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Tuberculosis and HIV

Tuberculosis and HIV. HAIVN Harvard Medical School AIDS Initiative in Vietnam. Learning Objectives. By the end of this session, participants will be able to: Explain the significance of TB/HIV co-infection Describe the clinical presentation of TB in PLHIV Outline TB treatment regimens

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Tuberculosis and HIV

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  1. Tuberculosis and HIV HAIVN Harvard Medical School AIDS Initiative in Vietnam

  2. Learning Objectives By the end of this session, participants will be able to: • Explain the significance of TB/HIV co-infection • Describe the clinical presentation of TB in PLHIV • Outline TB treatment regimens • Explain drug-resistant TB • Describe common interactions between ARV and TB drugs

  3. TB Epidemiology (1) • Vietnam is ranked 12th in the world for incident TB • The incidence in the general population is 180/100,000

  4. TB Epidemiology (2) Global TB Control. WHO 2010 Vietnam Ước tính các ca Lao mới (tất cả các dạng) trên 100 000 dân Không ước tính Ướctínhtỉlệmớimắclao, theoquốcgia, 2009

  5. Global TB Control. WHO 2010 TB / HIV Epidemiology Vietnam Tỉ lệ hiện mắc HIV trong các ca Lao mới, tất cả lứa tuổi (%) Không ước tính

  6. TB/HIV Interaction (1) • TB is the most common OI in developing countries and the most common cause of death among HIV patients • TB infection: • speeds the progression of HIV by increasing viral replication • worsens immunological suppression in HIV patients • HIV increases mortality among patients with TB

  7. TB/HIV Interaction (2) • Most TB cases are caused by reactivation of latent TB infection • In Vietnam, an estimated 50-60% of the population has latent TB infection • HIV greatly increases the chance for latent TB infection to become active

  8. Clinical Presentationof PLHIV with TB

  9. The Effects of HIV on TB HIV worsens the signs and symptoms of TB, as shown in the chart Ref: Chest 1994;106:1471-6

  10. Clinical Presentation and CD4 (1)

  11. Clinical Presentation and CD4 (2) Signs and Symptoms of Pulmonary TB

  12. Typical Chest X Ray • Early stages of HIV (CD4 > 500): • Infiltrates predominantly in upper lobes • Pulmonary cavities present • Pleural effusions

  13. Atypical Chest X Ray • Advanced stages of HIV (CD4 < 200): • Pulmonary cavities absent • Infiltrates in middle and lower lobes • Nodular infiltrates • Effusions can be pleural and pericardial • Mediastinallymphadenopathy with no pulmonary infiltrates • Normal CXR in 10 %

  14. Extra-pulmonary TB (1) • Extra-pulmonary Tuberculosis (EPTB) occurs when bacteria spread outside of the lung and cause disease • Occurs more commonly in people with weak immune systems e.g. PLHIV • May occur with or without concomitant pulmonary TB

  15. Extra-pulmonary TB (2) • Occurs most often when a person’s CD4 < 100 • Most commonly manifests as: • Abdominal and lymph node TB (very often) • TB meningitis (5-10%), Tuberculoma • Pericarditis • Pleural effusion • Cutaneous • Renal

  16. Extra-pulmonary TB (3)

  17. Extra-pulmonary TB (4)

  18. TB HIV Co-infection Key Clinical Practice Points • “Typical” pulmonary TB less common • “Atypical”, smear negative and extra-pulmonary TB more common • WHO and Vietnam MOH guidelines allow TB treatment on clinical suspicion without positive smear test

  19. MOH and WHO Recommend: “THE ANTIBIOTIC TRIAL” • When indicated, use one course of broad spectrum antibiotics including coverage for typical and atypical causes of community acquired pneumonia • Under such circumstances, avoid Fluoroquinolones to prevent undue delay in diagnosis of TB

  20. Treatment Regimens for PLHIV with TB

  21. TB National Treatment Protocol (1) Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, 2009.

  22. TB National Treatment Protocol (2)

  23. TB Treatment: Special Situations • Some special situations require a more aggressive course of treatment, including: • Miliary TB • Pericarditis • Meningitis • Spondilitis with neurological complications • For pregnant women: avoid streptomycin - can cause permanent deafness in baby • Use ethambutol instead

  24. Drug Resistant TB (1) Drug resistant TB is TB for which anti-TB drugs have little or no effect against the TB causing agent

  25. Drug Resistant TB (2) Causes of drug resistant TB include: • Inadequate treatment regimens • Interrupted availability to drug treatment • Poor quality of drug treatment • Incomplete treatment adherence • Results from spontaneous mutations of MTB exposed to drugs Quy HT, Buu TN et al Int J Tuberc Lung Dis 2006;10(2):160-166.

  26. Multi Drug-Resistant (MDR) TB in Vietnam • Among reported cases in 2008, it is estimated that: • 2.7% of new TB cases had MDR-TB • 19% of re-treatment cases had MDR-TB • 3500 MDR-TB cases among reported pulmonary TB cases in 2009 Global TB Control. WHO 2010

  27. TB and ARV Drug Interactions (1) • Rifampicin decreases drug levels of some ARVs:

  28. TB and ARV Drug Interactions (2) Note overlapping toxicities of TB and ARV drugs

  29. TB Prevention WHO Guidelines

  30. TB Prevention • TB is the most common OI in Vietnam • In the HIV OPC, a significant percentage of patients will have TB or on TB treatment at any one time • The waiting area and exam rooms at the OPC are an environment at high risk for TB transmission

  31. Prevent Transmission of TB in HIV Care Settings (1) Step 1: Screen and test • Early recognition of patients with suspected or confirmed TB disease. • Symptoms that may indicate TB include: • Cough > 2 weeks, fever, weight loss, night sweats, lymphadenopathy • Screen all patients who have any symptoms: • CXR, sputum BK • lymph node aspirate (if indicated)

  32. Prevent Transmission of TB in HIV Care Settings (2) Step 2 : Education • Instruct patients to wear face masks if they have active TB or if they are coughing/sneezing • Standard Face Masks • Prevent TB transmission if worn by the TB patient • DO not prevent the wearer from acquiring TB • Special Face Masks: N95 or FFP2 • Protect the wearer • Only needed in high risk areas: • spirometry or bronchoscopy rooms, or • MDRTB treatment centers

  33. Prevent Transmission of TB in HIV Care Settings (3) Step 3: Separate • All patients who have active TB or are TB suspects should: • wear a mask • be separated from other patients • At OPC, there should be a separate waiting area: • This waiting area should be well-ventilated

  34. Prevent Transmission of TB in HIV Care Settings (4) Step 4: Provide services quickly • If possible, triage active TB patients to the front of the line and quickly provide care to reduce the amount of time that others are exposed to them.

  35. Prevent Transmission of TB in HIV Care Settings (5) Step 5: Environmental Control Ventilation • Natural ventilation relies on open doors and windows to bring in air from the outside • Fans may also assist to blow the air out of the room.

  36. Key Points • TB/HIV co-infection is common among PLHIV in Vietnam • HIV infection increases risk for active TB infection by over 100 fold • TB treatment regimens are the same for both HIV+/- patients • Clinical presentation of TB varies by CD4 count • Measures to prevention TB at OPCs are needed

  37. Key Points • TB/HIV co-infection is common among PLHIV in Vietnam • HIV infection increases risk for active TB infection by over 100 fold • Clinical presentation of TB varies by CD4 count • TB treatment regimens are the same for both HIV+/- patients

  38. Thank you! Questions?

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