TB AND HIV/AIDS THE SITUATION AT BMC

1. TB AND HIV/AIDSTHE SITUATION AT BMC Care & Treatment Unit CME, 5/5/20166 PRESENTERS: Dr. Desideris Bernard, Dr. Magawa

2. INTRODUCTION

3. TB/HIV Global situation • TB and HIV have been declared as global emergencies demanding global attention(NACP,2015) • Worldwide, 34.3 million people are living with HIV. • Of these, 24.5 million (71%) live in sub-Saharan Africa and approximately one third are co-infected with TB • Globally in 2014, there were an estimated 9.6 million incident cases of TB: 5.4 million among men, 3.2 million among women and 1.0 million among children. • Of those who suffer TBs-related mortality, 31% are HIV-infected • Some countries have documented up to 70% of TB patients are HIV positive.

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6. Tanzania and the burden of TB/HIV • In Tanzania, TB cases have increased six-fold from 11,843 in 1983 to 64,267 in 2009, mainly due to HIV/AIDS. • About 37% of TB patients in Tanzania are co-infected with HIV, accounting for 60-70% of the increase in the number of TB patients. • About 41.5% of new TB patients present with smear positive pulmonary tuberculosis (PTB+) and 36.2% with smear negative pulmonary tuberculosis (PTB-) and 22.3% presented with ETB in 2009

8. INTERACTION OF TB & HIV • HIV -↑number of TB cases and alters the clinical course of TB disease. • As HIV infection progresses → CD4+ T-lymphocytes decline in number and function. • Thus, the immune system becomes less able to prevent the growth and local spread of M. tuberculosis • The most common types of TB in HIV are disseminated and extra pulmonary TB

9. TB/HIV IN THE MEDICAL WARDS • In the US, HIV clients accounts for 22% of re-admission (59% higher than non-HIV cases) but TB/HIV is <1% in the medical wards. • TB/HIV co-infection lead to prolonged hospital stay and significantly affect the economic status of clients (especially MDR TB –av. 6826 USD per person globaly). • A study at MNH medical wards, TB/HIV was reported the major cause of morbidity (27.9%) and mortality (39.6%) [Desderius BM, Munseri P, Pallangyo KJ 2015]

10. EFFORTS TO REDUCE BURDEN OF TB • ART initiation -Once the diagnosis of TB is made in PLHIV, Start TB Rx within 2 weeks(WHO, 2014) • Three I’s • Intensive case finding • Infection control • IPT

11. Three I’s • Intensive case finding – Based on TB screening tool • To increase the yield of confirmed cases from TB suspects/presumptive TB cases • Infection control – Each POC should take precautions to protect HCWs from acquiring TB and establish IC plans at each POC.

12. IPT

14. IPT PROVISION AT BMC • IPT Started July 2011 • Total clients given IPT - 3,428 • (Clients on care – 14,732, Not on ART -5,355)

15. TB/HIV Co-treatment challenges • Concurrent treatment of tuberculosis and HIV is complicated by:- • the adherence challenges of polypharmacy • overlapping side effect profiles of anti-TB and antiretroviral drugs, • immune reconstitution inflammatory syndrome (IRIS), and • drug-drug interactions

16. HIV/TB SITUATION AT BMC

17. At BMC,We are focused and working hard to fight TB through several activities: • EDUCATION • Clients:health talk,posters,??Audiovisual • TBtrasmission:Airborne,m.tuberculos • Risk factors:Time,burden,sunlight,ventilation • Staff:TBIC

18. SCREENING OF ACTIVE TB • TB screen tool:(a) cough of any duration (b) fever of any duration (c) excessive night sweats (d) loss of weight >3kg/1mo • Sites:CTC Clinic,VCT,PMTCT,OPDs,Wards,EMD • Cough registers

19. ISONIAZID PREVENTIVE THERAPY(IPT) • Tab 300mg OD of INH for 6months. • Repeat after every 2years • Eligibility: (a) no current/past h/o hepatitis (b)no h/o of TB Treatment in the past 2 years (c) no non-adherence to long term treatment

20. (d) no alcohol abuse (e)any medical contraindication to INH (f) no symptoms of peripheral neuropathy • TB INFECTION CONTROL (A)Admistrative measures: TBIC plan: • well-ventilated waiting area,consultation room • Ensure turn around time of sputum smear,G- Expert in 24hours • orientation of all staff on TBIC measures

21. (B)Environmental measures • Open windows and doors • Fans • Collect sputum outside and away from other people • Isolation of TB suspects • Isolation of TB patients in the ward

22. (C)Pesornal Protection • Provide handkerchiefs/tissues for all coughing patients • Use of mask N95 • Reduce time of staying with TB presumptive or active TB Cases

23. DIAGNOSIS • Smear Microscopy • GeneXpert • Solid Culture

25. Test statistics (2015): Tb laboratory register • Total smears: 2100 • Smear positivity 6.1% • Follow up positivity 1% • Low grade AFB: 1%

26. Test statistics(2015): Tb Culture register

27. Test statistics(2015): GeneXpert

28. Results feedback and reports • Results of AFB Smears and GeneXpert released to requesting clinician within 24 hours. • Critical results have been identified and are immediately communicated to clinician. • If RR in addition to clinician RTLC is informed • Customer satisfaction survey of January 2016 does not show negative statements or complaints for AFB smears or GeneXpert

29. TREATMENT • For new TB/HIV Patients, start ART within two weeks of antTBRX • All TB Patient should start ART regardless of CD4 count • Initiate co-trimoxazole prophylaxis to all PTB patients regardless of CD4 count • Drug-drug interaction:Nevirapine and atazanavir

30. Regimes • New adult 2RHZE/4RH • All retreatment and defaulters 2RHZE/1RHZE/5RHZE • Rifampicin resistant MDRTB RX

31. DOT -Treatment supporter -DOT Nurse or HCW

32. Trends of TB at BMC, 2014-2016 TB AMONG NON-HIV

33. BMC Trends of TB/HIV co-Infection

34. Trends of Types of TB/HIV co-infection 2015

35. Annual Trends for types TB in HIV 2015/2016

36. WAY FOWARD

37. THE FUTURE OF BMC ON TB Dx & Rx • Capacity building for TB culture • Microscopy -AFB • Gene expert/RIF • ?Line probe assay • ?DST • ?LAM test • ?ADA test • Establishment of MDR centre - MOH has appointed BMC as one of MDRTB Initiation site (once negative pressure is established)

38. WABEJA!