Tuberculosis often a symptom of underlying HIV infection

By Chris Green

JAKARTA (JP): There is no way to prove it at present, but it appears that tuberculosis (TB) is the most common infection associated with AIDS in this country.

However, it is probably not among the small proportion of cases of HIV infection actually treated by doctors here, which amount to less than 2 percent of the total. The overwhelming majority of HIV cases in Indonesia, that staggering remaining 98 percent, are not treated -- or at least not treated as HIV.

Infection with HIV, the virus that causes AIDS, leads to a weakening of the body's immune system, which protects the body against infection. Some 10 years after infection with HIV, the immune system becomes too weak to ward off infection.

Tuberculosis (Indonesia ranks third, behind China and India, for TB cases worldwide) is one of the so-called opportunistic infections that take advantage of this weakness of the immune system. When HIV-infected people fall sick and seek medical help, they are often diagnosed with a different condition, and this is most likely TB.

The World Health Organization estimates there are 6,000 new cases of TB every year in Indonesia attributable to HIV infection. This compares with less than a thousand cases of HIV identified in any year so far.

Thus, the figure of 6,000 can be little more than an educated guess; my guess is that the real number is higher. While only about 10 percent of the estimated number of new cases of TB in Indonesia are diagnosed and treated, it is probably rare that doctors even consider that the cases they find may be connected with HIV.

Because of their lifestyles, drug users are more vulnerable to infection with TB. And injecting drug users are at great risk of HIV infection. We all know that injecting drug use, and the sharing of needles, has exploded over the last few years in Indonesia. We can assume the rates of infection of both HIV and TB among this population are high. It is probable that as many as 100,000 -- or more -- injecting drug users in Indonesia are already infected with HIV. That's why I suspect that the figure of 6,000 new cases of TB connected with HIV each year in Indonesia is low.

Doctors diagnosing cases of TB among their patients should immediately consider the possibility that this is connected with HIV. They must discuss this with their patients to discover if they have been involved in behavior that may have put them at risk of HIV infection. This can occur mainly through sex (heterosexual or homosexual) without a condom or sharing needles, either while using illegal drugs or in a medical setting.

If this is the case, they should counsel the patient to consider having a voluntary HIV test.

Around the world, and probably also in Indonesia, TB is the most common cause of death among people with AIDS. TB is the only common opportunistic infection associated with AIDS that is easily spread to other members of the general population. But like other opportunistic infections, TB can be treated successfully.

And there is no denying Indonesia has a TB problem.

WHO estimated there were 591,000 new cases of TB infection in Indonesia in 1998, the last year for which figures are available. This was an increase of one third over the previous year, and more than 140,000 died of the disease. But the WHO-supported anti-TB program identified only a few of the new infectious cases.

Improving our response to TB, and understanding the connection between HIV and TB, will help us to address both epidemics. World TB Day on March 24, which commemorates the discovery of the tuberculosis bacillus in 1888, provides an opportunity for us all to advocate for these improvements.

The writer is an AIDS activist in Indonesia and publishes several newsletters in Indonesian on AIDS and drugs.