Beruflich Dokumente
Kultur Dokumente
Learning Objectives
Describe the epidemiology of TB-HIV coinfection
Characterize the impact of HIV on TB infection
Recognize the effect of TB on the progression of
HIV infection
List the recommended treatment of TB
List the challenges of combining TB treatment
with ART
Recognize the use of INH preventive therapy
3
5
Courtesy of Samuel Anderson, MD
Global Epidemiology
HIV has contributed to a substantial increase in the
incidence of TB worldwide
15 million people are co-infected with TB and HIV
90% of these infected people live in developing nations
8% of global tuberculosis is attributable to HIV infection
TB is the most common opportunistic infection in
Ethiopia
Ethiopia has the sixth-highest number of TB cases in the
world
Sources: WHO, UCSF Report HIV/AIDS in Ethiopia April
2003 CDC MMWR 2003:52:217
7
< 1 000
1 000 to 9 999
10 000 to 99 999
100 000 to 999 999
1 000 000 or more
No Estimate
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World
Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
WHO 2002
80
70
60
50
40
30
20
10
0
Blantyre, MAL Lusaka, ZAM Hlabisa, SAFR Kampala, UGA Abidjan, CIV
Estimated
ofTB
TB
EstimatedNew
NewAdult
Adult Cases
Cases of
300
Thousands
250
200
150
100
50
0
1984
1989
1994
1999
2004
2009
2014
Due to HIV
11
11
HIV/TB Co-Infection
13
Impact of HIV on TB
Increases rate of TB re-activation and
progression
Increases TB morbidity
Increases TB mortality (5-14 fold)
Alters clinical manifestations of TB
Creates diagnostic challenges
Complicates treatment
14
15
16
University of Alabama at Birmingham, Department of Pathology
Impact of TB on HIV
TB infection activates T-cells, indirectly supporting HIV
replication
Active TB is associated with
Increased HIV-1 viral load
Rate of progression to AIDS
Mortality
17
TB
T-cell
(inactive)
T-cell
(active)
HIV Viral
Replication
18
Clinical Manifestations
Clinical presentation of TB in HIV patients is
variable, depending on CD4
Extra-pulmonary disease is more likely as CD4
count declines
Reported in up to 70% when CD4 <200
Atypical clinical and radiographic manifestations
19
Lymphatic System
Pleura
Pericardium
CNS
GI
Kidney
Bone
20
21
ITECH, 2005
22
23
Diagnostic Methods
Microscopic examination of sputum smears
Specific, readily available, and most important test
3 specimens collected in 2 consecutive days (spot, early
morning, and spot)
Positive if 3 AFB are seen 100-oil immersion field
Histo-pathological examination
Specific, but not routinely available in Ethiopia
Culture
Specific, but not routinely available in Ethiopia
24
Diagnosis
Sensitivity of sputum smear for AFB is reduced
in HIV-related TB
A negative smear does not exclude diagnosis of
TB
25
AFB Stain
26
Courtesy of the Public Health Image Library/CDC/Dr. George P. Kubica
27
Standardized Treatment of TB
Duration
Intensive
phase (8
weeks)
Drugs
20-29
kg
ERHZ
1
(275/150/ tablets
75/400)
30-37
kg
38-54
kg
>55 kg
1
tablets
2 tablets 3 tablets
28
INH
Neuropathy Hepatotoxicity
GI intolerance
PZA
Hepatotoxicity
Joint pains
GI intolerance
Ethambutol
30
Immune Reconstitution
Inflammatory Syndrome
Development of clinical manifestations of a
previously sub-clinical opportunistic infection
and/or paradoxical worsening of active infection
despite appropriate treatment
Occurs usually within 3 months of starting ART
Reflects a restored, protective, pathogenspecific immune response
Not ART treatment failure
31
TB-related IRIS
Symptoms and signs
High fevers
Lymphadenopathy
Worsening cough
Worsening of chest radiographic findings
Management
TB treatment
Corticosteroids may be indicated for severe CNS and
pericardial disease, hypoxemia, and airway
obstruction
32
Cotrimoxazole Preventive
Therapy (CPT)
Background
Reduced morbidity and mortality in TB-HIV coinfected patients
Dose
One double strength tablet daily (or 2 single strength)
33
Dose
INH 300 mg/day (150mg/day if wt <30kg) x 6 months
Addition: Pyridoxine 25mg qd
34
35
Viral pericarditis
Toxoplasma myopericarditis
IRIS with underlying TB pericarditis
ZDV related myocarditis
36
37-58%
EFV
13-26%
NLF
82%
LPV/r
75%
38
39
41
42
43
44
45
46
Coordinating Treatment
Potential advantages of delaying ART:
Reduced pill burden and better drug adherence
Less chance of drug interactions and toxicity
Reduced chance of IRIS
47
49
50
Special Situations
Patient becomes pregnant while on ART and TB
therapy
Problem:
EFV contraindicated (possible exception: 3rd trimester)
NVP levels are substantially reduced in presence of
Rifampicin
Management:
Continue NVP-containing regimen with careful
monitoring for clinical treatment failure or
Stop entire regimen during initial (Rifampicincontaining) TB treatment phase and
Refer for PMTCT
51
Management options:
Continue NVP with careful monitoring for clinical failure
Stop entire ART regimen until initial phase (Rifampincontaining) TB therapy is complete
Consider switching to triple NNRTI regimen or SGV/r
based regimen
52
53
54
55
Courtesy of Samuel Anderson, MD
56
57
58
Courtesy of Samuel Anderson, MD
Anti-TB therapy
Ciprofloxacin x7 days
FNA cervical adenopathy, if present
Stool studies
Abdominal ultrasound
59
60
61
62
63
64
65
66
67
Key Points
Tuberculosis is a major cause of morbidity and
mortality in HIV-infected people
All HIV-infected patients should be carefully
evaluated for TB
All TB-infected patients should be offered VCT
HIV impacts the presentation of TB and makes
the diagnosis of TB difficult
Active TB increases the rate of HIV disease
progression
68
69