INT J TUBERC LUNG DIS 14(2):247–249 SHORT COMMUNICATION

© 2010 The Union

National estimate of HIV seroprevalence among

tuberculosis patients in India

P. K. Dewan,* D. Gupta,† B. G. Williams,‡ R. Thakur,§ D. Bachani,§ A. Khera,§ D. F. Wares,* S. Sahu,*

D. C. S. Reddy,* N. Raizada,¶ L. S. Chauhan†
* Office of the World Health Organization Representative to India, New Delhi, † Central Tuberculosis Division,
Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India;
‡ Consultant, Geneva, Switzerland; § National AIDS Control Organization, Ministry of Health and Family Welfare,

Government of India, New Delhi, ¶ Foundation for Innovative New Diagnostics, New Delhi, India

SUMMARY

The national estimate for human immunodeficiency vi-
rus (HIV) prevalence among tuberculosis (TB) patients
in India has previously been estimated indirectly from
global data. To derive an improved national estimate
from local data, we correlated district-level HIV surveil-
lance data from antenatal clinics and TB diagnostic
centres, and applied this correlation to state-level HIV
prevalence estimates for the antenatal population. We
estimate that among the 1.96 million incident TB cases
in 2007, 4.85% (95%CI 4.12–5.73) or 95 240 (95%CI
80 730–112 478) were HIV-infected. With these esti-
mates from local data, the national programme can bet-
ter plan TB-HIV collaborative activities and monitor ef-
forts to detect HIV infection in this large population.
K E Y W O R D S : HIV; tuberculosis; surveillance; India

THE ADVERSE INTERACTION between human
immunodeficiency virus (HIV) infection and tubercu-
losis (TB) poses difficult challenges to public health
programmes.1 Detection of HIV infection among TB
patients offers the opportunity to deliver prompt HIV
care, such as cotrimoxazole prophylaxis and antiretro-
viral treatment, which can reduce suffering and death.
Precise estimation of the burden of HIV among TB
patients is thus critical to effectively monitor TB-HIV
interventions.
India has one of the world’s highest burdens of
both TB (1.96 million cases annually) and HIV infec-
tion (2.31 million prevalent cases).2,3 Based on the
observed relationship between HIV prevalence in the
general population and among TB patients in a vari-
ety of settings worldwide, the World Health Organi-
zation (WHO) estimated that 1.2% of incident TB
cases in India in 2006 were HIV-infected.2 Until now,
however, national data have not been available to
validate this estimation. Recent HIV sentinel surveil-
lance in TB diagnostic centres in India provides an
opportunity to use local empirical data to develop a
more accurate national estimate of the prevalence of
HIV among TB patients. We evaluated the relation-
ship between HIV prevalence in TB patients at sentinel
surveillance sites and the prevalence of HIV among
women attending antenatal clinic (ANC) surveillance
sites to derive a national estimate for HIV prevalence
in TB patients.
METHODS
Data on HIV prevalence among TB patients were
taken from a 15-district survey conducted by the
national TB and AIDS control programmes in 2006–
2007. For this survey, all districts in India were strati-
fied into three groups according to ANC HIV surveil-
lance results (0–0.5%, 0.5–1% and >1%), with five
districts per strata being randomly selected.4 Surveys
enrolled all new notified TB patients, including smear-
negative and extra-pulmonary TB patients, for HIV
testing. Data from ANC site HIV sentinel surveillance
and state-level ANC HIV prevalence estimates were
taken from published surveillance reports.5 The Na-
tional AIDS Control Organization (NACO) conducts
ANC HIV surveillance at 646 sites across 476 (77%)
of India’s 622 districts, with 1–2 sites per district. We
used 3-year averages (2004–2006) of district and
state ANC HIV prevalence estimates to minimise the
influence of outlier values. TB notification data for
2007 for states and national level were taken from
published TB programme reports,6 and national TB
incidence estimates were taken from the WHO global
report.2

Correspondence to: Puneet Dewan, World Health Organization, Southeast Asia Regional Office, World Health House,
Indraprastha Estates, Mahatma Gandhi Marg, New Delhi 110011, India. Tel: (+91) 11 4259 5600 ext 23253. Fax: (+91)
11 2338 2252. e-mail: dewanp@searo.who.int
Article submitted 7 June 2009. Final version accepted 2 September 2009.
248 The International Journal of Tuberculosis and Lung Disease
To determine the correlation between HIV in TB
patients and HIV in ANC sentinel surveillance, we
first assessed the linearity of the relationship for the
15 surveyed districts by sum-of-squares linear regres-
sion of the logit-transformed data. We then used three
separate procedures, linear regression, the Mantel-
Haenszel method and a random effects model, to ex-
press the relationship as an odds ratio (OR). In linear
regression, the y-intercept of the logit-transformed
data was used to calculate the summary OR. The OR
derived from each approach was applied to NACO-
estimated state-level ANC HIV prevalence to estimate
the percentage of HIV among TB patients by state.
State-level estimates of HIV burden among notified
TB patients were summed to generate a national esti-
mate of HIV prevalence among notified TB patients.
The analysis was conducted using Excel (MicroSoft,
Redmond, WA, USA) and StatsDirect 2.7 (StatsDirect
Ltd, Cheshire, UK).
RESULTS
The 15 surveyed districts included a total of 5995 TB
patients tested for HIV in 2006–2007, and 28 396
women tested for HIV in 30 ANC surveillance sites
over 2004–2006. A linear model of logit-transformed
data (Figure) indicated that the slope was not signifi-
cantly different than one (slope 0.97, 95% confidence
interval [CI] 0.66–1.29, R2 = 0.77), which supported
the interpretation of linearity. With the slope con-
strained to one, the linear model yielded an estimated
y-intercept of 2.26 (standard error 0.22); exponenti-
ated, this yielded an OR of 9.62 (95%CI 7.76–11.93).
Calculation of the summary OR by the Mantel-
Haenszel technique (9.78, 95%CI 8.29–11.55) and a
random effects model (9.76, 95%CI 7.94–12.00)
yielded similar results. For the purposes of disease bur-
den estimation, the Mantel-Haenszel OR was used.
Figure Log-odds plot of the relationship between the preva-
lence of HIV in tuberculosis patients and patients attending an-
tenatal clinic surveillance sites. R2 = 0.77. HIV = human immuno-
deficiency virus; TB = tuberculosis; ANC = antenatal clinic.
When this OR was applied to state-level ANC HIV
prevalence estimates, the estimated HIV prevalence
among TB patients varied substantially by state (range
0.49–13.46%) (data not shown). Summed, this yielded
a national HIV prevalence among notified TB pa-
tients of 4.85% (95%CI 4.12–5.73). This translated
to 62 849 (95%CI 53 274–74 223) HIV-infected TB
patients among the 1.294 million incident TB cases re-
ported to the national programme in 2007, or 95 240
HIV-infected TB patients (95%CI 80 730–112 478)
among the larger population of 1.962 million inci-
dent TB cases estimated by the WHO.
DISCUSSION
These estimates suggest that the 2007 HIV preva-
lence among TB patients in India was 4.85%. This is
four times higher than previously estimated, and sug-
gests that TB patients may be an efficient source for
HIV case-finding efforts in India. These results have
been used to guide the state-by-state intensification
of joint TB-HIV collaborative activities across the
country and to monitor the effectiveness of HIV case-
finding among TB patients.
This analysis showed that the use of local surveil-
lance data can improve estimates of TB-HIV burden.
In 2009, the WHO refined estimates of HIV among
TB patients using routinely reported data from multi-
ple countries;7 the revised WHO estimate of 5.25%
for India was much closer to our estimate, supporting
the validity of our approach. India has now imple-
mented a policy of provider-initiated HIV counselling
and testing for all TB patients in higher HIV preva-
lence states.8 If HIV testing uptake is high, routine re-
porting of HIV status for all TB patients would pro-
vide even better information on which to base future
disease burden estimates.
Our analysis is subject to a number of limitations.
We derived these estimates from ANC results, which
intrinsically have a number of weaknesses. ANC sur-
veillance is conducted at just 1–2 sites per district and
shows substantial year-to-year variation; our use of
3-year averages may have helped to reduce the influ-
ence of outlier values. ANC HIV prevalence is known
to be higher than the general population, but general
population HIV prevalence is not available at the dis-
trict level; we thus consistently used ANC HIV preva-
lence from district and state levels. These estimates of
HIV prevalence in TB patients are expected to be
valid only for the national and state levels, and should
not be applied to the district level for programme
monitoring due to the expected heterogeneity of HIV
prevalence in the general population.
References
1 Havlir D V, Getahun H, Sanne I, Nunn P. Opportunities and
challenges for HIV care in overlapping HIV and TB epidemics.
JAMA 2008; 300: 423–430.

2 World Health Organization. Global tuberculosis control: sur-
veillance, planning, financing. WHO report 2008. WHO/HTM/
TB/2008.393. Geneva, Switzerland: WHO, 2008.
3 National AIDS Control Organization. HIV sentinel surveillance
and HIV estimation in India, 2007. A technical brief. New Delhi,
India: Ministry of Health and Family Welfare, Government of
India, 2008.
4 Raizada N, Chauhan L S, Khera A, et al. HIV seroprevalence
among tuberculosis patients in India, 2006–2007. PLoS One
2008; 3: e2970.
5 Ministry of Health and Family Welfare, Government of India.
HIV sentinel surveillance and HIV estimation, 2006. New Delhi,
India: National AIDS Control Organization, Ministry of Health
and Family Welfare, Government of India, 2008.
Antérieurement, en Inde, l’estimation nationale de la
prévalence du virus de l’immunodéficience humaine
(VIH) chez les patients tuberculeux avait été établie in-
directement à partir des données mondiales. Pour obte-
nir une amélioration de l’estimation nationale à partir
des données locales, nous avons corrélé les données de
surveillance des districts dans les polycliniques préna-
tales et dans les centres de diagnostic de tuberculose
(TB), et avons appliqué cette corrélation aux estima-
El cálculo de la frecuencia de infección por el virus de la
inmunodeficiencia humana (VIH) a escala nacional en
los pacientes con tuberculosis (TB) en la India se ha
realizado en forma indirecta a partir de los datos mun-
diales. Con el propósito de obtener un dato nacional más
preciso partiendo de los datos locales, se correlaciona-
ron los datos de la vigilancia de la infección por el VIH
a escala distrital en los consultorios de consulta prenatal
y los centros de diagnóstico de la TB y se aplicó esta
HIV seroprevalence among TB patients in India 249
6 Ministry of Health and Family Welfare, Government of India.
TB India 2008: RNTCP status report. New Delhi, India: Cen-
tral TB Division, Directorate General of Health Services, Min-
istry of Health and Family Welfare, Government of India,
2008.
7 World Health Organization. Global tuberculosis control: epide-
miology, strategy, financing. WHO/HTM/TB/2009.411. Geneva,
Switzerland: WHO, 2009.
8 Ministry of Health and Family Welfare, Government of India.
National framework for joint TB/HIV collaborative activities:
February 2008. New Delhi, India: Ministry of Health and Fam-
ily Welfare, Government of India, 2008.
RÉSUMÉ
tions de prévalence du VIH par état dans la population
prénatale. Nous estimons que sur les 1,96 millions de
nouveaux cas de TB en 2007, 4,85% (IC95% 4,12–
5,73), soit 95 240 (IC95% 80 730–112 478), étaient in-
fectés par le VIH. Grâce à ces estimations issues de don-
nées locales, le programme national peut améliorer la
planification des activités de collaboration VIH-TB et
surveiller les efforts de détection de l’infection VIH dans
cette grande population.
RESUMEN
correlación al cálculo estatal de prevalencia de infección
por el VIH en la población de la consulta prenatal. Se
calculó que en 1,96 millones de casos nuevos de TB en
el 2007, 4,85% (IC95% 4,12–5,73), o 95 240 personas
(IC95% 80 730–112 478), padecían infección por el VIH.
Con estas cifras a partir de los datos locales, el programa
nacional puede planear mejor las actividades conjuntas
contra la TB y el VIH y vigilar los esfuerzos de detección
de la infección por el virus en esta vasta población.