Tuberculosis-HIV co-infection in Kiev City, Ukraine.In 2004, we tested all patients with newly diagnosed tuberculosis tuberculosis (TB), contagious, wasting disease caused by any of several mycobacteria. The most common form of the disease is tuberculosis of the lungs (pulmonary consumption, or phthisis), but the intestines, bones and joints, the skin, and the genitourinary, (TB) for HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. in Kiev City. The results were compared to information from medical records of 2002, when co-infection prevalence was 6.3%. Of 968 TB patients, 98 (10.1%) were H IV infected in·fect tr.v. in·fect·ed, in·fect·ing, in·fects 1. To contaminate with a pathogenic microorganism or agent. 2. To communicate a pathogen or disease to. 3. To invade and produce infection in. . TB-H IV co-infection is increasing, especially in injecting drug users. ********** In Ukraine, the prevalence of HIV infection has been increasing since the mid-1990s (1,2). By January 2005, a total of 74,856 cases of HIV infection had officially been registered (http://www.aidsalliance.kiev.ua/). The real number of HIV infected persons may be much higher, an estimated 330,000-410,000 in 2001 (>1% of adult population) (3). An increase in HIV prevalence is usually closely followed by an increase in tuberculosis (TB) (4). In Kiev City, the number of TB patients registered for treatment doubled from 629 in 1992 to 1,274 in 2004. This increase is mainly explained by economic and social changes after independence (August 1991), but the progressing HIV epidemic may also play a role in the increase in the number of TB patients. In a previous study in Kiev City, we estimated the prevalence of HIV infection in patients with newly diagnosed TB at 6.3% in 2002 (5). In this study, we assess the prevalence of HIV infection [approximately or equal to] 2 years later and compare the results of the 2 studies. We also determine risk factors for TB-HIV co-infection. The Study From March 2004 to February 2005, all patients with newly diagnosed TB, who were >18 years of age and living in Kiev City, and who had begun anti-TB chemotherapy in the Kiev City TB Services were eligible for inclusion. Patients were informed about the study, counseled, and asked to participate. Basic information was collected about all TB patients from medical records and by interview. Reasons for not providing a blood sample for HIV testing HIV test Various tests have been used to detect HIV and production of antibodies thereto; some HTs shown below are no longer actively used, but are listed for completeness and context. See HIV, Immunoblot. were also recorded. In Ukraine, TB diagnosis is made by smear smear (smer) a specimen for microscopic study prepared by spreading the material across the slide. Pap smear , Papanicolaou smear see under test. and culture examination. All persons with suspected TB are evaluated by a committee of experts. TB is classified as pulmonary TB pulmonary TB Pulmonary tuberculosis, see there bacteriologically confirmed (smear or culture positive), pulmonary TB bacteriologically not confirmed (smear and culture negative or not done), and extrapulmonary TB extrapulmonary TB Infectious disease Clinical TB outside the lungs–eg, lymph nodes, pleura, brain, kidneys, or bones . Blood samples were tested for HIV by using Genscreen Plus HIV Ag-Ab (Bio-Rad Laboratories, Steenvoorde, France). Confirmation of the test result was done by Abbott IMx system HIV-1/-2 3rd Generation Plus (M/S M/S Meter(s) per Second M/S Milestone M/S Modeling and Simulation M/S Master/Slave M/S Messieurs (plural of Mister) M/S Minesweeping M/S miles per second M/S Miniature Sheet Abbott GmbH, Wiesbaden, Germany). We tried to retest re·test tr.v. re·test·ed, re·test·ing, re·tests To test again. n. A second or repeated test. cases with an indeterminate That which is uncertain or not particularly designated. INDETERMINATE. That which is uncertain or not particularly designated; as, if I sell you one hundred bushels of wheat, without stating what wheat. 1 Bouv. Inst. n. 950. HIV test result. TB patients with a positive test result were referred to the Kiev AntiAIDS Centre. We used SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. 12.0 (SPSS Inc., Chicago, IL, USA) for data analysis with t tests and Z2 tests. Differences at the = 5% level were regarded as significant. We examined predictive factors for HIV infection by logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. . The results were compared to those of a study using medical record information from patients newly diagnosed with TB in Kiev City in 2002 (5). The study was approved by the medical ethics medical ethics The moral construct focused on the medical issues of individual Pts and medical practitioners. See Baby Doe, Brouphy, Conran, Jefferson, Kevorkian, Quinlan, Roe v Wade, Webster decision. committee of the Yanovskiy Institute of Phtisiology and Pulmonology pul·mo·nol·o·gy n. The branch of medicine that deals with diseases of the respiratory system. pulmonology The study of the lungs and respiratory function , Kiev City, Ukraine. Written informed consent was obtained from all participants. A total of 1,090 TB patients were included from the 9 TB clinics and hospitals in Kiev City. Of those 1,090 TB patients, 4 (0.4%) could not be counseled because they were too ill or intellectually impaired, 83 (7.6%) did not provide informed consent, and 15 (1.4%) had to be excluded from the study, primarily because medical workers could not obtain a blood sample. The 102 (9.4%) TB patients who did not participate in the study were significantly older than those included: mean ages, respectively, 45.4 and 39.1 years (p<0.001). Other characteristics were not significantly different. Of the 988 TB patients tested for HIV infection, 33 (3.3%) had an initial indeterminate test result. Sixteen of those were retested, 3 refused retesting, and 14 were not approached. Of those retested, 12 tested negative, 1 tested positive, and 3 again had an indeterminate test result. Thus, 968 TB patients with a definite HIV test result could be included in the analysis. Of those, 98 (10.1%) were HIV infected, 64 (65.3%) were identified in our study as HIV infected, and 34 (34.7%) had received a diagnosis of HIV infection from the Kiev Anti-AIDS Centre laboratory before being referred to the TB services with suspected TB. Reported injecting drug use was the strongest independent predictor for HIV infection (Table 1). Those reporting injecting drug use were 31.4 times more likely to be HIV infected than those not reporting injecting drug use (95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI] 17.4-56.9). Also, those who had reported a sexually transmitted disease sexually transmitted disease (STD) or venereal disease, term for infections acquired mainly through sexual contact. Five diseases were traditionally known as venereal diseases: gonorrhea, syphilis, and the less common granuloma inguinale, in the past 5 years were more often HIV infected (odds ratio [OR] 4.4, 95% CI 1.6-12.4). The prevalence of HIV infection among TB patients significantly increased from 6.3% in 2002 to 10.1% from March 2004 through February 2005 (p = 0.011) (Table 2). The prevalence of HIV-infected TB patients who reported injecting drug use increased from 1.8% of all tested patients with newly diagnosed TB in 2002 to 5.8% in March 2004 through February 2005. Thus, the main increase in TB-HIV co-infection was attributable to an increase in TB-HIV co-infected patients who reported injecting drug use. A larger proportion of persons with a positive HIV test result reported injecting drug use in 2004 (57.1%) than in 2002 (27.8%) (p = 0.003). HIV co-infection prevalence may be slightly overestimated in the 2002 study (5). In the study conducted between March 2004 and February 2005, TB patients included in the study were more frequently <50 years of age (p<0.001). TB patients <50 years of age were more frequently HIV infected. Both studies may therefore overestimate o·ver·es·ti·mate tr.v. o·ver·es·ti·mat·ed, o·ver·es·ti·mat·ing, o·ver·es·ti·mates 1. To estimate too highly. 2. To esteem too greatly. the prevalence of TB-HIV co-infection. Conclusions HIV infection increased in patients with newly diagnosed TB in Kiev City between 2002 and 2004. This finding is in agreement with the increase in the number of registered cases of HIV infection in Ukraine since 1995 (6). The main risk factor for being co-infected with HIV was reported injecting drug use. In 2002, 62.5% of the TB patients that reported injecting drug use were HIV infected and in 2004 this number was 66.7%. In Ukraine, the HIV epidemic started in injecting drug users thus that the main risk factor for HIV infection was injecting drug use is not surprising. We used voluntary confidential HIV testing. Previous studies have found that use of this testing method can result in participation bias because those at higher risk of infection are more likely not to contribute specimens (7-11) or selection bias if clinicians encourage testing in those they consider to be more at risk (5). Although unlinked anonymous testing anonymous testing Public health The testing of an individual for certain infections, in particular, HIV, providing the results to public health departments without identifying that person by name, but rather by a number. Cf Named reporting. would have prevented these problems, the TB physicians participating in the study believed that using this strategy was not feasible. In our study, 7.6% refused to provide informed consent. This finding is comparable to researchers' experiences in other countries (7,11,12). In the 2002 study, HIV testing was performed with a locally produced HIV test with unknown specificity and sensitivity. We do not know whether the estimated co-infection prevalence is valid or if we are likely to underestimate the true co-infection prevalence. Even if the locally produced HIV test did not correctly identify 12% of the HIV-positive patients (sensitivity 88%), the prevalence of TB-HIV co-infection was still significantly higher in 2004. In the 2002 study, the percentage of persons not tested was high (38.0%), compared to a proportion of 10.5% in the 2004 study. If we assume that no HIV infections existed among those not tested, the minimum HIV-infection prevalence in the 2002 study is 3.9% and in the 2004 study 9.1%. No notable differences were identified between those tested and those not tested in variables that were strongly associated with HIV infection. In conclusion, TB-HIV co-infection is increasing in Kiev City, especially in injecting drug users. Acknowledgments We acknowledge the cooperation of the physicians of the Kiev City Tuberculosis Services for including TB patients in the study and providing data. This study was performed within the European Union European Union (EU), name given since the ratification (Nov., 1993) of the Treaty of European Union, or Maastricht Treaty, to the European Community funded project, Tuberculosis Prevention and Control in Kiev City, Ukraine. Data collection was performed in the health facilities of the Kiev City TB department, HIV testing was performed in the Kiev Anti-AIDS Centre, and data analysis and writing were performed at KNCV KNCV Koninklijke Nederlandse Chemische Vereniging (Royal Dutch Chemical Association) KNCV Koninklijke Nederlandse Centrale Vereniging tot bestrijding der Tuberculose (Dutch Tuberculosis Foundation) Tuberculosis Foundation. Dr Van der Werf is senior epidemiologist epidemiologist an expert in epidemiology. and head of the research unit at KNCV Tuberculosis Foundation, a nongovernmental organization nongovernmental organization (NGO) Organization that is not part of any government. A key distinction is between not-for-profit groups and for-profit corporations; the vast majority of NGOs are not-for-profit. that contributes to the global elimination of TB. Her research interests include epidemiologic studies epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect on TB, for example, measuring the impact of TB and TB and HIV coinfection and operational research studies to improve TB control programs. References (1.) Hamers FF. HIV infection in Ukraine (1987-96). Rev Epidemiol Sante Publique. 2000;48(Suppl 1): 1 $3-15. (2.) Hamers FF, Downs AM. HIV in central and eastern Europe The term "Central and Eastern Europe" came into wide spread use, replacing "Eastern bloc", to describe former Communist countries in Europe, after the collapse of the Iron Curtain in 1989/90. . Lancet lancet /lan·cet/ (lan´set) a small, pointed, two-edged surgical knife. lan·cet n. . 2003;361 : 1035-44. (3.) Balakireva O, Galustian Y, Yaremenko O, Scherbyns'ka A, Krugtov Y, Levchuk N, et al. The social and economic impact of HIV and AIDS in Ukraine: a re-study. Kyiv City; Ukraine: British Council The British Council is one of the United Kingdom's cultural relations organisations and which specialises in educational opportunities. It is a non-departmental public body and is registered as a charity in England. ; 2001. (4.) Corbett EL, Watt C J, Walker N, Maher D, Williams BG, Raviglione MC, et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med. 2003;163:1009-21. (5.) van der Werf M J, Yegorova OB, Chechulin Y, Hasker E, Veen J, Turchenko LV. HIV testing practices of TB patients after introduction of a new testing policy in Kiev City, Ukraine. Int J Tuberc Lung Dis. 2005,9:733-9. (6.) Mavrov GI, Bondarenko GM. The evolution of sexually transmitted infections in the Ukraine. Sex Transm Infect infect /in·fect/ (in-fekt´) 1. to invade and produce infection in. 2. to transmit a pathogen or disease to. in·fect v. 1. . 2002;78:219-21. (7.) Hull HF, Bettinger CJ, Gallaher MM, Keller NM, Wilson J, Mertz GJ. Comparison of HIV-antibody prevalence in patients consenting to and declining HIV-antibody testing in an STD (Subscriber Trunk Dialing) Long distance dialing outside of the U.S. that does not require operator intervention. STD prefix codes are required and billing is based on call units, which are a fixed amount of money in the currency of that country. clinic. JAMA JAMA abbr. Journal of the American Medical Association . 1988;260:935-8. (8.) Jones JL, Hutto P, Meyer P, Dowda H, Gamble WB Jr, Gunn RA. HIV seroprevalence seroprevalence Immunology The proportion of a population that is seropositive–ie, has been exposed to a particular pathogen or immunogen; the seropositivity of a population is calculated as the number of individuals who produce a particular antibody divided and reasons for refusing and accepting HIV testing. Sex Transm Dis. 1993;20:334-7. (9.) Groseclose SL, Erickson B, Quinn TC, Glasser D, Campbell CH, Hook EW 3rd. Characterization of patients accepting and refusing routine, voluntary HIV antibody HIV antibody A self antibody specifically directed against one or more proteins or antigens on the surface of HIV, which may be minimally protective against HIV testing in public sexually transmitted disease clinics. Sex Transm Dis. 1994;21:31-5. (10.) Postema EJ, Willems PW, de Ridder MA, van der Meijden WI. Comparison of patients refusing with patients accepting unlinked anonymous HIV testing in an outpatient STD department in The Netherlands. Int J STD AIDS. 1997;8:368-72. (11.) Paget WJ, Zwahlen M, Eichmann AR. Voluntary confidential HIV testing of STD patients in Switzerland, 1990 5: HIV test refusers cause different biases on HIV prevalences in heterosexuals and homo/bisexuals. Swiss Network of Dermatovenereology Policlinics. Genitourin Med. 1997;73:444-7. (12.) Abouya L, Coulibaly IM, Wiktor SZ, Coulibaly D, N'Krogbo M, N'Gbo A, et al. The Cote d'Ivoire national HIV counseling and testing program for tuberculosis patients: implementation and analysis of epidemiologic ep·i·de·mi·ol·o·gy n. The branch of medicine that deals with the study of the causes, distribution, and control of disease in populations. [Medieval Latin epid data. AIDS. 1998;12:505-12. Marieke J. van der Werf, * Olga B. Yegorova, ([dagger]) Nelly nel·ly or nel·lie n. pl. nel·lies Offensive Slang Used as a disparaging term for an effeminate homosexual man. [Probably from the name Nelly, nickname for Helen.] Chentsova, ([double dagger double dagger n. A reference mark (  ) used in printing and writing. Also called diesis.Noun 1. ]) Yuriy Chechulin, ([section]) Epco Hasker, * ([section]) Vasyl I. Petrenko, ([paragraph]) Jaap Veen, * and Leonid V. Turchenkot * KNCV Tuberculosis Foundation, The Hague, the Hague, The (hāg), Du. 's Gravenhage or Den Haag, Fr. La Haye, city (1994 pop. 445,279), administrative and governmental seat of the Kingdom of the Netherlands, capital of South Holland prov., W Netherlands, on the North Sea. Netherlands; ([dagger]) Kiev City Tuberculosis Department, Kiev, Ukraine; ([double dagger]) Kiev Anti-AIDS Centre, Kiev, Ukraine; ([section]) Project Tuberculosis Prevention and Control in Kiev City, Ukraine, Kiev, Ukraine; and ([paragraph])O.O. Bogmolic National Medical University, Kiev City, Ukraine Address for correspondence: Marieke J. van der Werf, KNCV Tuberculosis Foundation, PO Box 146, 2501 CC The Hague, the Netherlands; email: vanderwerfm@kncvtbc.nl
Table 1. Risk factors for a positive HIV test in patients with
newly diagnosed TB in Kiev City, Ukraine *
No. (% HIV Univariate,
Variable infected) OR (95% CI)
Sex
Male 712 (11.0) 1
Female 256 (7.8) 0.69 (0.41-1.15)
Age, y
18-29 318 (14.8) 1
30-39 224 (17.4) 1.22 (0.76-1.93)
40-49 195 (4.6) 0.28 (0.13-0.58)
[greater than
or equal to] 50 231 (1.3) 0.08 (0.02-0.25)
Classification
PTB+ 541 (10.5) 1
PTB- 379 (8.2) 0.76 (0.48-1.20)
EPTB 48 (20.8) 2.24 (1.06-4.72)
STD in last 5 y
No 880 (8.6) 1
Yes 27 (22.2) 3.02 (1.18-7.72)
Unknown 61 (26.2) 3.76 (2.03-7.00)
Homeless
Yes 56 (12.5) 1.29 (0.57-2.93)
No 912 (10.0) 1
Injecting drug use
Yes 84 (66.7) 40.10 (23.15-69.45)
No 884 (4.8) 1
Abuse of alcohol
Yes 105 (10.5) 1.04 (0.54-2.03)
No 863 (10.1) 1
Incarcerated >1994
Yes 117 (15.1) 1.75 (1.01-3.05)
No 851 (9.4) 1
Multivariate,
Variable OR (95% CI)
Sex
Male
Female
Age, y
18-29 1
30-39 1.69 (0.94-3.04)
40-49 0.56 (0.24-1.30)
[greater than
or equal to] 50 0.18 (0.05-0.62)
Classification
PTB+
PTB-
EPTB
STD in last 5 y
No 1
Yes 4.41 (1.57-12.38)
Unknown 1.99 (0.84-4.71)
Homeless
Yes
No
Injecting drug use
Yes 31.42 (17.35-56.87)
No 1
Abuse of alcohol
Yes
No
Incarcerated >1994
Yes
No
* n = 968; TB, tuberculosis; OR, odds ratio; CI, confidence interval;
STD, sexually transmitted disease; PTB+, pulmonary TB bacteriologically
confirmed; PTB--, pulmonary TB bacteriologically not confirmed;
EPTB, extrapulmonary TB.
Table 2. Comparison of TB patients tested for HIV in 2002 and 2004
Variable 2002 study, 2004 study, p
n = 567 (%) n = 968 (%)
HIV infected 0.011
Yes 36 (6.3) 98 (10.1)
No 531 (93.7) 870 (89.9)
Sex 0.720
Male 412 (72.7) 712 (73.6)
Female 155 (27.3) 256 (26.4)
Age, y 0.091
0-29 153 (27.0) 318 (32.9)
30-39 133 (23.5) 224 (23.1)
40-49 131 (23.1) 195 (20.1)
[greater than
or equal to] 50 150 (26.5) 231 (23.9)
Classification * 0.002
PTB+ 360 (63.5) 541 (55.9)
PTB- 172 (30.3) 379 (39.2)
EPTB 35 (6.2) 48 (5.0)
Homeless 0.508
Yes 38 (6.7) 56 (5.8)
No 529 (93.3) 912 (94.2)
Injecting drug user <0.001
Yes 16 (2.8) 84 (8.7)
No 551 (97.2) 884 (91.3)
Abuse of alcohol 0.020
Yes 85 (15.0) 105 (10.8)
No 482 (85.0) 863 (89.2)
Ever incarcerated <0.001
Yes 40 (7.1) 132 (13.6)
No 527 (92.9) 836 (86.4)
* TB, tuberculosis; PTB+, pulmonary TB bacteriologically confirmed;
PTB-, pulmonary TB bacteriologically not confirmed;
EPTB, extrapulmonary TB.
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