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Co-incidence of HIV/AIDS and Tuberculosis -- Chicago, 1982-1993

In 1985, the epidemic of human immunodeficiency virus (HIV) infection was recognized as an influence on the increasing occurrence of tuberculosis (TB) in the United States (1). Programs to control and prevent TB require information characterizing the interaction between HIV infection and TB, particularly in locally defined populations. This report describes the overall occurrence of TB in Chicago (1990 population: 2,783,726) during 1982-1993 and characterizes the co-incidence of TB and HIV/ acquired immunodeficiency syndrome (AIDS) in Chicago during 1989-1993.

The Chicago Department of Public Health (CDPH) maintains computerized registries for all reported incident cases of TB and AIDS among city residents. This analysis compared the 3738 incident cases of TB registered from 1989 through 1993 with the 8207 cumulative cases of AIDS reported through March 1994. A match was defined as any person whose name appeared in both registries and was based on the patient's first name, last name, and date of birth. AIDS cases were reported based on the case definition in effect at the time of the report; for example, pulmonary TB in persons aged greater than or equal to 13 years was added as one of the AIDS-defining conditions in 1993. Racial/ethnic groups included in this analysis were non-Hispanic blacks, non-Hispanic whites, and Hispanics. Numbers of persons in other racial/ethnic groups were too small for meaningful analysis.

From 1982 through 1987, cases of TB decreased by 39%, but from 1987 through 1993 cases increased 23% Figure_1. The annual number of persons with TB but without AIDS reported during 1989-1993 increased from 633 to 677 (7%).

During 1989-1993, a total of 458 co-incident cases of AIDS and TB were identified in Chicago. The proportion of co-incident cases increased from 8% (52 of 685 cases of TB) in 1989 to 15% (122 of 799 cases of TB) in 1993 Figure_1. Pulmonary TB was the sole AIDS-defining illness for 77 (17%) of the 458 co-incident cases; 381 (83%) had TB and other AIDS-defining illnesses.

During 1989-1993, non-Hispanic blacks accounted for 50% of the cases of AIDS, 62% of the cases of TB, and 71% of the co-incident cases Table_1. Non-Hispanic whites accounted for 36% of cases of AIDS but smaller proportions of cases of TB (15%) and co-incident cases (12%), and Hispanics accounted for 14%-17% of cases of TB, AIDS, and co-incident cases. Injecting-drug use accounted for the highest proportion of co-incident cases (52%). The rates for the 5-year period for co-incident cases were 6.0 per 100,000 population for non-Hispanic blacks, 1.0 for non-Hispanic whites, and 2.8 for Hispanics.

Among persons with co-incident cases, analysis of the year TB was reported in relation to the year AIDS with opportunistic illnesses other than pulmonary TB was diagnosed indicated that a small number (17 {4%}) of TB cases were reported greater than 2 calendar years before the diagnosis of AIDS Table_2. Reported by: G Mueller, DVM, S Whitman, PhD, C Plummer, Epidemiology Program; Tuberculosis Control Program, Chicago Dept of Public Health. Div of Tuberculosis Elimination, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: During the mid-1980s, AIDS was identified among approximately 2% of TB cases in some areas (2-5). Although the proportion of TB cases attributed to HIV/AIDS has increased each year, the number of TB cases not co-incident with HIV/AIDS increased only slightly, suggesting that the increase in total TB cases would not have been as great in the absence of the HIV/AIDS epidemic.

In Chicago, the percentage of cases varied by race/ethnicity; however, it is unclear whether these variations reflect differences in factors such as socioeconomic status, access to medical care, and prevalence of specific risks. Race is most likely a risk marker rather than a risk factor for TB and HIV infection; risk markers may be useful for identifying groups that should be targeted for prevention and education efforts.

The 1993 expansion of the AIDS case definition to include pulmonary TB increased the number of co-incident cases identified in Chicago and facilitated earlier recognition of co-incident cases. If the expanded AIDS definition had not included pulmonary TB, these co-incident cases probably would have been detected through matching when different AIDS-defining conditions were diagnosed (except for persons who died before such conditions were diagnosed). In addition, changes in the epidemiology of TB have promoted modification of the management of TB cases to include testing for HIV infection and expanded the ability to detect co-incident TB and HIV/AIDS cases.

Most TB cases that precede a diagnosis of AIDS by several years may not be attributable to the immunosuppression from HIV infection. However, the incubation of AIDS is long and variable. The finding that TB was rarely reported greater than 2 calendar years before AIDS was diagnosed suggests that the occurrence of TB in co-incident cases is related temporally with HIV immunosuppression.

The findings in this report are subject to at least three limitations that probably undercounted the number of co-incident cases in Chicago. First, some matches between the two registries may have been missed because of discrepancies in the information used for matching (e.g., the transposition of first and last name between registries). Second, the lack of HIV testing data for all persons with TB limits analysis because some co-incident cases may be unrecognized. Third, because of reporting delays for AIDS cases, the final number of co-incident cases for the period covered by this report probably will increase (6,7).

The finding that more than 15% of persons with newly diagnosed TB in Chicago were HIV positive underscores the importance of assessing the HIV status of all persons with TB, the need for prompt contact investigation, and the appropriate use of isoniazid preventive therapy in contacts (8). In addition, these findings suggest the need for intensified monitoring of the co-incidence of these two epidemics. Although registry reviews can assist in this effort, the methods are complex.

Concerns about confidentiality limit the ability to conduct such TB and AIDS registry matches. Although in Chicago confidentiality precludes the direct reporting of persons with AIDS and TB directly to the TB-control program, CDPH recognizes the substantial impact of HIV/AIDS on the TB epidemic and the need for timely follow-up of contacts. Therefore, CDPH has instituted measures to both ensure and expedite TB case reporting among AIDS cases. TB-related AIDS case reports now must include the date of reporting to the TB-control program. AIDS case reports without this information are followed up by the AIDS surveillance program. Quarterly database reviews are conducted to ensure that all AIDS cases with possible TB have been reported to the TB-control program by the medical practitioner. This process has strengthened cooperation between the AIDS and TB programs to control these two epidemics in Chicago. Other state and local health departments should consider a similar process of matching TB and AIDS registries to better describe the comorbidity of TB and HIV.

References

  1. CDC. Tuberculosis -- United States, 1985 -- and the possible impact of human T-lymphotropic virus type III/lymphadenopathy-associated virus infection. MMWR 1986;35:74-6.

  2. CDC. Tuberculosis and acquired immunodeficiency syndrome -- Florida. MMWR 1986;35: 587-90.

  3. CDC. Tuberculosis and AIDS -- Connecticut. MMWR 1987;36:133-5.

  4. CDC. Tuberculosis and acquired immunodeficiency syndrome -- New York City. MMWR 1987; 36:785-90,795.

  5. Cote TR, Nelson MR, Anderson SP, Martin RJ. The present and future of AIDS and tuberculosis in Illinois. Am J Public Health 1990;80:950-3.

  6. CDC. Projections of the number of persons diagnosed with AIDS and the number of immunosuppressed HIV-infected persons -- United States, 1992-1994. MMWR 1992;41(no. RR-18):4.

  7. Chicago Department of Public Health. Delay in reporting. In: AIDS Chicago. Chicago, Illinois: Chicago Department of Public Health, 1993:7.

  8. CDC. Tuberculosis and human immunodeficiency virus infection: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR 1989;38:236-8,243-50.



Figure_1

Figure_1
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Table_1
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TABLE 1. Number of cases of AIDS * and tuberculosis (TB) and co-incident cases of
AIDS and TB, by race/ethnicity, sex, age, and mode of HIV transmission -- Chicago,
1989-1993
==================================================================================================
                               AIDS cases        TB cases        Co-incident cases
                               ------------     ------------     -----------------
Characteristic                 No.     (%)      No.     (%)         No.       (%)
----------------------------------------------------------------------------------
Race/Ethnicity
  Black, non-Hispanic          3014   ( 50)     2319   ( 62)        323      ( 71)
  White, non-Hispanic          2176   ( 36)      570   ( 15)         53      ( 12)
  Hispanic                      835   ( 14)      530   ( 14)         76      ( 17)
  Other +                        35   (  1)      319   (  9)          6      (  1)

Sex
  Male                         5319   ( 88)     2485   ( 66)        395      ( 86)
  Female                        741   ( 12)     1253   ( 34)         63      ( 14)

Age group (yrs) &
   0-12                          80   (  1)      192   (  5)          1      ( <1)
  13-19                          16   ( <1)      129   (  3)          1      ( <1)
  20-29                        1009   ( 17)      502   ( 13)         66      ( 14)
  30-39                        2769   ( 46)      902   ( 24)        200      ( 44)
  40-49                        1544   ( 25)      683   ( 18)        145      ( 32)
   >=50                         642   ( 11)     1330   ( 36)         45      ( 10)

HIV transmission mode
  Homosexual/Bisexual male     3518   ( 58)      ---    ---         160      ( 35)
  Injecting-drug use           1824   ( 30)      ---    ---         239      ( 52)
  Heterosexual                  470   (  8)      ---    ---          45      ( 10)
  Other                         248   (  4)      ---    ---          14      (  3)

Total                          6060   (100)     3738   (100)        458      (100)
----------------------------------------------------------------------------------
* AIDS cases were reported based on the case definition in effect at the time of the report; for
  example, pulmonary TB in persons aged >=13 years was added as one of the AIDS-defining
  conditions in 1993.
+ Numbers for other racial groups were too small for meaningful analysis.
& Age at which TB was reported in AIDS patients or AIDS was diagnosed in TB patients.
==================================================================================================

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Table_2
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TABLE 2. Year of AIDS diagnosis *, 1986-1993, and year of report of tuberculosis (TB),
1989-1993, for co-incident cases of AIDS and TB -- Chicago
==================================================================================================
                                 Year of TB report
Year of AIDS        -------------------------------------
  diagnosis         1989    1990     1991    1992    1993   Total
-----------------------------------------------------------------
1986                   0       0        0       1       0       1
1987                   2       1        2       1       0       6
1988                   8       3        2       2       0      15
1989                  29      12        2       4       2      49
1990                   6      42       17       5       2      72
1991                   5       5       69      32       5     116
1992                   1       2        4      68      30     105
1993                   1       3        4       3      83      94

Total                 52      68      100     116     122     458
-----------------------------------------------------------------
* AIDS cases were reported based on the case definition in effect at the time of the report; for
  example, pulmonary TB in persons aged >=13 years was added as one of the AIDS-defining
  conditions in 1993.
==================================================================================================

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