Tuberculosis and HIV Coinfection.ppt

National Centre for AIDS
and STD Control
Tuberculosis and HIV Coinfection

and STD Control
Session Objectives (1)
By the end of the session participants will be able to:
• Describe the relationship and interaction between TB
and HIV co-infection
• Describe the clinical presentation of TB
• Explain the management and treatment of people with
TB and HIV co-infection in relation to ART

and STD Control
Session Objectives (2)
• Describe Nepal’s national guidelines for the treatment
and management of TB and HIV co-infection
• List out the activities for prevention of TB transmission
including intensive case finding and the use of the
National TB screening questionnaire
• Explain infection prevention
• Describe Isoniazid Preventive Therapy

and STD Control
Tuberculosis: HIV-TB co-infection
– Most common cause of death in people with HIV
worldwide
– HIV increases new infection with M. tuberculosis to
progress rapidly to TB disease
– HIV is the most potent factor known to increase risk of
progression from M. tuberculosis infection to disease

and STD Control
Overview
– Among HIV-infected individuals, lifetime risk of
developing active TB is 50 percent, compared to 5-10
percent in persons who are not HIV-infected
– In a person infected with HIV, the presence of other
infections, including TB, allows HIV to multiply more
quickly. This may result in more rapid progression of
HIV infection

and STD Control
– HIV-related TB can present typical or atypical
clinical and/or radiological features. Atypical
features are usually found in HIV-infected
individuals with severe immunosuppression
– Initial signs of TB disease may become apparent at
any time during the evolution of HIV-infection
– May be pulmonary or extra-pulmonary

and STD Control
Patterns of HIV-related TB
Pulmonary TB
• PTB is the commonest form of TB in HIV infected
person
• The presentation depends on the degree of
immunosuppression.

and STD Control
Pulmonary tuberculosis,
sputum smear-positive (PTB+)
• Two or more initial sputum smear examinations
positive for Acid-fast bacilli by microscopy at the
start of the treatment or
• One sputum smear examination positive for AFB
plus radiographic abnormalities consistent with
active PTB as determined by a clinician or
• One sputum positive for AFB plus culture positive
for M. Tuberculosis.
Source: NTP general manual, 2015

and STD Control
Pulmonary tuberculosis,
sputum smear-negative (PTB-)
• At least two sputum specimens negative for acid-
fast bacilli, and
• Radiographic abnormalities consistent with active
pulmonary tuberculosis, and
• No response to a course of broad-spectrum
antibiotics, and
• Decision by a clinician to treat with a full course of
anti tuberculosis chemotherapy

and STD Control
PTB in early and late HIV infection
Features of PTB
Stage of HIV Infection
Early Late
Clinical Picture
Often resembles
post-primary PTB
Often resembles
primary PTB
Sputum smear
result
Often positive Often negative
CXR appearance
Often cavities Often infiltrates
with no cavities

and STD Control
Extra pulmonary Tuberculosis
• A patient with tuberculosis affecting organs
other than the lungs.
• Diagnosis should be based on one culture-
positive specimen (if available), x-ray, or
histological or strong clinical evidence
consistent with active extra pulmonary
tuberculosis, followed by a decision by a
clinician to treat with a full course of anti -
tuberculosis chemotherapy
.

and STD Control
Extra pulmonary TB
Disseminated and extra pulmonary TB is more
common in advanced HIV infection because the
immune system is less able to prevent growth
and local spread of M. tuberculosis.

and STD Control
Extra pulmonary TB
Commonest forms:
– Pleural effusion
– Lymphadenopathy
– Pericardial disease
– Miliary disease
– Meningitis
– Disseminated TB (with mycobacteraemia)

and STD Control
Signs and symptoms of TB
• The most important symptoms are:
— Cough lasting more than two weeks and not
responding to usual antibiotic treatment
— Production of purulent, sometimes blood
stained sputum
— Evening fevers
— Night sweats
— Weight loss

and STD Control
Taking a history
• History of contact with a chronically coughing person
• Treatment history : previous treatment of TB

and STD Control
Treatment
HIV-infected patients should be treated according to
national guidelines and through the National TB
Program
Aims of treatment are to:
• to cure the patient and restore quality of life and
productivity
• to prevent death from active TB or its late effects;
• to prevent relapse of TB
• to reduce transmission of TB to others
• to prevent the development and transmission of
drug resistance.

and STD Control

and STD Control
• For details of the mangemant of different
forms of TB please consult National TB
Program , clinical manuals and other relevant
literatures

and STD Control
Case Study 1:
Sunila, a 43 year old migrant worker from Dang new
HIV positive. TB screening questionnaire reveals:
– cough for 4 weeks
– productive and blood tinged
– fevers off and on, but is afebrile now
– Exam: Chest is clear and no palapable nodes
– CXR: lower lobe infiltrate and sputums are AFB
positive

and STD Control
Case Study 1:
• What is the most likely diagnosis?
• What therapy does he need?
• Is he eligible for ART (even without knowing his
CD4)?
• if so, when would you start ART?
• Which antiretroviral drugs would you chose for him?
• What specific issues of adherence need to be
addressed in relation to the co-infection that he has?

and STD Control
Strategy for initiation of treatment for
both TB and HIV infection
1. Start ART in all PLHIV with active TB, irrespective
of CD4 count.
2. Start TB treatment first, followed by ART as soon
as possible thereafter, but between 2 and 8
weeks.
3. Use Efavirenz as preferred NNRTI in TB-HIV
co-infection

and STD Control
ART drug choice in TB co-infection:
• First line treatment option is TDF/3TC/EFV
• The first alternative is ZDV/3TC/ plus EFV
• The second alternative is ZDV/3TC or TDF/3TC plus
Nevirapine for those unable to take EFV
• Special circumstances regimen containing ABC and
boosted PIs

and STD Control
ART drug choice in TB co-infection
• Rifampicin decreases Nevirapine levels by hepatic
induction. However, with close monitoring NVP
containing regimens may be considered ( exception:
women with baseline CD4 >250 should not be given
NVP along with Rifampicin.)
• ART patients who subsequently develop TB should
have ART adjusted to be compatible with TB
treatment
• Once ATT is completed, the ART regimen can be
continued or changed depending upon the clinical
and immunologic status of the patient

and STD Control
Second line ART and TB- coinfection: Use of
Rifabutin
• Rifampicin lowers PIs levels through cytochrome
P450 interactions
• Rifampicin should not be taken with any boosted PIs
• Substitute rifampicin with rifabutin and maintain the
standard PI- based ART regimen
• Rifabutin dose is 150 mg 3 times a week when taken
with LPV/r containing ART
• If rifabutin is not available use double-dose LPV/r
(that is, LPV/r 800/200 mg twice daily) or ATT
without rifampicin

and STD Control
Case Studies
Case Study #2
Mahesh, a 40 year old HIV positive man from
Biratnagar presents to your clinic complaining of
headache for 5 days now. It started gradually. His wife
states that he has had intermittent fevers. He has been
losing weight for about one month now and has a mild
cough as well.
O/E: Temperature 38.5°, neck stiffness and positive
Kernig’s sign, no focal neurological signs, few
crepitations in the right lower lung field

and STD Control
Case Studies (continued)
Case Study #2 (continued)
You perform an LP and find the following:
CSF: Protein 80 mg/dL (High)
WBC 850 (70% monos)
Glucose 10mg/dL (Low)
India Ink: Negative
AFB: pending (no results yet)
• What other exams would you order?
• What is in your differential at this point?

and STD Control
Case Studies (continued)
Case Study #2 (continued)
The AFB stain of the CSF returns with positive results.
• What treatment is needed?

and STD Control
TB Meningitis
Presenting Signs and Symptoms
Gradual onset of headache and decreased
consciousness
• Low grade evening fevers
• Night sweats
• Weight loss
• Neck stiffness and positive Kernig’s sign
• Cranial nerve palsies result from exudate around
base of the brain

and STD Control
CSF Values
• Normal: 5-10%
• Protein: High (40mg/dl-100 mg/dl)
• WBC: 5-2000 (average is 60-70% monos)
• Glucose: low (<20 mg/dl)
• AFB smear pos: 20%
TB Meningitis Diagnostics

and STD Control
Unique features, Caveats of TB Meningitis
• CD4<350
• Up to 10% of HIV/AIDS patients who present
with TB will show involvement of the
meninges. This results either from the rupture
of a cerebral tuberculoma or is blood-borne
infection
• Always exclude cryptococcal meningitis by
CSF microscopy (India ink stain)

and STD Control
Intensified TB case findings in ART
centers
Group Discussion

and STD Control
What is intensive TB Case finding?
• Refers to the approach of finding TB cases actively by
routine screening clients visiting specific clinics for
purposes not related to TB
• Since TB is one of the most common OIs among
PLHIV, all those visiting ART sites should be screened
for TB using a standard screening process

and STD Control
Why intensive case finding is needed?
• HIV-infected persons attending ART centers for the
first time have a high prevalence of TB
• The incidence of TB among ART clients is also very
high
• While ART reduces the risk of TB disease, this risk
still remains many times higher than the general
population
• Hence intensified TB case finding at ART centers is
very important for early suspicion and diagnosis of
TB

and STD Control
Why intensive case finding is needed?
Early identification of TB and treatment in PLHIV:
• increases the chances of survival,
• improves quality of life
• reduces transmission of TB in the community

and STD Control
How is intensive case finding done?
All clients seen at ART, pre ART, OI clinics and
Community Care Centres, should undergo screening
for tuberculosis using the questionnaire at initial and
follow-up visits every 3 months by health care
provider.

and STD Control
TB Screening Questions
• Adults:
– Current cough ?
– Fever or evening rise in temperature ?
– Experienced weight loss ?
– Night sweats ?
• Children:
– In addition to above mentioned questions
– History of contact with TB case

and STD Control
Case Study 3:
Bhagawan is a 24 year old with HIV who is asymptomatic
with a CD4 of 523. It is his first visit to the ART site. His TB
screening questionnaire is completely negative. He
wonders if there are any medications that he could take
to help him stay well.
• What can you offer?
• At what dose and for how long?
• If he were well, but his CD4 was 210 what medications
would he need then?

and STD Control
Isoniazid Preventive Therapy (IPT)
IPT refers to taking at 6 months of isoniazid daily for
latent TB infection regardless of CD4 cell count or ART
status.

and STD Control
Identifying those in need of IPT:
• Perform TB screening for all new HIV infected clients
at their first visit with TB screening questions, a full
initial history and physical examination,
• If the patient answers yes to any of the screening
questions send for chest X ray (CXR) and other
investigations as needed if no to all send for IPT
• If there are any signs of active TB or any concerns
about unexplained illness, do NOT offer IPT, but refer
client to TB doctor or supervising doctor as
appropriate.
• All PLHIV without active TB or other unexplained
illness are offered IPT with appropriate counseling

and STD Control
Yes
Adults and adolescents living with HIV
Screen for TB with any one of the following symptoms: Current cough, Fever,
Weight loss, Night sweats
Assess for contraindications to IPT Investigate for TB and other diseases
Give IPT Defer IPT
Other diagnosis Not TB TB
Give appropriate
treatment and
consider IPT
Follow up
and
consider IPT
Treat for
TB
Algorithm
No
Yes
No
Screen for TB regularly at each encounter with a health worker or visit to a health facility
•Contraindications active hepatitis , regular and heavy alcohol consumption, and peripheral neuropathy.
•Past history of TB and current pregnancy should not be contraindications for starting IPT.

and STD Control
Yes
Child more than 12 months of age and living with HIV
Screen for TB with Poor weight gain, Fever, Current cough, Contact history with a TB case
Assess for contraindications to IPT Investigate for TB and other diseases
Give IPT Defer IPT
Other diagnosis Not TB TB
Give appropriate
treatment and
consider IPT
Follow up
and
consider IPT
Treat for
TB
Algorithm
No
Yes
No
Screen for TB regularly at each encounter with a health worker or visit to a health facility
•All children and infants less than one year of age should be provided with IPT if they have a history
of household contact with a TB

and STD Control
Initiating IPT
• Explain the IPT program to the client and assess
predicted adherence to 6 months of Isoniazid
• Cotrimoxazole and ART should not be started at the
same time as IPT
• Contraindications: active hepatitis , regular and
heavy alcohol consumption, and peripheral
neuropathy
• Past history of TB and current pregnancy should not
be contraindications for starting IPT
• DOT is not needed for IPT
• Patients on full TB treatment should complete 6
months of IPT at completion of ATT

and STD Control
Isoniazid Preventive Therapy (IPT)
IPT Regimen:
• Isoniazid 300 mg daily for 6 months, Vitamin B6
25 mg (pyridoxine) should be given with IPT for 6
months
• Children should receive Isoniazid 10mg/kg daily
Follow-up visits while on IPT:
• Client must be seen every month for adherence
check, side effect check and medication refill
• Ask about symptoms of breakthrough TB at each
visit. If any occur, evaluate for TB

and STD Control
Small Group Activity on TB
Prevention in the HIV Care
Settings

and STD Control
Tuberculosis Prevention in the HIV Care
Settings (1)
Five Steps for Patient Management to Prevent Transmission of TB in
HIV Care Settings
Step Action Description
1. Screen
Early recognition of patients with suspected or
confirmed TB disease is the first step in the protocol.
It can be achieved by assigning a staff member to
screen patients for prolonged duration of cough
immediately after they arrive at the facility. Patients
with cough of more than two weeks duration, or who
report being under investigation or treatment for
TB*, should not be allowed to wait in the line with
other patients to enter, register, or get a card.
Instead, they should be managed as outlined below.

and STD Control
Settings (2)
Five Steps for Patient Management to Prevent Transmission of TB
in HIV Care Settings
2. Educate
Instructing the above mentioned persons
identified through screening in cough hygiene.
This includes instructing them to cover their
noses and mouths when coughing or sneezing,
and when possible providing face masks or
tissues to assist them in covering their mouths.

and STD Control
Settings (3)
3. Separate
Patients who are identified as TB suspects or
cases by the screening questions must be
separated from other patients and requested to
wait in a separate well-ventilated waiting area,
and provided with a surgical mask or tissues to
cover their mouths and noses while waiting.

and STD Control
Settings (4)
4.
Provide
HIV
services
Triaging symptomatic patients to the front of the
line for the services they are seeking (e.g.
voluntary HIV counseling and testing, medication
refills), to quickly provide care and reduce the
amount of time that others are exposed to them
is recommended. In an integrated service delivery
setting, if possible, the patient should receive the
HIV services they are accessing before the TB
investigation.

and STD Control
Settings (5)
5.
Investigate
for TB or
Refer
TB diagnostic tests should be done onsite or, if
not available onsite, the facility should have an
established link with a TB diagnostic center to
which symptomatic patients can be referred.
Also, each facility should have a linkage with a
TB treatment center to which those who are
diagnosed with TB can be referred.

and STD Control
Thank You

Tuberculosis and HIV Coinfection.ppt

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