Case Management of the TB/HIV Infected Patient
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1 TB Nurse Case Management San Antonio, Texas December 8-10, 2009 Case Management of the TB/HIV Infected Patient Sarah Hoffman, MPH, MSN, ACRN December 9, 2009 TB/HIV: Considerations in the Care of the Coinfected Patient Sarah Hoffman MPH MSN ACRN Sarah Hoffman, MPH, MSN, ACRN Network Nursing Education Coordinator, Acute Care Seton Family of Hospitals December 9,
2 3 Global Perspective Classified in 1993 as AIDS-defining illness by the CDC Increasing global burden of TB strongly connected to global HIV epidemic Primary cause of death in HIV infected individuals Congruent epidemics raise the potential threat of a global epidemic of drug resistant TB 4 2
3 Global Statistics Tuberculosis Approximately 1/3 of the global population infected with TB at a given time 9 million new cases per year 2 million annual deaths from TB HIV/TB In 2007, 1.4 million cases of HIV positive TB globally. 15% of total incident TB cases are found among PLWHIV Double previous estimates 42 million individuals globally infected with HIV More than 25% also infected with MTB 5 Epidemiology of TB/HIV in the US 12,904 TB cases (4.2/100,000) reported in the US in 2008 Overall rate declining, but the decrease has slowed over time In 2005, HIV status of 31% of TB patients was unknown 9% of TB patients were HIV positive in 2005 Areas of ongoing concern: # of cases of TB declining nationally, however still reported in almost all states with increases in areas National data on coinfection incomplete Given these interactions, missed opportunities to intervene in both disease processes 6 3
4 Implications of Coinfection Risk of developing active TB from LTBI increased 100- fold with HIV infection Risk of developing TB disease 7-10% each year with coinfection, 10% over a life time for non-hiv infected individuals with LTBI HIV increases risk of contracting TB regardless ess of CD4 count TB accelerates progression of HIV disease process 7 Case Management A collaborative process in which a case manager assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health (treatment) needs through communication and available resources to promote quality cost-effective outcomes. ~Case Management Society of America;
5 Considerations in the NCM of the Coinfected Patient Screening and Diagnosis Drug-Drug interactions Monitoring Adherence challenges with polypharmacy & DOT Overlapping side effect profiles IRIS Drug resistant t TB Health Literacy Nutrition 9 Basics of HIV Terms: CD4 Function Normal range: AIDS defining criteria Viral Load (copies/ml) HAART Opportunistic Infection Testing: ELISA with confirmatory Western Blot (antibody) Antigen testing Natural History In absence of treatment 10 5
6 Screening Understand and act on screening guidelines for TB and HIV. (2006) CDC recommendation for universal testing of HIV. TB screening guidelines in HIV positive individuals CDC recommends testing in HIV-infected pts w/out previously positive TST. TST should be repeated annually if initial test negative and patient at high risk for TB. TST should be repeated upon immune reconstitution or when CD4 count reaches 200. Risk for TB greatest with CD4 count in the range of % false negative in AIDS patients with active TB 11 Interferon Gamma Release Assay Selects for protein specific to Mycobacterium tuberculosis Positives: Eliminates false positives from BCG vaccine or non- tuberculous mycobacteria Less likely than TST to be inaccurate Requires only one visit for blood draw Limitations: Limited accuracy data in HIV positive populations Three versions of test Quantiferon-TB Gold (QFT-G) Quantiferon-TB Gold In-Tube (QFT-GIT) T-Spot TB Can be used in all situations in which TST is used 12 6
7 Percentage of Notified TB Cases Tested for HIV % Number of TB cases tested (thousands) % 3.2% 8.5% Percentage of notified TB cases tested Source: WHO, % 2002 (9, 37%) 2003 (92, 53%) 2004 (84, 61%) Year (118, 83%) (112, 90%) 2 0 Note: Numbers under bars represent the number of countries reporting data followed by the percentage of total estimated HIV-positive tuberculosis cases accounted for by reporting countries. 13 Special Populations & Risk Factors Foreign born persons 59% national case total (increase) 48.1% of cases in TX Low income 48.3% of cases in TX Overlapping risk factors with HIV infection ETOH and substance abuse Inmates Migrant populations Homeless Disenfranchised individuals 14 7
8 TB Diagnosis Presumptive diagnosis: Based on clinical symptoms Abnormal CXR Sputum smear positive for AFB Nucleic acid amplification (NAA) positive more sensitive than AFB smear (80% vs 50%) Definitive confirmation of diagnosis depends on a positive MTB culture 50% of patients (HIV positive or negative) with culture positive MTB have negative smears Clinical features varying with CD4 count Greater than 350 Less than Overview of HIV Treatment Drugs developed to interfere with viral replication at major points in HIV lifecycle HIV treated with at least 3 drugs from at least 2 classes Rationale similar to treatment of TB Avoid propagation of resistant virus 16 8
9 Treatment Considerations in Coinfection Initiation of HAART and TB treatment Initiation should not be simultaneous Ideally treat TB first with initiation of HAART introduced at 4-8 weeks. Possible exception, pts with CD4 < 50 Management of TB Regimen Similar to patients without HIV 2 month initial phase 4 month continuation phase Pts with CD4 < 100, dosing daily or tri-weekly 17 Drug-Drug Interactions: Rifamycins & ARVs **Goal is to manage complications, not avoid them Preferred regimen: Rifampin and the NNRTIs Rifampin Efavirenz concentrations Can dose adjust Efavirenz: mg q day Not all patients can tolerate NNRTIs Alternative ti choice: PIs Rifampin contraindicated with all boosted PIs Alternative choice: Rifabutin 18 9
10 Drug-Drug Interaction: Rifabutin and PI Based HIV Therapy Preferred therapy for patients unable to tolerate NNRTI-based regimens PI s concentrations of Rifabutin Dose adjusted Rifabutin Concern with discontinuation of med or nonadherence No published studies of potential drug-drug interactions between 2 nd line TB drugs and ARVs
11 Treatment Options 21 Monitoring: Baseline LFT s Renal function CBC CMP Uric Acid with PZA Visual acuity with EMB CD
12 Ongoing Monitoring Clinical assessment monthly Laboratory LFT s at 1 and 3 months routine, and with symptoms hepatotoxicity Sputum smear and culture at least monthly until 2 consecutive smears are negative CXR at 2 months and termination of therapy VL at 1-4 weeks and 3-4 months if starting HAART CD4 at 3-4 months if starting HAART Improvement (Similar to HIVΘ): Afebrile within 7-14 days Sputum culture becomes negative within 2 months in 85% coinfected pts Important to distinguish IRIS from treatment failure 23 Managing Pill Burden & Adherence 24 12
13 Overlapping Side Effects HEPATOTOXICITY NEUROLOGICAL DERMATOLOGIC RENAL OPTHALMOLOGIC HEMATOLOGIC METABOLIC INH Periph Neuropathy Rash Streptomycin Vision Changes Rifampin Lactic Acidosis Rifampin INH INH Amikacin Ethambutol Rifabutin AZT PZA Ethionamide ABC Capreomycin Rifabutin Ethambutol D4T Ethionamide Linezolid Lipo-Dyst/Atrophy Rifampin Linezolid INH ddi PAS CNS d4t Rifabutin Uveitis PZA Hyperlipidemia NVP INH AZT TDF Rifabutin Linezolid d4t EFV Ethionamide PI s IDV Orange Tears AZT PI s except ATV PI s Fluoroquinolones Rifampin d4t EFV > NVP d4t Cycloserine Insulin Resistance AZT Amikacin PI s except ATV ddi Linezolid EFV *HIV *TB 25 TB IRIS Emergence of new manifestations of TB or the worsening of existing symptoms of TB in the presence of appropriate anti-tb therapy Frequency of reaction varies from 11% to 45% Occurs more often in patients with: lower CD4+ counts extra-pulmonary disease disseminated disease shorter interval from TB diagnosis to antiretroviral initiation Reported most frequently within 6 weeks of TB treatment initiation in the presence of HAART Cues to place IRIS on differential 26 13
14 Drug Resistant TB HIV considered risk factor for drug resistant tuberculosis Drug resistant TB is a significant cause of death in HIV/TB coinfected patients Sudden epidemic of XDR-TB in KwaZulu, Natal in South Africa in : Countries Reporting at Least One Case of XDR-TB 28 14
15 Health Literacy WHO defines as: The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health. People with limited health literacy skills: Report poorer overall health Less likely to make use of screening Present in later stages of disease More likely to be hospitalized Have poorer understanding of treatment Have lower adherence to medication regimens 29 Nutrition: Major Impact on Health Outcomes WHO recommendations for energy intake in the HIV infected patient Asymptomatic ti HIV-infected adults Symptomatic HIV-infected adults Symptomatic children Nutrition & TB Risk factor in the development of active disease Increase rates of relapse Likelihood of treatment failure Research 50% rate of relapse Weight gain during initial phase of therapy 30 15
16 Questions? Thank you. 31 References Infectious Diseases Society of America (2009, March 27). Alarming New Data Shows TB-HIV Co-infection A Bigger Threat. ScienceDaily. Retrieved June 9, 2009, from p p pp p Morbidity and Mortality Weekly Report. Reported HIV Status of Tuberculosis Patients -- United States, Published: 11/12/2007. TB and HIV Coinfection: Current Trends, Diagnosis and Treatment Update Liza King, MPH and Shama Ahuja, MPH Based on a Presentation at PRN by: Sonal S. Munsiff, MD
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