Резюме
Шевченко О.С. Ко-інфекція ВІЛ/туберкульоз: динаміка епідеміологічної ситуації за останні п’ять років в Харківській області.
Туберкульоз є основним вторинним захворюванням при ВІЛ-інфекції і основною причиною смерті в стадії СНІД, і це потребує спільних скоординованих зусиль фтизіатричної служби і служби боротьби зі СНІДом для своєчасної профілактики та діагностики туберкульозу у ВІЛ-інфікованих.
Ключові слова: туберкульоз, ВІЛ, епідеміологія.
Резюме
Шевченко О.С. Ко-инфекция ВИЧ/туберкулез: динамика эпидемиологической ситуации за последние пять лет в Харьковской области.
Туберкулез является основным вторичным заболеванием при ВИЧ-инфекции и основной причиной смерти в стадии СПИД, и это требует совместных скоординированных усилий фтизиатрической службы и службы борьбы со СПИДом для своевременной профилактики и диагностики туберкулеза у ВИЧ-инфицированных.    
Ключевые слова: туберкулез, ВИЧ, эпидемиология.
Summary
Shevchenko О.S. Сo-infection HIV/tuberculosis: dynamics of epidemiology situation for the last five years in the Kharkov region.
Tuberculosis is a main secondary disease with HIV-infection and the main cause of death in AIDS stage. This demands mutual coordinated efforts of Phthisiology and anti AIDS services for in time prophylaxis and diagnosis of tuberculosis in HIV-infected persons.
Key words: tuberculosis, HIV, epidemiology.

УДК 616.24-002.5:616.98:578.828.]-036.22 (47754)

Kharkiv National Medical University,

4 Lenin Avenue, Kharkiv,61022,Ukraine

проспект Ленина, 4, Харьков, 61022,Украина 

Харьковский национальный медицинский университет

Exacerbation of worldwide epidemic situation with tuberculosis experts associates with the rapid growth of the scale of the HIV infection. In countries where much of the population is HIV-positive, 30-50% of patients with HIV infection are at risk to develop TB [1, 2].

Experts stress that HIV will lead to a further increase in the incidence of resistant forms of TB [2, 3].

Scientists focus on the difficulties of early diagnosis of TB due to peculiarities of the disease. Cases of co-infection of HIV / TB are detected late due to atypical and malignant course, which results in fatal consequences. TB treatment is successful in approximately 30% of all the cases, relapse occurs in a significant number of the cases, the other patients die within 1-3 years from disease progression and opportunistic infections that follow the disease. [2].

Given this, we examined the dynamics of indicators of infecting population with HIV, TB and HIV / TB in the Kharkiv region for five years, over the period of stabilization of the epidemic situation of tuberculosis. We explored ways of detection, clinical manifestations, and the course of HIV-associated tuberculosis.

Examination of HIV-associated tuberculosis patients was conducted under the order № 276 of 28.05.2008 "On the approval of the clinical protocol of care for patients with polypathia."

A retrospective study on patient history in antitubercular clinic number 1 in Kharkiv. Diagnosis of MBT was carried out by flotation and culture method, including the MBT drug sensitivity test to first-line and second-line antitubercular drugs, according to the instructions on the bacteriological diagnosis, regulated by Order of Ministry of Health № 45 of 06.02.2002.

Analyzing the statistics for the years 2007-2011 [4], we note the reduction in the incidence of tuberculosis both in Ukraine – by 15. 8% (from 79. 8 to 67. 2 per 100 000) and the Kharkiv region – 27. 2% (from 72. 5 to 52. 7 per 100 000). However, the dynamics of HIV infection in Ukraine has grown by 12% in Ukraine over the last 5 years (from 38. 0 to 46. 2 per 100 000) and 21% in the Kharkiv region (from 16. 2 to 20, 5 per 100 000). As to TB / HIV co-infection, the indicators worsen from year to year. In Kharkiv region, the TB / HIV incidence in the last 5 years has increased by 11% (from 2. 4 to 2. 7 per 100 000) in Ukraine by 45% (from 5. 0 to 9. 1 per 100 000).

The mortality from 2007 to 2011 both in Ukraine and in the Kharkiv region reduced (by 29% and by 24% respectively). Deaths from AIDS increased by 34% in Ukraine (from 5. 4 to 8. 2 per 100 000) and by 17% in Kharkiv region (from 2. 0 to 2. 4 per 100 000), followed by growth mortality from TB / HIV co-infection – 36% (from 3. 9 to 6. 1 per 100 000) in Ukraine and by 19% in the Kharkiv region [4].

According to UNAIDS, AIDS epidemic in Ukraine today is the most severe in Europe, HIV prevalence among the adult population is more than 1,63% (UNAIDS report, 2008). Since the first case of HIV in 1987 and through 2011, about 203 thousand cases of HIV infection among citizens of Ukraine were officially registered in Ukraine, including 46 thousand AIDS cases and 24 thousand deaths from it. In 2011, the country officially registered 21,177 new cases of HIV infection (46.2 per 100 000) – the highest rate for the whole period of monitoring HIV infection in Ukraine [5].

Analysis on the epidemic situation of HIV-AIDS in Ukraine indicates that the infection has challenged health system: rates of AIDS epidemic outpace the deployment activities for its diversion, including the administration of antiretroviral therapy (hereinafter – ART) to all those in need. Death directly from diseases caused by AIDS has become a real threat to thousands of HIV-positive people in Ukraine, and in 2011 the figure was 8.4 per 100 000 (3,736 people, including 22 children) [5].

It is known that the main routes of HIV transmission are parenteral (including injecting drug users), vertical (mother to child) and sex. In Ukraine, the proportion of IDUs among new HIV infections was 31% in 2011. At the same time, increases the proportion of sexual transmission among new HIV infections, which in 2011 amounted to 49% in Ukraine. In 4.7% of cases established transmission of HIV to children from HIV-positive mothers. In 2009-2011, Ukraine ‘increases’ in the number of HIV-infected persons identified due to the manifestation of clinical signs of the disease (22 and 26%, respectively) [5].

The most common AIDS-indicator disease in Ukraine still remains tuberculosis, which is found in 61. 6% of all new AIDS cases. In 43. 4% of cases, tuberculosis developed against the backdrop of existing HIV infection, in 46. 8% of cases – HIV infection and tuberculosis were detected simultaneously; in 9. 8% of cases – HIV infection developed against the backdrop of tuberculosis. Males dominated (69.2%); age of the patients is closely correlated with the age groups of patients with tuberculosis: from 18 to 24 years – 8. 2%, 25 to 44 years – 86. 2%, and from 45 to 54 years – 5. 6% patients. In 69% of cases – urban residents, the homeless constitute less than 1% of patients. With comorbidities in registered HIV / TB patients more common were: chronic hepatitis – in 65% of cases, anemia – in 21. 6% of cases, addiction – in 2. 5%, body weight deficit – in 10. 9% of cases. Of the total number of patients, alcohol abuse found in 17.4% of cases, smoking more than 10 cigarettes per day – in 35.3% of cases, and smoking and alcohol abuse – in 20.6% of cases.

50.5% of HIV / TB cases were registered when applying at preventive examinations, of those – the examination in hospitals for many reasons – 6.8%. Voluntary counseling and testing TB patients for HIV antibodies in TB facilities revealed 2% of the cases.

In terms of the localization process, dominated pulmonary form of TB reached 85.5%. Of the clinical forms of pulmonary tuberculosis, infiltrative is often diagnosed – in 80. 7% of cases, disseminated – in 12. 2% of cases, miliary tuberculosis – in 6. 6% of cases, and focal – in 0. 5% of cases. Among extrapulmonary forms of tuberculosis, the most common was intrathoracic tuberculosis and tuberculosis of peripheral lymph nodes, and other localization, representing 8. 9% of cases.

Bacteria defined in 63. 9% of cases are confirmed by microscopy in 38. 8% of cases, the culture method – in 61. 2% of cases.

Since 20.11.2009, on the basis of  RATD №1 (Kharkiv) was founded department of registration and case management of chemo-resistant tuberculosis (MRTB-office). After analyzing MRTB-registered patients, we found that among those – 39 co-infected HIV / TB patients (4.8%); men dominated – in 77% of cases.

Drug resistance to first-line drugs was in 21 patients representing 53. 8% of cases. Most frequent were strains resistant to 4 drugs (HRES) – in 62% of cases (13 patients), 2 times less were strains resistant to 3 drugs (HRS) – in 28. 6% of cases. Total frequency resistance of MBT to streptomycin was 90. 5% of the cases, to ethambutol – 66. 7% of the cases.

Strains resistant to the first-line and second-line drugs at a time were found in 18 patients; we failed to find variants of extensive drug-resistance among them. The total incidence of strains resistant to kanamycin was 61. 1% of cases, to amikacin – 44. 4% of cases, to capreomycin – 11. 1% of cases, to all the injecting drugs – 11. 1% of cases. The total incidence of strains resistant to etionamid was diagnosed in 16. 7% of cases, to ofloxacin – in 5. 6% of cases.

Among MRTB-registered patients, in ‘final changes after suffering tuberculosis’ was transferred one patient representing 5. 6% of cases; death was recorded in 20 patients, ie in 51. 3% of cases.

Analysis of the epidemiological situation regarding co-infection TB / HIV in the Kharkiv region allows to confirm the following considerations:

1. The situation with co-infection of HIV / TB in Kharkiv region worsens from year to year; over the past 5 years, the incidence has increased by 11% and mortality by 19%.

2. Tuberculosis on the background of HIV is often evolving passively over 2-6 years after HIV infection. The most common form is infiltrative tuberculosis followed by destruction and bacterioexcretion.

3. Among patients with co-infection, the most common are strains of Mycobacterium tuberculosis with HRES-resistance profile – both in intact sensitivity to second-line drugs, and in the presence of additional resistance to different amounts of second-line antitubercular drugs.

4. The least common, according to the study, are strains of Mycobacterium tuberculosis with HRE-resistance profile – both in intact sensitivity to second-line drugs, and in the presence of additional resistance to different amounts of second-line antitubercular drugs.

5. Tuberculosis is the major secondary disease in HIV infection and the main cause of death in AIDS stage, and it requires joint and coordinated efforts of TB services and services for AIDS prevention and timely diagnosis of tuberculosis in HIV-infected individuals.

Література
1. Черенько С.О. Проблеми ко-інфекції туберкульоз/ВІЛ в Україні / С.О. Черенько, Л.В. Щербакова // Туберкульоз. Легеневі хвороби. ВІЛ-інфекція. – 2010. – № 1. – С. 18-23.
2. Петренко В.І. Медико-соціальні проблеми ВІЛ-інфекції/СНІДу в Україні / В.І. Петренко // Туберкульоз. Легеневі хвороби. ВІЛ-інфекція. – 2010. – № 2. – С. 5-9.
3. Stop TB Partnership and World Health Organization. An International Roadmap for Tuberculosis Research [Електронний ресурс]. - Geneva: World Health Organization, 2011. – Режим доступу: www.stoptb.org/assets/documents/resources/publications /technical/tbresearchroadmap.pdf.
4. Туберкульоз в Україні: аналітично- статистичний довідник за 2000-2011 роки / Під. ред. І.М. Ємець. – Київ, 2012. - 106 с.
5. ВІЛ - інфекція в Україні: інформаційний бюлетень № 37 / Під ред. Т.А Александріної, Н.М. Нізової, В.Ф. Марієвського, Ю. В. Кобища. – Київ, 2011. - 90 с.