How to treat 14,000 TB/HIV dual infection patients in China? Experts propose “4 I”
Winter in Beijing is cold and dry.
In the afternoon, a ray of sunlight sprinkled on the desk through the blurry glass of the old-fashioned balcony, and a book that was yellowed and out of cover was not known how many times it was read by Zhao Nan (pseudonym).
He slowly raised his head, looked at the clock on the wall, stood up on the desk, moved to the coffee table, picked up a few white pills and swallowed them.
In another half an hour, he will take another antiviral drug.
Zhao Nan is an AIDS (AIDS) patient with tuberculosis. Here, the clock is completely divided into different modules by the time of medication. He takes seven or eight drugs every day: anti-tuberculosis drugs, antiviral drugs, antifungal drugs…
“For fear of forgetting to take the medicine someday, I also bought the medicine packaging box, and every time I put the medicine in it a week in advance.” Zhao Nan’s words showed a hint of helplessness.
He said that he is still “interested” to listen to the doctor’s words to take medicine on time, “I will wait to die if I am too lazy to take it one day.”
According to estimates from the “Global Tuberculosis Report 2020” and the “Global AIDS Report 2020”, there are about 14,000 patients in China who “have the same disease” with Zhao Nan.
“Mycobacterium tuberculosis (TB) infection is the most common and first opportunistic infection after the human immunodeficiency virus (HIV) infects the body, and it is also one of the main causes of death in AIDS patients.”
Zhou Lin, director of the Patient Care Department of the Chinese Centers for Disease Control and Prevention’s Tuberculosis Prevention and Control Center, said in an interview with the China Science Daily that due to HIV infection, the body’s immunity is reduced, and the proportion of AIDS patients with TB in my country is about 3%.
December 1st is World AIDS Day. As a group of concomitant diseases, TB/HIV dual infection can mutually promote the progress of the disease and quickly lead to death. It has become one of the public health problems of human concern.
Curb Dual Infection
Tuberculosis is an infectious disease of the respiratory tract. According to the “Global Tuberculosis Report 2020” released by the World Health Organization, in 2019, there were approximately 9.96 million new tuberculosis patients worldwide.
Among them, TB/HIV dual infection accounted for 8.2% of new-onset patients.
Tuberculosis is still one of the top 10 causes of death in the world, and has been the leading cause of death from a single infectious disease since 2007.
Since the first report of AIDS cases in the world, according to the “Global AIDS Report 2020” released by the UNAIDS, there were approximately 1.7 million new infections in 2019. There are still 38 million HIV-infected people in the world today, and only 25.4 million people are receiving treatment.
According to the latest data from the National Health Commission of China, China has reported 1.045 million cases of HIV infection, which is still at a low prevalence level. In 2019, there were approximately 833,000 new tuberculosis patients in China, which is still one of the countries with a high burden of tuberculosis in the world.
“Although the number of TB/HIV dual-infected patients in China is not high, studies have shown that the risk of TB among HIV-infected patients is 20 to 37 times that of non-HIV-infected patients, and the death risk of TB/HIV dual-infected patients is that of simple tuberculosis patients. 2.87 times.”
Zhou Lin said that there are regional differences in the TB/HIV dual infection epidemic in China, which are mostly related to the local HIV epidemic situation. Therefore, how to control the spread of tuberculosis in HIV-endemic areas is very important.
But the difficulty is that tuberculosis and AIDS are both complex diseases and are managed by two different departments.
This undoubtedly increases the difficulty of early detection of TB/HIV dual infection.
“In particular, the clinical manifestations and X-ray manifestations of TB/HIV dual infection are not typical, and the detection rate of sputum tuberculosis bacteria and the positive rate of tuberculin test are relatively low.”
Sun Xin, Department of Prevention, Tianjin Haihe Hospital, said that the clinical manifestations of TB/HIV dual infection are very complex, and the diagnosis of this type of disease requires experienced clinicians to comprehensively consider the patient’s epidemiological characteristics, clinical manifestations, laboratory examinations, pathological examinations, Correct diagnosis is made by imaging examination and experimental anti-tuberculosis treatment results.
Not a simple addition of therapeutic drugs
Even if the diagnosis is clear, TB/HIV dual infection still faces the difficulty of treatment.
“TB treatment is time-limited, usually non-drug-resistant tuberculosis treatment takes 6 months. Even drug-resistant tuberculosis basically ends in two years. But the treatment of AIDS is a lifelong medication. The treatment of two diseases requires at least six or seven drugs. In this way, the superposition of adverse reactions between drugs will undoubtedly affect the treatment process of dual infection.” Zhou Lin said that TB/HIV dual infection is not simply adding anti-tuberculosis drugs and antiviral drugs.
In addition, the relatively high proportion of TB/HIV dual infection patients with non-tuberculous mycobacterial infection also increases the difficulty of treatment.
“The proportion of people without HIV infection who are infected with non-tuberculous mycobacteria is about 10%. If they are TB/HIV dual-infected people, non-tuberculous mycobacteria infection can even reach 40% to 50%. But non-tuberculous mycobacteria and The treatment principles of Mycobacterium tuberculosis are completely different.” Zhou Lin suggested that when diagnosing patients with TB/HIV dual infection, doctors should identify the type of mycobacterium to avoid long-term misdiagnosis.
Based on the pathogenic mechanism of AIDS, HIV attacks the human immune system. After AIDS patients’ immune function declines, they may be infected with Mycobacterium tuberculosis, fungi and other bacteria, which will naturally affect the treatment effect of tuberculosis.
Although there is a treatment dilemma, it does not mean that there is no treatment principle.
During the interview, industry experts said that the principles of anti-tuberculosis treatment for patients with TB/HIV dual infection are usually the same as those for patients with simple tuberculosis. Early detection, early diagnosis, and early treatment are essential to improve the prognosis of the disease.
For the antiviral treatment of AIDS, the primary problem is to choose the right time to give antiviral treatment (ART) during the anti-tuberculosis treatment.
“But when is the right time, this is the key.” Zhou Lin said.
Past guidelines recommended that the timing of ART be determined based on the patient’s CD4+ T lymphocyte count. When the CD4+ T lymphocyte count is less than 50/μl, it is recommended to start ART after 2 weeks of anti-tuberculosis;
When the CD4+ T lymphocyte count is not less than 50/μl, it is recommended to start ART after 8 weeks of anti-tuberculosis.
For patients with TB/HIV dual infection, the application of high-efficiency antiretroviral therapy (HAART) and anti-tuberculosis therapy can improve the prognosis and reduce the mortality rate, while HAART can also effectively reduce the incidence of tuberculosis in HIV-infected patients.
Treatment is the best prevention
Since the treatment of TB/HIV dual infection is much more difficult than the treatment of any disease of tuberculosis or AIDS, how to reduce the risk of TB patients infected with HIV and AIDS patients?
In this regard, Zhou Lin believes that HIV infection is more of a behavioral infection besides mother-to-child transmission. Therefore, if TB patients have a history of drug use, unprotected sexual contact, repeated fungal infections, etc., HIV antibody testing should be done. .
And AIDS patients who have symptoms of tuberculosis, such as fever, sputum, hemoptysis, swollen lymph nodes, sudden weight loss, etc., need to be screened for tuberculosis.
As early as 2008, the World Health Organization proposed three measures to reduce the burden of tuberculosis among HIV/AIDS patients (“3 I”).
The first I is patient discovery, implementing a two-way screening strategy (providing HIV testing for all tuberculosis patients and screening for tuberculosis among HIV/AIDS patients).
In 2010, the former Ministry of Health of China issued the “National TB/AIDS Dual Infection Prevention and Control Work Implementation Plan (Trial)” to provide HIV antibody testing services for newly registered tuberculosis patients in counties (districts) with high or moderate AIDS epidemics. .
In 2011, the “National Tuberculosis Prevention and Control Plan (2011-2015)” issued by the State Council of China clearly stipulated that the HIV screening rate of newly registered tuberculosis patients in key AIDS epidemic counties (districts) should reach 70%.
“At present, the area where AIDS is endemic in China is different from 10 years ago, so the relevant prevention and control strategies should also be adjusted.” Zhou Lin said.
The second I is infection control. That is to teach AIDS knowledge and conduct behavioral interventions for tuberculosis patients, standardize personal behavior, and enhance protection awareness.
The third I is preventive treatment (IPT), which is anti-tuberculosis preventive treatment for people with HIV/AIDS.
“This kind of preventive medication can effectively prevent HIV-infected/AIDS patients from developing active tuberculosis.” Zhou Lin, Wang Ni and others once published a report entitled “Anti-HIV Infected People’s Resistance” in the “China AIDS and STD” magazine. The article of “Implementation and Effect Analysis of Tuberculosis Prevention and Treatment Pilot”.
The conclusion is that it is feasible to implement isoniazid preventive treatment strategy in China’s TB/HIV prevention and treatment plan. The key is to establish a working mechanism and workflow according to local characteristics, clarify the responsibilities of relevant institutions, and ensure that patients receive full treatment management. The work quality of active tuberculosis screening should be strengthened.
But at present, there are not many areas in China that actually carry out tuberculosis preventive medication.
Previously, the “Administrative Measures for the Prevention and Treatment of Tuberculosis” issued by the Chinese government only required medical observation of close contacts of infectious pulmonary tuberculosis patients. If necessary, preventive chemotherapy should be given to them after obtaining their consent. However, it has not yet been issued in HIV/AIDS. Specific methods for IPT in the patient population.
Based on the current trend of the slow increase in AIDS and the slow decline in tuberculosis in China, Zhou Lin believes that how to reduce the number of HIV-infected persons with tuberculosis infection, actively carry out IPT work and related scientific research, is the “14th Five-Year Plan” period for China to control the dual The important work of infection.
In addition to the above-mentioned “3 I”, Zhou Lin believes that there should be another “I”, that is, one-stop service.
Although AIDS and tuberculosis prevention and treatment belong to two systems, management concepts and methods should be changed, and work should be patient-centered, so that patients with TB/HIV dual infection can be diagnosed, treated and managed in one institution. AIDS prevention and treatment agencies are running back and forth.
In fact, there is indeed a meta-analysis found that the success of IPT depends on the integration of the local AIDS control and tuberculosis control systems.
In the future, with the widespread application of artificial intelligence, molecular biology, genomics, nanotechnology, etc. in the medical field, Zhou Lin believes that the role of artificial intelligence in the diagnosis and follow-up of TB/HIV dual infection should be brought into play to improve grassroots TB /HIV diagnostic capabilities.
At the same time, new diagnostic tools with high sensitivity and specificity have been developed to quickly diagnose double infections, develop more effective new anti-tuberculosis drugs, and improve the effectiveness of tuberculosis treatment.
Related paper information:
https://doi.org/10.13419/cnki.aids.2018.10.07
https://doi.org/10.11816/cn.ni.2019-182959
https://doi.org/10.13419/j.cnki.aids.2017.09.12
“Chinese Journal of Science” (2020-12-07 3rd Edition Medicine and Health The original title is “When HIV meets Mycobacterium tuberculosis…”)
Original article：
https://www.redsunmedizone.com/2020/12/18/how-to-treat-14000-tb-hiv-dual-infection-patients-in-china-experts-propose-4-i/