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Case management of TBCase management of TBWith HIV/AIDS co-infectionWith HIV/AIDS co-infection
Chris Nelson, Public Health Nurse
DisclosuresDisclosuresnone
Global TB/HIVGlobal TB/HIV2011---13% TB cases are co-
infected
Estimated 400,000 people
Leading cause of death among people with HIV
32
Global Leading Causes of Death, 2008Global Leading Causes of Death, 2008
SOURCE: http://who.int/mediacentre/factsheets/fs310/en/
47
TB Case Rates in U.S.-born vs. Foreign-born Persons United States, 1993–2011*
National Tuberculosis Surveillance System, data updated as of June 25, 2012.
Cases per 100,000
HP 2020 GH-2 Target: 14.0
17.2
10
5
0
15
25
20
30
1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
39
HIV Co-infection Among TB Patients: U.S., 1993-2011
SOURCE: National Tuberculosis Surveillance System Highlights from 2011, CDC/NCHHSTP.
All ages
25-44 yearsPercent
General ConsiderationsGeneral Considerations
About 10% of all TB cases in US are HIV-infected.
Many are unaware of their HIV status and do not acknowledge their risk factors
Clinical presentation of TB in the HIV-infected may differ from other immunocompetent clients—especially if CD4 counts <200
CXR may be normal (usual cornerstone to diagnosis)
Extra pulmonary TB is more frequent (so signs and symptoms vary per site of infection)
With extra pulmonary TB-must r/o pulmonary TB
Wisconsin NumbersWisconsin Numbers
2012 – 71 TB disease cases with 4 being co-infected
2013 – 50 TB cases with 2 co-infectedLTBI – # unknown as we do not record this
data 2012—new HIV recorded-241 plus 157 more
that moved into WICurrent cumulative +HIV known cases in WI:
◦ At the end of 2012-- 6,547 individuals presumed to be alive and living.
◦ 76% of this +HIV 2012 number were diagnosed in WI◦ 18% of +HIV are unaware of their diagnosis-per CDC
Issues to Consider Issues to Consider Current IGRA tests are not currently licensed to be used with
immune compromised such as HIV/AIDS. TST may not be accurate if:
◦ low CD-4 count,◦ concurrent bacterial, fungal or viral infection ◦ TB disease is present
Do 2-step if never tested.◦ If 0mm TST repeat if CD4 is 200 or over.
Clients with HIV have a 7-10% risk of progressing from LTBI to TB disease per year. (Contrast to 10% for others over a life time)
For HIV+, TB disease must be ruled out prior to LTBI treatment
Meds used to treat TB and HIV have many potential drug interactions and over lapping toxicities-this complicates treatment.
Possibilities:◦ treatment failure for either TB disease or HIV or both◦ Possible: paradoxical reactions during treatment for both
Other overlapping risks may exist:◦ Hep B/C, chronic liver disease, ETOH use, pregnancy, age and other offending OTC
agents (Tylenol)
Potential Daily Living IssuesPotential Daily Living Issues
Mental, Emotional, and Cognitive statusAccess to transportationUsual places of residence, where and how to
locate the client, impending plans to relocate, travel, housing needs and living situation
Cultural and religious beliefs that may impact adherence
Language and literacy barriersSubstance abuseAbility to pay for medical careWork history/income sourceSupport systemsFamily dynamics
TreatmentTreatment
LTBI tx should be daily and all options may be used if not on ART
Length of TB disease tx is similar for those that are HIV+ and those who are not +HIV (6-9 months)
+HIV with drug-susceptible TB respond well to standard treatment
TB disease tx should be daily-not intermittent (some studies from NY confirm rifamycin containing regimens given intermittently caused resistance)
TB disease--potential for immune reconstitution inflammatory syndrome (IRIS) if both TB medications and ART are started at the same time.
Medical experts should guide treatment (esp. drug-drug interaction and clinical response to therapy is slow)
Treatment OptionsTreatment Options For clients that have not started ART- at the time of TB
diagnosis, many MD’s defer the initiation of ART until the intensive 1st phase (first 2-months) of TB treatment is completed. MD’s can manage the med side effects from TB drugs without the complications of ART. This also minimizes the likelihood of immune reconstitution syndrome(IRIS)
Pill burden is also more tolerable
If TB is diagnosed after client is on ART, their ART regimen may need to be changed to be compatible with TB treatment.
Anti-TB regimens may be modified to not contain any rifamycins.
Pregnant women are challenging-as ART regimens are difficult when rifabutin is not an available option
Monitoring Therapy Monitoring Therapy Common baseline blood tests: LFT’s, CBC with
differential, CD4 counts Client should be seen by MD monthly-at minimum Sputum for smear/culture monthly until #2 consecutive
neg cultures If initially smear +, test more frequently (q 2 weeks to
assess Tx response Repeat CXR after 2 months of Tx End of Tx CXR Repeat drug susceptibility testing if culture + after 3
months of Tx Daily DOT Always assess for OTC meds, diet issues, weight loss, GI
upset, alcohol and other substance use. Report: vomiting-as this may require addition of meds to
control and be given before meds are taken. Assess for peripheral neuropathy- If on EMB-baseline eye exam (acuity/color)-monthly
while on this med
Therapeutic Drug MonitoringTherapeutic Drug Monitoring
Need to be considered in clients who are slow to respond to Tx or have complex Drug-drug interactions.
Consider this when on cycloserine
Symptom ConcernsSymptom Concerns
Risk of adverse reactions to TB tx is higher in HIV+ occurring about 25% and 13% respectively
Hepatotoxicity is common in tx of TB for HIV+ esp. if on ART, antibiotics, or co-infected with HepB/C
Symptoms can be subtle and mimic drug effects, indigestion or another infectious process (decreased energy or appetite, fatigue, indigestion, abdominal discomfort, nausea, vomiting, myalgia and rash
Evaluating a Rash Early: it can be maculopapular. If this rash does not
resolve in 24 hours or have a likely cause-refer to provider. LFT’s may be needed.
Some of the antiretrovirals (abacavir) can cause this and it maybe life threatening.
Rashes warrant a thorough and prompt evaluation by the medical provider.
Drug and Food InteractionsDrug and Food Interactions Multiply significant Drug-Drug interactions especially
with TB/ART meds.
Also INH-may increase hepatotoxicity, may cause problems
with many seizure and psych meds Rifampin-decrease many other medication effects Food/Drug interactions:
◦ Some TB meds need to be taken 1-2 hr before a meal (INH, Rif,)
◦ Some meds may to be taken with food (ethambutal, PZA, ethioamide, amikacin, capriomycin, para-aminosalicylic(PAS), linezolid)
◦ Some meds may require increased fluid intake (amikacin, streptomycin, capreomycin, PAS )
Need to avoid alcohol Client may need vitamin supplements with some meds Diet becomes very important-need for weight checks on
regular basis
Indicators Needing AttentionIndicators Needing AttentionDOT failureSlow sputum conversion or delayed
clinical improvementMarginal or no acceptance of TB
diagnosisClinical deterioration while on TB therapyFailure to attend medical appointmentsPregnancySubstance abuseMalabsorption of TB medicationsComplaints that TB medications taste
bad or make the client sick.
Final wordsFinal wordsCase management requires good
communication with all providers of care
Client education to ensure compliance
Support of other systems if problems arise during tx
Problems will arise