TB/HIV CO-INFECTION ADULT & CHILDREN (INCLUDING INH PROPHYLAXIS) ART Treatment Guideline Training 31 st January to 4 th February, 2011
OUTLINE Background Global Incidence The Problem" The 3 I s Drug Resistant TB Nutrition Support
BACKGROUND Globally, one third of the world is infected with TB, though roughly 90-95% of people without HIV will never go on to develop active disease Tuberculosis is the commonest opportunistic infection in people with HIV in Sub- Saharan Africa & can present at any CD4 count TB is the primary cause of morbidity & mortality in patients with HIV & difficult to diagnose in patients with HIV Sputum smears are usually ve in active disease & patients often have atypical clinical & radiographic presentations HIV infected patients are more likely to present with extra pulmonary TB TB can occur at any point in the course of progression of HIV infection & the risk of developing TB rises sharply with worsening immune status
BACKGROUND (CONTD) A person infected with HIV has 10 times increased risk of developing TB With a co-infection rate ranging from 64% to 80% and the emergence of MDR-TB in the country, a huge strain has been put on the existing health infrastructure WHO estimates that HIV contributes to 68% of deaths in TB patients on treatment (Increased from 10% in 1995 to 13.5% in 2000) Mortality is 2-4 times higher, 6-39% in SSA Early diagnosis & effective treatment of TB among HIV infected patients are critical for curing TB, minimizing the -ve effects of TB on the course of HIV & interrupting the transmission of M. Tuberculosis to other persons in the community
Incidence per 100,000 per year Global incidence of tuberculosis 600 500 AFR high HIV 400 300 AFR low HIV 200 So East Asia World West. Pacific 100 East. Medit. East. Europe Lat. America 0 Cent. Euro, Est Market 1990 1995 2000 2005 2010 2015
THE PROBLEM
ESSENTIAL TB FIGHTING ACTIVITIES FOR HIV PROGRAMS The 3 I s Intensive case Finding INH Prophylaxis Therapy Infection Control
Intensified Case Finding(ICF): To increase the early identification of TB disease Provision of Isoniazid Preventive Therapy (IPT): To reduce the risk of TB to those in whom active TB disease can be excluded Infection Control practices(ic): To reduce the likelihood of exposure to TB bacilli, in clinical, congregate settings and in the community
SCREENING FOR TB
1. INITIAL ASSESSMENT OF HIV STATUS IN TB PATIENTS Be offered by trained counselors & health care workers HIV pre-test counseling Do Rapid test, if +ve, draw blood for CD4 count & encourage partner testing in household & children Post-test counseling & give information on reducing risky sexual behaviour Open TB card & enroll into HIV care & Treatment if HIV +ve If ve, repeat test after 3 months & Health educate on how to remain ve If Indeterminate, do tie-braker test using Rapid test or ELISA
KEY FEATURES SUGGESTIVE OF ACTIVE TUBERCULOSIS Close contact with an active case of TB; especially if smearpositive Symptoms suggestive of TB Cough Fever: Temperature > 38 degrees Celsius for > 2 weeks (after common causes such as pneumonia have been excluded) Night sweats Weight loss or failure to thrive Sputum production, dyspnoea, haemoptysis, etc (not part of routine symptom screen, but if a patient reports, this should raise the provider s suspicion for TB)
PHYSICAL SIGNS HIGHLY SUGGESTIVE OF TB Pulmonary crackles, wheezing, decreased breath sounds Extra pulmonary Manifestations: Non-painful enlarged cervical lymph nodes with or without fistula formation Meningitis not responding to the usual antibiotic treatment Distended abdomen with ascitis Non-painful enlarged joints Documented weight loss or failure to gain weight
Positive tuberculin skin test Not routinely available in Lesotho An induration of 5 mm or more in diameter is significant CXR suggestive of TB Enlarged hilar or subcarinal lymph nodes Persistent opacification in the lung which does not improve after a course of antibiotics Miliary pattern Large pleural effusions Apical infiltrates with cavity formation
TREATMENT Initiate patients on ATT as soon as a diagnosis is made & enroll in TB register TB treatment regimens should include four drugs Children with TB can be given Ethambutol, recommended in Lesotho given the high rates of drug resistance (> 3%) Initiate ART within 2 to 4 wks after starting ATT due to high mortality rate & risk of OIs
NEW RECOMMENDATIONS FOR INITIATION OF FIRST-LINE ART IN ADULTS/ADOLESCENTS ALREADY ON ANTI-TB TREATMENT Start ART in all HIV-infected individuals with active TB irrespective of the CD4 cell count. Start TB treatment first followed by ART within 2-4 weeks of ATT commencement. Use Efavirenz (EFV) as the preferred NNRTI in patients on TB treatment.
INITIATING FIRST-LINE ART IN CHILDREN ALREADY ON ATT Any HIV-infected child with active TB disease should begin TB treatment immediately and start ART within 2-4 of TB therapy irrespective of CD4 count or clinical stage For concurrent HAART and ATT: Children < 3 years of age: AZT or d4t + 3TC + NVP (at maximum target dose of 200mg/m 2 ) Children > 3 years of age: AZT or d4t + 3TC + EFV NVP although interact with Rifampicin, it is recommended due to its demonstrated clinical efficacy as well as current familiarity with its use among health care providers Abacavir is not recommended due to the known inferior potency of triple NRTI therapy and the potential difficulty in diagnosing hypersensitivity reaction especially in rural settings.
DEVELOPING TUBERCULOSIS WHILE ON ART Adults and children > 3 years and > 10 kg who are on Nevirapine based regimens must be switched to Efavirenz. Children < 3 years of age and < 10 kg can be maintained on a Nevirapine- based regimen LPV/r and other PIs have significant interactions with rifampicins and should not routinely be used together If a patient is on LPV/r, consider adding Ritonavir (RTV) in a ratio of 1:1 (LPV: RTV) to achieve the full therapeutic dose of RTV. A superboosted Kaletra can be an alternative in adults Due to difficulty of taking ATT & ART as well as the risk of developing drug resistance, patients should receive (Directly Observed Therapy) DOT during the course of their TB Treatment
ADVERSE EFFECTS overlapping toxicities exists between ATT and ART closely monitor co-infected patients on dual therapy (i.e. monthly ALT) Give pyridoxine (vitamin B 6) as a routine part of ATT in co-infected patients because of peripheral neuropathy due to d4t, INH, Patient on ATT as much as possible should not receive d4t as part of their ART regimen. Give Pyridoxine 25 mg daily for adults and Children > 3 years 12.5 mg daily for children < 3 years
OVERLAPPING SIDE EFFECTS/ADVERSE REACTIONS TO 1 ST LINE ANTI TB & ART DRUGS POSSIBLE CAUSES SIDE EFFECTS ANTI TB DRUGS ARV DRUGS SKIN RASH PZA, RIF, INH NVP, EFV, ABC NAUSEA, VOMIITING PZA, RIF, RBT, INH AZT, RTV HEPATITS PZA, RIF, RBT, INH NVP, PIs LEUKOPENIA, ANEAMIA RBT, RIF AZT
2. ISONIAZID PROPHYLAXIS THERAPY (IPT) IPT is beneficial in preventing morbidity and mortality from TB. Isoniazid prophylaxis should be administered to HIV positive adults. The prophylaxis should also be administered to eligible PLWHIV. It should be offered regardless of ART To avoid the risk of treating TB with a single agent, active TB must first be ruled out before administering IPT: TB exposed, HIV-infected children should be given isoniazid 10-20 mg/kg daily for 6 months Adults: 5 mg/kg/day (up to maximum of 300 mg daily) Children: 10-20 mg/kg/day (up to maximum of 300 mg daily)
IPT PROTOCOL Before offering INH prophylaxis, active TB must be ruled out clinically For children > 5 years, IPT should be administered if a child has been in contact with active Pulmonary Tuberculosis patients whether the child is HIV positive or negative All HIV positive adults patients and children >12months should receive IPT if they are well and active TB has been ruled out or a full course of TB treatment if active TB is suspected IPT prophylaxis for children < 15 years who are HIVinfected and TB-exposed
Isoniazid: 10-20 mg/kg daily for 6 months Pyridoxine (to prevent peripheral neuropathy): 12.5 mg daily for 6 months for children < 3 years 25 mg daily for 6 months for children 3 years and above All HIV-infected children exposed to TB through household contacts but with no evidence of active disease, should begin Isoniazid Preventive Therapy (IPT). Children >12 months of age should receive 6 months of IPT as part of a comprehensive package of HIV care irrespective of TB exposure ALT assay should be done as a baseline test for everyone
Infants <12 months HIV infected and TB exposed should receive IPT and followed clinically as part of a comprehensive package of HIV care. However, children in this age range who are not TB exposed should not receive IPT INH 300 mg is administered once daily in adults
The risk of hepatitis increases with increased age, alcoholism, prior liver disease, pregnancy and concurrent Rifampicin use (2%). Monitored for clinical evidence of hepatitis, other side effects; TB symptoms; and adherence to the prophylactic regimen. Monthly ALT assays should be done in patients with baseline liver disease and in cases where abnormal ALT levels develop during treatment Discontinue INH in case: ALT levels increase to >5 Upper Limit of Normal (ULN) The patient develops symptoms of Hepatitis The patient develops symptoms of TB
If symptoms of TB occur culture and Drug Susceptibility Test (DST) should be systematically performed
3.INFECTION CONTROL MEASURES Control measures include: (Screen, Educate, Separate, Triage, Investigate) Give priority to TB patients & TB suspects at OPD Health educate on cough hygiene (cover mouth & nose with tissue & dispose safely) Proper ventilation of waiting areas & consultation rooms ( Windows should remain opened) Do not sit directly opposite TB patients/tb suspects Do not face the direction of the wind Educate TB supporters Health workers should use N 95 Mask Educate on nutrition
DRUG-RESISTANT TB Drug-resistant forms of TB (such as MDR-TB and XDR-TB) are commoner among HIV infected people patient not clinically or bacteriologically responding to antituberculosis therapy after 2 months should have sputum sent for culture and drug susceptibility testing (DST) or rapid molecular assay using GeneXpert
NUTRITIONAL SUPPORT Both TB & HIV are wasting diseases and patients have been shown to have improved outcomes when nutritional support is provided. Health centres should pair with relevant partner organizations for provision of actual food supplements to patients
Kea Leboha