TB Intensive San Antonio, Texas. TB/HIV Co-Infection. Lisa Armitige, MD, PhD has the following disclosures to make:

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1 TB Intensive San Antonio, Texas August 2-5, 2011 TB/HIV Co-Infection Lisa Armitige, MD, PhD August 4, 2011 Lisa Armitige, MD, PhD has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1

2 Tuberculosis in the HIV Patient Lisa Y. Armitige, MD, PhD Medical Consultant Heartland TB Center Associate Professor of Medicine/Pediatrics University of Texas HSC at Tyler Effect of HIV on Tuberculosis Epidemiology 2

3 Estimated Incidence of TB per 100,000 Population in African Countries in 1990 and 2005 Chaisson R and Martinson N. N Engl J Med 2008;358: Newly reported cases of tuberculosis per persons by year in the United States, 1980 to 1995 Snider, G. L. Ann Intern Med 1997;126:

4 Estimated HIV Coinfection in Persons Reported with TB, United States, * 30 % Coinfection Aged All Ages *Updated as of July 1, Note: Minimum estimates based on reported HIV-positive status among all TB cases in the age group. Outcomes of Exposure to M. tuberculosis Inhalation of Droplet Nuclei Regional replication in lungs, dissemination ~90% ~5% ~5% Killing, clearance of organisms Latent disease Active disease 4

5 Outcomes of Exposure to M. tuberculosis in HIV-negative and HIV-positive patients Inhalation of Droplet Nuclei Regional replication in lungs, dissemination ~90% 10% reactivation ~5% reactivation per year lifetime Up to 36% active disease ~5% Killing, clearance of organisms Latent disease Active disease Signs & Symptoms - Pulmonary TB Pulmonary Symptoms: Productive, prolonged cough of over 3 weeks duration Chest pain Hemoptysis Systemic Symptoms: Fever Chills Night sweats Appetite loss Weight loss Easy fatigability 5

6 An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV N Engl J Med 2010;362: Clinical Presentation HIV-positive vs. HIV-negative patients Driven mostly by degree of immunity HIV-positive patients are more likely to have: Isolated extrapulmonary localization (53-63% in some studies) Primary infection Pulmonary basilar involvement Tuberculous pneumonia Hilar or mediastinal lymphadenopathies Miliary or disseminated TB Normal CXR (8-20% in some studies) Clinical Microbiology and Infection, Volume 10 Number 5, May

7 An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV N Engl J Med 2010;362: * * * An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV N Engl J Med 2010;362:

8 Testing for TB Infection -TST The tuberculin skin test (TST) may help differentiate infected from uninfected people with signs and symptoms A negative TST does not exclude the diagnosis of TB (especially for patient s with severe TB illness or infection with HIV) Classifying the Tuberculin Reaction 5 mm is classified as positive in HIV-positive persons Recent contacts of TB case Persons with fibrotic changes on chest radiograph consistent with old healed TB Patients with organ transplants and other immunosuppressed patients 8

9 IFN-γ (gamma) release assays (IGRAs) Antigens for Gamma-Release Assays 9

10 FDA-approved IGRAs Quantiferon-Gold In-Tube (IT) T-SPOT SPOT.TBTB Quantiferon Gold In-Tube 10

11 ELISPOT S. A. Clark et al Clinical and Experimental Immunology Poor concordance between interferon-γ release assays and tuberculin skin tests in diagnosis of latent tuberculosis infection among HIV-infected individuals BMC Infectious Diseases 2009, 9:15 Cross sectional study in 2 HIV clinics in Atlanta, Georgia (n= 336), 85% black, 65% male, 91% US-born, 69% on HAART, 60% with a history of an OI. Median CD4 = 334, median viral load 400 copies/ml Conclusion: We found a low prevalence of LTBI and poor concordance between all 3 diagnostic tests (TST, QF-IT, T-SPOT.TB). 11

12 Role of Interferon Gamma Release Assay in Active TB Diagnosis among HIV Infected Individuals PLoS ONE May vol 4(5) 105 HIV/TB patients in India 50% were culture positive 31% were TST positive Sensitivity decreased with declining CD4 count 65% were positive by Quantiferon-IT More indeterminate results with CD4 <200 Role of interferon-gamma release assays in the diagnosis of pulmonary tuberculosis in patients with advanced HIV infection Cattamanchi et al. BMC Infectious Diseases 2010, 10:75 ** 12

13 CXR HIV infected persons In HIV-infected persons almost any abnormality on CXR may indicate TB May cause infiltrates without cavities in any lung zone May cause mediastinal or hilar lymphadenopathy with or without infiltrates or cavities Clinical Presentation HIV-positive vs. HIV-negative patients Driven mostly by degree of immunity HIV-positive patients are more likely to have: Isolated extrapulmonary localization (53-63% in some studies) Primary infection Pulmonary basilar involvement Tuberculous pneumonia Hilar or mediastinal lymphadenopathies Miliary or disseminated TB Normal CXR (8-20% in some studies) Clinical Microbiology and Infection, Volume 10 Number 5, May

14 Primary Tuberculosis 14

15 Miliary Tuberculosis 15

16 CXR Special Situations Pregnant women who are highly suspicious and being evaluated for active disease should undergo a CXR without delay, even during the first trimester Patients suspected of extrapulmonary TB should have a CXR to rule out pulmonary TB 16

17 Bacteriologic or histologic exam Sputum Three (8-24 hours apart, at least one first thing in the morning) Tissue Lymph node biopsy Bone marrow biopsy Other specimens Urine CSF Peritoneal fluid Pleural fluid (pleural biopsy) Diagnosis * * * Clinical Microbiology and Infection, Volume 10 Number 5, May

18 An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV N Engl J Med 2010;362: Diagnosis Summary Must have a high index of suspicion Must utilize many pieces of information in making the diagnosis TB can present very differently in HIV TB can present very differently in HIVinfected patients when compared to HIVnegative patients 18

19 Case Scenario #1 A 35 year old HIV+ man (A.G.) is referred to you for a TST measuring 12 mm. On questioning, the patient states he was skin tested because one of his roommates was diagnosed d with pulmonary cavitary TB. How should you approach this patient? Classifying the Tuberculin Reaction 5 mm is classified as positive in HIV-positive persons Recent contacts of TB case Persons with fibrotic changes on chest radiograph consistent with old healed TB Patients with organ transplants and other immunosuppressed patients 19

20 Case Scenario # 1 (cont) A.G. reveals his TST 3 years ago was negative. He currently takes Atripla (efavirenz-based treatment), his CD4 count is 453 and his viral load is <40. He has HCV and hypertension managed with HCTZ. Case Scenario #1 (cont) He has 2 other roommates who will see you later this week. They are also HIV+ but were TST-negative. How would you evaluate these individuals? 20

21 Case Scenario #1 (cont) Roommate #1 only recently moved into the home. He has a CD4 count of 638, takes no meds, has no significant health issues and denies any current symptoms. Roommate #2 was recently diagnosed with HIV and is not currently on medications. His CD4 count is 45 and he has a cough he attributes to post-nasal drip. He feels well, denies weight loss or other suggestive symptoms. Testing for TB Infection - Principles Individuals id who have a + TST result, a + IGRA result or symptoms suggestive of TB (regardless of TST/IGRA results) should be evaluated with an chest x-ray Patients with HIV who may not react to testing by TST or IGRA should have a chest x-ray if TB is suspected or if exposed to an active TB case If abnormalities are noted, or the client has symptoms suggestive of extrapulmonary TB, additional diagnostic tests should be conducted 21

22 CXR HIV infected persons In HIV-infected persons almost any abnormality on CXR may indicate TB May cause infiltrates without cavities in any lung zone May cause mediastinal or hilar lymphadenopathy with or without infiltrates or cavities Case Scenario #1 (cont) Assuming a negative CXR in all three, how would you approach each patient? A.G. (TST 12 mm, CD4 453, HCV, denies symptoms) Roommate #1 (TST 0mm, CD4 638, no symptoms) Roommate #2 (TST 0mm, CD4 45, cough, no symptoms) 22

23 Risk reduction by treatment of Latent TB Infection (LTBI) in HIV-infected patients Churchyard et al. JID 2007:196 (Suppl 1) S52 Initiating Treatment for LTBI Before initiating treatment for LTBI Rule out TB disease i.e. wait for culture results if specimen obtained Determine prior history of treatment for LTBI or TB disease Assess risks and benefits of treatment Determine current and previous drug therapy 23

24 Isoniazid Regimens for LTBI 9-month regimen of isoniazid (INH) is the preferred regimen 6-month regimen is less effective but may be used if unable to complete 9 months May be given daily or intermittently (twice weekly) Use directly observed therapy (DOT) for intermittent regimen Persons with the following conditions need special precautions while on isoniazid a. Age 35 years and over b. Taking other medications on a long term basis c. Alcohol abusers d. History of previous discontinuation of isoniazid because of toxicity/adverse reactions e. Chronic liver disease f. Peripheral neuropathy g. Pregnancy 24

25 Rifampin Regimens for LTBI Rifampin (RIF) given daily for 4 months is an acceptable alternative when treatment with INH is not feasible. In situations where RIF cannot be used (e.g., HIV-infected persons receiving protease inhibitors), rifabutin may be substituted. RIF and PZA for 2 months should generally not be offered due to risk of severe adverse events 6 6 MMWR August 8, 2003; 52 (31): LTBI treatment MMWR August 8, 2003 / Vol. 52 / No

26 Case Scenario #1 (cont) Assuming a negative CXR in all three, how would you approach each patient? A.G. (TST 12 mm, CD4 453, HCV, denies symptoms) Roommate #1 (TST 0mm, CD4 638, no symptoms) Roommate #2 (TST 0mm, CD4 45, cough, no symptoms) Case Scenario #2 A 28 year old Latino male with HIV presents with a 2 ½ month history of productive cough, night sweats, fevers, fatigue and 30 lb weight loss. The patient has been under the care of an ID physician for his HIV and has been stable on a protease inhibitor (PI)- containing regimen. The patient has been working construction out of state and has not been able to visit his doctor until now. He has been compliant with his HIV meds and his current laboratory studies show a CD4 count of 281 and viral load <50. Two of 3 sputums collected on consecutive days are positive for AFB Which anti-tb regimen do you start him on? What do you do with his HIV meds? 26

27 Anti-Tuberculosis drugs (ATS/CDC/IDSA) First-Line drugs Isoniazid Rifampin Rifapentine Rifabutin* Ethambutol Pyrazinamide *Not FDA approved for TB Second-Line Drugs Cylcoserine Ethionamide Levofloxacin* Moxifloxacin* PAS Streptomycin Amikacin/Kanamycin Capreomycin Purpose 1 5. Recommended Treatment Regimens 36 What s New In this Document 1 CONTENTS OF 6. Practical Aspects of Treatment 42 Summary 1 THE 80 Page 7. Drug Interactions Introduction and Background 13 Document 8. Treatment in Special Situations Organization and Supervision of Treatment Management of Relapse, Treatment Failure, and Drug Resistance 3. Drugs in Current Use Treatment of Tuberculosis in Low Income Countries: Recommendations and Guidelines of the WHO and the IUATLD 4. Principles of Antituberculosis Chemotherapy Research Agenda for Tuberculosis Treatment

28 Updates and Changes in Therapy Changes in dosing schedules: HIV + individuals with low CD4 counts should NOT be given twice weekly therapy Daily therapy can be 7 days per week OR can be 5 days per week IF given by DOT and the Mtb is drug susceptible Role of New Agents Rifabutin (RBT): May be used as a primary drug for patients (especially HIV+) receiving medications having unacceptable interactions with rifampin (e.g. Protease Inhibitors, methadone) Fluoroquinolones: May be used when first line drugs are not tolerated or the organism is resistant Moxifloxacin is rapidly becoming the agent of choice 28

29 ATS recommendations for treatment of tuberculosis * * Morbidity and Mortality Weekly Report June 20, 2003 / Vol. 52 / No. RR 11 Rifamycins Have significant interaction with all ARVs except nucleoside analogues (other than AZT) and enfuvirtide Once or twice weekly regimens show high rate of rifampin resistance in HIV patients with CD4 cell count <100 Most common locus of interaction is the cytochrome P450 system As inducers, rifampin > rifapentine > rifabutin 29

30 Effect of rifampin on serum efavirenz levels Effect on plasma level of efavirenz by rifampin co-administration Effect of increasing efavirenz dose with rifampin co-administration López Cortés et al. Clin Pharmacokinet 2002; 41 (9): Effect of efavirenz dosing with rifampin on treatment outcomes Manosuthi et al AIDS 2005, 19: Manosuthi et al AIDS 2006, Vol 20 No 1 30

31 Rifampin and PIs Note: Decrease in serum protease inhibitor level is NOT overcome by low dose ritonavir Clinical Microbiology and Infection, Volume 10 Number 5, May 2004 Rifabutin Has much less effect than rifampin on drugs metabolized by CYP3A Requires dosage adjustment due to effects by many other drugs (such as ritonavir). PIs (especially if boosted with ritonavir) cause a marked increase in serum rifabutin serum concentrations and toxicity Rifabutin dose should be decreased when using PI-based regimens. Concerns regarding adequate dosing if patient is not compliant with PI medication 31

32 Rifabutin Good virological and immunological outcomes when administered with PI-based HAART Treatment of choice when pt cannot tolerate NNRTIbased treatment (though no head-to-head studies) Expensive 32

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34 New recommendations state Do not co-administer New rec s: Increase dose to 800 mg bid 34

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37 Remember Rifamycins can be safely added to almost any regimen. TB treatment regimens that do not contain rifampin have an unacceptably high failure rate Every effort should be made to treat within the CDC guidelines to increase the chances of treatment success, decrease the chances of relapse and minimize the length of time with toxicities. 37

38 Overall Treatment Outcomes * * Ronan. A. M. JID 2006:193 (15 May) 1439 When should treatment be started when patient is being treated for TB? Considerations Treatment of HIV improves outcomes in patients with TB Decreased death or relapse Multiple medications with multiple potential toxicities that are overlapping If the CD4 count is < 200, generally most ID physicians would treat for HIV with treatment for TB If the CD4 count is > 200 Arguments to start both treatments concurrently Arguments to delay the start of HAART 38

39 National Institute of Allergy and Infectious Diseases (NIAID) Embargoed for Release Thursday, July 22, a.m. EDT Contact: Laura Sivitz Leifman NIH-Funded Study Finds Early HAART during TB Treatment Boosts Survival Rate in People Co-Infected with HIV and TB When should treatment be started when patient is being treated for TB? ACTG 5221 STRIDE Study 806 individuals from 26 sites on 4 continents Conclusions: Overall, immediate ART did not reduce AIDS and death compared to early ART. For persons with CD4 50 cells/mm3 immediate ART resulted in lower rates of AIDS and death compared to early ART. Findings of the SAPiT Trial Findings support integration of TB and HIV treatment Recommend: Patients with CD4+ counts <50 cells/mm 3 Early ART initiation as soon as possible after TB treatment initiation Patients with CD4 counts 50 cells/mm 3 ART initiation can be deferred to start of the continuation phase of TB treatment Decision on early or late initiation: use clinical judgment of capacity to manage IRIS & toxicities 39

40 Case Scenario #3 A 30 year old black woman presents with fever, chills, night sweats and a 20 lb weight loss over the past month. She has large anterior cervical lymph nodes and a left lower lobe infiltrate. Biopsy of one of the lymph nodes reveals granulomas and AFB which are probe positive for Mtb. After further testing, the patient is found to be HIV positive with a CD4 count of 80. The patient is started on 4 drug therapy and, once stable on anti-tb drugs, is started on HAART with efavirenz. Two months into treatment, the patient has worsening cough, a return of fevers, night sweats and worsening LAD. How do you proceed with this patient? IRIS Meintjes et al Lancet ID 8:

41 IRIS Manosuthi et al Journal of Infection, p. 1-7 One more thing 41

42 Co-trimoxazole prophylaxis Nunn et al. BMJ 2008;337;a257 THEY ALWAYS COME BACK Do It Right The First Time! Barbara Seaworth 42

43 Thanks!! Questions? Heartland National Tuberculosis Center TEX-LUNG 43