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大家好
Hello.

我是Véronique Joly
I am Véronique Joly.

我在巴黎的Claude Bernard医院工作
I work in Paris at the Claude Bernard Hospital.

我是一名负责艾滋病病人的医生
I am a physician taking care of patients with HIV infection.

今天的话题是结核病
Today, the topic will be the interaction

艾滋病和糖尿病之间的相互作用
between tuberculosis, HIV and diabetes.

这三种疾病之间有相互作用
There are interactions between these three diseases.

首先
First,

是流行病学上的重叠性
overlapping epidemics.

其次
Second,

结核病在HIV或糖尿病患者中更为常见
TB disease is more frequent in patients with HIV or diabetes.

有一些非典型的临床症状
There are some atypical clinical aspects.

结核病会加重
TB disease may be more severe

因为HIV的治疗会干扰结核病治疗
and HIV therapy interferes with TB therapy.

2015年
Worldwide,

世界卫生组织公布说
the WHO reported 10.4 million people

全球有1040万结核病患者
with TB disease in 2015.

估计约有12%患者为HIV阳性
About 12% are estimated to be HIV positive

其中71%在非洲
and 71% in Africa.

2015年 有180万结核病患者死亡
There were 1.8 million TB deaths in 2015

其中四分之一为HIV阳性
and one fourth in HIV-positive patients.

但从2000年起
However,

结核病发病率每年平均下降1.5％
there is a decrease in TB incidence from 2000 by an average of 1.5% every year.

2015年 有4.22亿人患有糖尿病
422 million people were living with diabetes in 2015.

自1980年以来
Prevalence increased from 4

患病率从4％上升到8％
to 8% since 1980.

这张幻灯片说明了预测的糖尿病变化
This slide depicts the projected diabetes changes

和当前全球结核病的发病率
and current worldwide TB incidence.

如您所见
As you can see,

这两种疾病的流行病学方面也有重叠
there is also an overlap between epidemics.

一些研究表明
Several studies show

高收入国家和低收入国家都存在糖尿病
that coaffliction with diabetes

和结核病共存的现象
and TB exist in both high-income and low-income countries.

艾滋病和糖尿病有共同的流行病学特征
HIV and diabetes share common epidemiologic features.

糖尿病和艾滋病都会引起免疫功能障碍
Both diabetes and HIV cause immunocompromission

增加结核病复发的可能性
and increase the likelihood of the reactivation of TB.

正如我们所看到的
As we have seen,

流行病学方面有重叠
there is an overlap between the epidemics

而且糖尿病急剧增长
and a dramatic increase in diabetes,

特别是在亚洲
particularly in Asia.

糖尿病和艾滋病毒都影响
Both diabetes and HIV affect lower socioeconomic groups

经济阶级较低的社群和少数民族
and ethnic minorities

且他们结核病患病率也较高
that also have a higher prevalence of TB.

两者都有隐藏的流行性
There is a hidden epidemic for both affections.

据估计
It is estimated

四分之一的糖尿病患者不知道自己患病
that one fourth of the people with diabetes do not know they have it.

只有40％的结核病病人
HIV status is known

知道自己的HIV感染状况
in only 40% of TB cases.

所以
So,

免疫功能正常者与免疫功能低下患者的
the natural history of TB is different

结核病自然史是不同的
in immunocompetent and immunocompromised patients.

在免疫力较强的患者中
In immunocompetent patients,

80％的患者接触结核病后会有潜伏感染
in blue, 80% will have latent infection after exposure to TB.

但只有10%患者一生中
But only 10% have a lifetime risk

有发展成活动性结核病的风险
of developing active TB.

在免疫力低的患者中
In immunocompromised patients,

如标红部分所示
in red,

患活动性结核病的风险急剧升高
the risk of active TB is highly increased.

而且
Furthermore,

还有再感染的可能
there may be reinfections.

所以我们可以看到
So,

在HIV感染者中
in HIV-infected patients,

每年从潜伏性感染转变成
we have seen that the annual risk of evolution

活动性结核病的风险达到10％
from latent TB infection to active TB is 10%.

而HIV阴性患者一生中的转变风险
Contrasting with a risk of 10% lifetime

只有10%
in HIV-negative patients.

在任何程度的免疫抑制情况下
This risk is increased

这种风险都会增加
at all levels of immunosuppression.

当CD4水平低时
But of course it is more important

就更重要了
when CD4 levels are low.

在HIV感染后早期阶段
This risk increased early

这种风险就会升高
after the HIV infection.

糖尿病也是患上活动性结核病的风险因素
Diabetes is also a risk factor for developing active TB.

在队列研究中
In cohort studies,

风险增加且相对危险度为3.11
there is an increased risk with a relative risk of 3.11.

病例对照研究的结果更加多样化
The results of case-control studies are more heterogeneous.

相对危险度范围从1.15到7.9
The relative risk ranges from 1.15 to 7.9.

此外
Furthermore,

亚组分析说明这种关联在非北美研究中
in subgroup analysis, it has been shown that this association

更重要
was more important in non-North American studies.

在HIV感染者中
In HIV-infected patients,

结核病可能发生在任何CD4水平
TB may occur at any CD4 level counts

但当CD4数量少时更易发生
but it is more important when the CD4 count is low,

如标黑部分所示
in black.

这里展示了抗逆转录病毒治疗前
This represents the incidence of TB

HIV感染者的结核病发病率
in HIV-infected patients before the availability of antiretroviral therapy.

如您所见
As you can also see,

发病率取决于地理区域
the incidence depends on the geographic region,

与意大利相比
more important in high-incidence countries

南非等高发国家更为严重
such as South Africa compared to Italy.

HIV和糖尿病患者的临床表现改变
The clinical presentation is altered in HIV and diabetic patients.

与非HIV患者相比
In HIV patients compared to non-HIV patients,

HIV患者的表现取决于免疫状态
the presentation depends on the immune state.

40％至80％的患者发生肺外疾病
Extrapulmonary disease occurs in 40 to 80% of patients

5％至10％的患者发生中枢神经系统结核病
and central nervous system TB develops in 5 to 10% patients.

当CD4少时
When CD4 counts are low,

空洞少见
cavitations are rare,

无免疫性
anergy is common,

菌血症频繁
bacteremia is more frequent

药物反应频繁
and also drug reactions are frequent.

药物与抗病毒疗法的相互作用阻碍了
Drug interactions with antiviral therapy

这些患者的治疗
hampered the treatment of these patients.

与非糖尿病患者相比
In diabetic patients compared to non-diabetic patients,

糖尿病患者下肺受累和空洞病变更为频繁
lower lung involvement and cavitary lesions are more frequent.

肺外疾病发病率增加了两倍
There is a twofold increase in extrapulmonary disease.

研究表明复发率和死亡率都会上升
And studies report a more frequent occurrence of relapse and death.

在感染HIV的患者中
In HIV-infected patients,

HIV治疗与利福霉素之间的
interactions between HIV treatment and rifamycin complicate the treatment.

相互作用使治疗更复杂
Rifampin,

利福平是治疗结核病的
the main drug in TB treatment,

主要药物可以与依法韦仑
can be given with efavirenz,

整合酶抑制剂
integrase inhibitors

和核苷一起使用
and nucleosides.

但不和蛋白酶抑制剂一起使用
But not with PIs.

当需要使用蛋白酶抑制剂时
And when a PI is needed,

应该用利福布汀
rifampin should be replaced

替代利福平
by rifabutin

并调整剂量
with a dosage adjustment.

在结核病治疗期间
During TB treatment,

当HIV感染患者接受抗逆转录病毒疗法（antiretroviral therapy，简称"ART"）时
when HIV coinfected patients receive ART,

预防其他机会性感染的发生是有益的
there is a benefit to preventing the occurrenceof other opportunistic infections.

然而
However,

免疫恢复可能在治疗开始后的几天
immune restoration may induce inflammatory reactions in the days

或几个月内引起炎症反应
or months following the initiation of the therapy.

这就是所谓的IRIS
This is called IRIS,

免疫重建炎症综合征
Immune Reconstitution Inflammatory Syndrome

已经进行了不同的研究来确定在患者中
Different studies have been conducted to precise the optimal time

开始抗逆转录病毒治疗的最佳时间
to initiate antiretroviral therapy in patients with a disease.

这个表格展示了三项重要的研究
This table represents three important studies.

如您所见
As you can see,

尽早开始治疗有利于预防这些患者死亡
an early initiation of treatment was beneficial to prevent death

或出现新的艾滋病并发症
or the occurrence of a new AIDS-defining event in these patients,

特别是在CD4数量少的受试者亚组中
particularly in the subgroup of subjects with a low CD4 count.

但当HIV治疗开始不久后
However, there was an increased incidence of IRIS

免疫重建炎症综合征（Immune Reconstitution Inflammatory Syndrome，简称"IRIS"）的发病率有所增加
when the treatment for HIV was initiated early.

总之
In conclusion,

患有结核病的HIV感染者
in patients with TB

应该在结核病治疗结束后
and HIV infection,

尽早开始高效抗逆转录病毒治疗（Highly Active Anti-Retroviral Therapy，简称"HAART"）
HAART should be initiated early after the treatment of TB.

有中枢神经系统参与是特例
There is an exception,

因为在这种情况下
the involvement of the central nervous system,

IRIS可能非常严重
because in this case the IRIS could be very severe.

所以
So,

对于患有结核病和脑膜炎的患者
in patients with TB and meningitis,

高效抗逆转录病毒治疗（Highly Active Anti-Retroviral Therapy，简称"HAART"）应有所改变
HAART should be differed.

感谢您的关注
Thank you for your attention.