1. Presented by Guided by
Dr. Virendra Gupta Dr. Jagdish Singh
SPMCHI, SMS Medical College, Jaipur

2. INTRODUCTION
• Tuberculosis (TB) is a leading killer among people living with
human immunodeficiency virus (HIV).
• More than 33 million people now live with HIV/AIDS, out of
them 2.5 million are under the age of 15yr(UNICEF report 2010)
• At least one in four deaths among people living with HIV can be
attributed to TB.
• Addressing the TB and HIV epidemics are key priorities for
WHO.

3. HIV Prevalence in
Incident TB Cases 2010
• Global 23.0%
• India 5.0%
• Rajasthan 2.0%
• Sources: WHO, Global Tuberculosis Control 2011, available at
http://www.who.int/tb/publications/global_report/en/index.html.
For country data, see also WHO, TB database, available at
http://www.who.int/tb/country/data/download/en/index.html.

4. AIMS AND
OBJECTIVES
• To know the magnitude of HIV infection in
patients diagnosed with tuberculosis.
• To know the differences in clinical profile of
tuberculosis between HIV+ve and HIV-ve patients
in pediatric age group

5. MATERIAL AND
METHODS
Study design and setting :
Hospital based, observational, descriptive study.
Subjects :
Patients with diagnosis of tuberculosis(as per
RNTCP guidelines) attending the pediatric DOTS
Center / OPD and IPD Patients of SPMCHI .
Sample size :
Included 315 eligible patients from Sept. 2011 to
Sept. 2012.

6. INCLUSION CRITERIA
• Age - 6 weeks to 15 years.
• Fulfilling the criteria for diagnosis of
tuberculosis. (As per RNTCP guidelines )
• Willing to give written informed consent.

7. METHODS
• Detailed clinical history
• Complete general, physical and systemic
examination
• Relevant investigations
• Fulfilled the criteria for diagnosis of
tuberculosis were screened for HIV infection
( As Per NACO Guidelines )

8. NACO Guidelines to diagnose HIV
• < 18 Month-DNA PCR 3 Test kits required
A1
• > 18 Month – A1 +Ve A1 -Ve
(Report Negative)
3 Different antibody test
A2
A1- Combaid Test Kit (ELISA)
A1 + A2+ A1+ A2-
A2- SD Bioline (Immunochromatographic) ( Report positive )
A3
A3- Tridot Test Kit (Immunofiltration)
A1+ A2- A3 + A1+ A2- A3 -
(Indeterminate ) ( Report Negative)

9. STATISTICAL
ANALYSIS
• Qualitative Data summarized in percentage
& Quantitative data in form of mean +/- SD
• Quantitative data analyzed with
parametric tests (unpaired t-test) while
Qualitative data analyzed with non-
parametric tests (χ2 test and z-test for
difference of proportions).

10. RESULTS
Out of 315 patients, 22 were HIV positive(6.98%)
6.98%
HIV +ve
HIV-Ve
92.02%

11. Age and sex distribution of
total TB patients
Age group Male Female Total
No.(%) No.(%) No.(%)
06wk -1 year 16 (05.07) 11 (03.49) 27 (08.57)
(Infancy)
1y-5y 58 (18.41) 46 (14.60) 104 (33.01)
(Pre school )
5y-10y 54 (17.14) 43 (13.65) 97 (30.79)
(School going)
>10y 48 (15.24) 39 (12.38) 87 (27.62)
(Adolescent)
Total 176 (55.87) 139 (44.12) 315

12. Age and Sex Distribution
of Total TB Patient
Male To Female Ratio - 1.21:1
60
No. of patients
50
40
30
Male
20
Female
10
0
06wk -1 year 1y-5y 5y-10y >10y
Male Female Total
Mean age 7.18 ± 4.39 Yr 7.30 ± 4.36 Yr 7.23 ± 4.35 Yr

13. OPD/IPD Distribution of
Total TB Patient
100% 6
90% (27.27%)
80%
215
IPD
70% 221
(73.38%) (70.16%)
60%
50% OPD
40% 16
(72.73%)
30% 78 94
20% (26.62%) (29.84%)
10%
0%
HIV+ve Hiv-ve Total

14. Socio-Demogrphic
Distribution
Rural Urban
8 134
126
(36.36%) (42.54%)
(43.00%)
14 167 181
(63.64%) (57.00%) (57.46%)
HIV+ve Hiv-ve Total

15. Distribution of tuberculosis
patients according to type of
tuberculosis and HIV serostatus
100%
80%
123 9 161
60% (87.23%) (90%) (98.17%)
40%
18 1
20% 3
(12.77%) (10%)
0% (1.83%)
Pulmonary Disseminated Extra-
/Miliary Pulmonary
HIV-Ve 87.23 90 98.17
HIV+Ve 12.77 10 1.83
Chi- square = 86.070 p-value = <0.0001

16. Nutritional Status of Tubercular
children according to HIV
serostatus
Wt/Age %
70.69% 69.95%
72.00%
70.00%
68.00%
66.00% HIV+ve
64.00% 60.37%
62.00% HIV-ve
60.00%
58.00%
Total
56.00%
54.00%
HIV+ve HIV-ve Total
Chi- square = 48.039 p-value = 0.038

17. Comparison of Symptoms profile in
HIV +ve And HIV –ve Tubercular
Children
symptom HIV +ve HIV-ve Total p-value
90 81.81% No. No. No.
80 71.33% (%) (%) (%)
70 63.48%
59.09% 59.09%
60 Weight 18 186 206 0.13
50 45.05% 45.45% loss (81.81) ( 63.48) (65.39)
40
Pyrexia 13 209 222 0.33
30
>14 Day (59.09) (71.33) (70.47)
20 10.23%
10
cough >14 13 132 145 0.29
0
Day (59.09) (45.05 ) (46.03)
Weight Pyrexia cough Loose
loss >14 Days >14 Days Motion
Loose 10 30 40 <0.001
Motion (45.45) (10.23 ) (12.70)
HIV +ve HIV-ve

18. Comparison of Signs in HIV +ve
And HIV –ve Tubercular
Children
68.18% Sign HIV +ve HIV-ve Total p-value
70 62.12%
NO NO NO
60 (%) (%) (%)
50 41.81%
Pallor 15 182 197 NS
40
27.77% (68.18) (62.12) (62.54)
30
20 15.35% 13.99%
HSM 07 45 52 0.04
10 (41.81) (15.35) (60.50)
0
Pallor HSM LNP LNP 05 41 46 0.12
(27.77) ( 13.99) (14.60)
HIV +ve HIV-ve
HSM=Hepatospleenomegaly ,LNP= Lymphadenopathy

19. Comparison of Investigations in
HIV+ve And HIV–ve Tubercular
Children
%
68.18
70
60 54.92
53.92
49.48
48.49
50 40.9 38.1
35.49
40
30
20
7.27 4.434.43
10 0
0
Radiological Mantoux Test BCG Scar Sputum /GA
Lesion AFB
HIV+ve 68.18 40.9 7.27 0
HIV-ve 53.92 49.48 35.49 4.43
Total 54.92 48.49 38.1 4.43

20. CONCLUSION
• Magnitude of HIV sero-positivity is 6.98% in Tubercular
children.
• Co-existence of HIV is more with
Pulmonary, Disseminated & Miliary tuberculosis than
Extra-pulmonary tuberculosis.
• HIV positive children suffer more often with severe
symptoms.

21. RECOMMENDATIONS
• Health personnel need to recognize such
dual infection and take proper steps to
manage the epidemic.
• HIV screening should be carried out in all
tubercular children.

22. DR. VIRENDRA GUPTA

23. FLOW CHART
649 CASE DIAGNOSED TB(As Per RNTCP Guidelines )
334 CASE EXCLUDED
•Not Given Consent
•Unwilling To Blood Sampling
•Drop Out
315 CASES INCLUDED IN STUDY
HIV TEST DONE
(As Per NACO Guidelines)
22 case HIV +Ve 293 CASE HIV -Ve
Results are shown after statistical data applied

24. RESULTS
• Out of 315 patients, 22 were HIV positive(6.98%).
• 57.46% were rural, Most patients were in the
school going age (43.80%).
• M:F ratio was 1.21:1, Mean weight for age was
69.94%.
• History of contact with tuberculosis in 47.94%.
• 52.06% of cases had one or more extra-pulmonary
tubercular sites.
• And 3.17% disseminated or military tuberculosis

25. RESULTS
• Out of 315 tubercular children, 22 were HIV positive(6.98%).
• 57.46% were rural patients
• Most patients were in the school going age (5-12yr)group (43.80%).
• Male to female ratio was 1.21:1.
• Mean weight for age was 69.94%.
• History of contact with tuberculosis in 47.94%.
• 52.06% of cases had one or more extra-pulmonary tubercular sites.
• And 3.17% disseminated or military tuberculosis

26. Distribution of tuberculosis patients according to type of
tuberculosis.. and HIV serostatus
Type of disease HIV +Ve HIV –Ve Total
Pulmonary 18 (81.81) 123 (41.97) 141 (44.76 )
Diss.TB / Mill.TB 1 (04.55) 9 (03.07) 10 (03.17)
Extra-pulmonary 3 (13.64) 161 (54.95) 164 (52.06)
TOTAL 22 (06.98) 293 (93.02) 315(100)
P- Value < .0001

27. Distribution of tuberculosis patients according to type of
tuberculosis and HIV serostatus
HIV +Ve HIV -Ve
0% 4.5%
4.5% 6% 1% 3%
4.5%
4.5% 0%
10%
42%
10%
82% 28%
Pulmonary TBM
Pleural effusion Lymphadenopathy(LN)
Abd. Tb(ABD) other
Diss.tb/Mill.
Pulmonary TBM

28. Comparison of clinical profile in HIV +ve And HIV –ve
Tubercular Children
Signs and HIV +ve HIV-ve Total p-value
symptoms
Pyrexia >14 13(59.09) 209(71.33) 222(70.47) 0.14
Day
cough >14 13(59.09) 132(45.05 ) 145(46.03) 0.07
Day
Weight loss 18(81.81) 186( 63.48) 206(65.39) 0.04
Mean 60.37% 70.69% 69.95% 0.03
Wt/Age
Lymphadeno 05(27.77) 41( 13.99) 46(14.60) 0.12
pathy
Hepatosplee 07(41.81) 45(15.35) 52(60.50) 0.04
nomegaly
Loos Motion 10(45.45) 30(10.23 ) 40(12.70) <0.0007

29. Comparison of clinical profile in HIV +ve And HIV –ve Tubercular
Children
90
80
70
60
50
%
40
30
20
10
0
Wt loss Fever > cough HSM Loos BCG L. N .
14 D >14 D Motion Scar
HIV +ve 81.81 59.09 59.09 41.81 45.45 27.27 18.18
HIV-ve 63.48 71.33 45.05 15.35 10.23 35.49 20.13

30. Study the Magnitude of HIV Infection in Tubercular Children and Their Clinical
Profile
ABSTRACT
Introduction: Tuberculosis was noted to be the most frequent cause of death amongst people living with
HIV not only in India but all over the world.
Aims and objectives: To know the magnitude and differences in clinical profile of HIV infection in
tubercular children.
Study design and setting: Hospital based cross-sectional & descriptive study.
Material & method: Study group included patients attending hospital during period Sept. 2011 to Sept.
2012, diagnosed with tuberculosis as per NACO guidelines and screened for HIV infection.
Results: Out of 315 tubercular children, 22 were HIV positive giving a magnitude of 6.98%, Most
patients were in the school going age (5-12yr)group (43.80%). The male to female ratio was1.21:1.
Mean weight for age was 69.94%. History of contact with tuberculosis was present in 47.94%.
Out of HIV positive cases Fever(81.81%),weight loss(81.81%) and weakness(81.81%) were most
frequent complaints followed by cough(68.18%). Examination showed hepatosplenomegaly(41.81%)
and lymphadenopathy(18.18%). Chest X-ray revealed miliary findings in 10.8%.
Out of total number, 57.46% were rural patients. 52.06% of cases had one or more extra-pulmonary
tubercular sites, and 03.17% disseminated or military tuberculosis. BCG vaccination was seen in only
34.92% cases. Overall Mantoux test positivity was 8.49%.
Conclusion: Increasing magnitude of HIV seropositivity with positive patients more likely to suffer
from pulmonary tuberculosis while HIV negative with extra pulmonary involvement. HIV-positive
children suffer from prolonged symptoms. Health personnel need to recognize such dual infection and
take proper steps to manage the epidemic. HIV screening should be carried out in patients with
prolonged illness resistant to usual mode of treatment.
Keywords: HIV, Paediatric tuberculosis, Magnitude, seropositivity

33. IAP GUIDELINES

34. RNTCP

38. FINAL DIAGNOSIS

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40. SEED ARTICLE
Prevalence of Human Immunodeficiency Virus Infection in
Children with Tuberculosis
T. Shahab, M.S. Zoha, M. Ashraf Malik, Abida Malik* and K. Afzal
From the Departments of Pediatrics and Microbiology*, Jawaharlal Nehru Medical College,
AMU, Aligarh, UP 202 002, India.
Correspondence to: Dr. Kamran Afzal, Department of Pediatrics, JN Medical College, Aligarh
Mulsim University, Aligarh, UP 202 002, India. E-mail: drkafzal@hotmail.com
Manuscript received: July 1, 2003, Initial review completed: August 14, 2003;
Revision accepted: November 28, 2003.
ABSTRECT
This prospective study was carried out in the pediatric ward and outpatient department of a tertiary care
centre to estimate the prevalence of HIV seropositivity in children with tuberculosis. Two hundred and fifty
consecutive children below 12 years of age with (pulmonary and Extrapulmonary) tuberculosis diagnosed
between March 1999 and July 2000 were screened for HIV infection. A patient was labeled as HIV positive if
two consecutive ELISA tests were found positive using different antigen/principle. Supplemental western blot
test was also done. Parents ofseropositive children were also screened for HIV infection and tuberculosis.
Total 5 cases were HIV positive giving a seroprevalence of 2%. All the five patients had disseminated
tuberculosis. We suggest regular screening of children with disseminated/miliary tuberculosis for HIV co-
infection.

41. DR. VIRENDRA GUPTA

42. REVIEW OF LITERATURE
•
“PREVALENCE OF HUMAN IMMUNODEFICIENCY VIRUS
INFECTION IN CHILDREN WITH TUBERCULOSIS”
conducted by Shahab et al. from the AMU, UP, India,
CONCLUSION
INDIAN PEDIATRICS,VOLUME 41__JUNE 17, 2004)
1-An study conducted by Hussain et al.“Seroprevalence of HIV infection among pediatric tuberculosis
patients in Agra, India”: from 2003 to 2004,
CONCLUSION:
2-Recently by National AIDS Control Organization (NACO)

43. S D RAPID KIT TEST
General Information
The SD BIOLINE HIV-1/2 test is an immunochromatographic test for the
qualitative detection of antibodies of all isotyoes (IgG, IgM, IgA) specific to HIV-1
including subtype O and HIV-2 simultaneously, in human serum, plasma or whole
blood.
•3rd Generation Method (Direct Sandwich Method, Ag-Ab-Ag)
•Serum, Plasma, Whole Blood
•Detects all antibodies including Subtype "O"
•Highly sensitive, even to IgM during early infection stage
•Differentiation of HIV-1 and HIV-2 by clear 3-line formation.
•Sensitivity: 100%, Specificity : 99.8%
•Capture Ag: HIV-1 (p24, gp41),HIV-2 (gp36)Ag
•Evaluated by WHO (Sensitivity 100%, Specificty 99.3%)
•Procured by WHO,UNICEF, etc.
•Long shelf life: 24 months at Room Temperature

45. BI-DOT RAPID KIT TEST
PRINCIPLE OF THE TEST
HIV antigens are immobilized on a porous immunofiltration membrane. Sample and reagents pass through the membrane
and are absorbed into the underlying absorbent. As the patient's sample passes through the membrane, HIV antibodies, if
present, bind to the Immobilized antigens. Conjugate binds to the Fc portion of the HIV antibodies to give distinct pinkish
purple DOT against a white background. (Fig.-3)
LIMITATIONS OF THE TEST
1. The kit works best when used with fresh samples. Samples which have been frozen and thawed several times contain
particulates which can block the membrane, hence resulting in improper flow of reagents and high background colour
which may make the interpretation of results difficult.
2. Optimum test performance depends on strict adherence to the test procedure as described in this manual. Any deviation
from test procedure may lead to erratic results.
3. HIV-1 and HIV-2 viruses share many morphological and biological characteristics. It is likely that due to this, their
antibodies have a cross reactivity of 30-70%. Appearance of test for HIV-1& /or HIV-2 antibodies on the test device does not
necessarily imply co-infection from HIV-1 & HIV-2.
4. Some samples show cross reactivity for HIV antibodies. Following factors are found to cause false positive HIV antibody
test results: Naturally occurring antibodies, Passive immunization, Leprosy, Tuberculosis, Myco-bacterium avium, Herpes
simplex, Hypergamma-globulinemia, Malignant neoplasms, Rheumatoid arthritis, Tetanus vaccination, Autoimmune
diseases, Blood Transfusion, Multiple myeloma, Haemophelia, Heat treated specimens, Lipemic serum, Anti-nuclear
antibodies, T-cell leukocyte antigen antibodies, Epstein Barr virus, HLA antibodies and other retroviruses.
5. This is only a screening test. All samples detected reactive must be confirmed by using HIV Western Blot. Therefore for a
definitive diagnosis, the patient’s clinical history, symptomatology as well as serological data, should be considered. The
results should be reported only after complying with above procedure.

46. NACO Guidelines to detect HIV infection in Asymptomatic individuals
3 test kit RequiredSlide 7