIV in sub-Saharan Africa.