Introduction to

HIV TB INTER ACTION

AND CO-INFECTION
CURRENT PROBLEM AND FUTURE CHALLENGE
Sunardi Radiono
Dept. Dermatology and Venereology
Lecture Out Line
Global Epidemiologic Facts on TB and
HIV
HIV-TB interaction, A deadly Synergism
Clinical implication
Diagnostic PROBLEMS
Drug interactions
Impact on Treatment program and

evaluation
Global Facts on TB and HIV EPIDEMI

TB (PULMONARY AND EXTRA PULMONARY) AN

AIRBORNE CONTAGIOUS DIESEASE CAUSED BY
SEVERAL SPECIES OF GRAM POSITIVE BACTERIA
KNOWN AS TUBERCLE BACILLI (Mycobacterium
tuberculosis Complex = MTBC)
TB AS A PERMANENT PUBLIC HEALTH PROBLEMS IN
DEVELOPING COUNTRY (INCLUDING INDONESIA)

STEADY DECLINING THE PREVALENCE IN THE DEVELOPED

COUNTRY IN THE MIDDLE OF THE LAST CENTURY

IN RELATION TO INCREASING HIV PREVALENCE ON THE

LAST DECADE OF 20THTH CENTURY, NEW OUT BREAK OF TB

WORLD WIDE

Together with P carionii pneumonia, cerebral

toxoplasmosis and extra pulmonary systemic mycoses, tb
classified as true AID ill defining diseases in HIV infected
individual.
LONG TERM NEGLECTED TB RESEARCH AND
PRODUCT DEVELOPMENT:

TB DIAGNOSTIC TOOLS ALREADY A

CENTURY METHODS

TB DRUGS AVAILABLE : > 80 YRS MEDICINE

THAT KNOWN SOME IN EFFECTIVE,
BACTERIAL RESISTENCY, INEFFECTIVE
VACCINE, AND ONLY FEW DRUGS WERE
ONLY DECADE OLD (RIFAMPICYN,
STREPTOMYCINE, ETHAMBUTOL ETC)
Global problem of TB
From: The Growing Burden of Tuberculosis: Global Trends and Interactions With the HIV Epidemic

Arch Intern Med. 2003;163(9):1009-1021. doi:10.1001/archinte.163.9.1009

Figure Legend:
Estimated numbers of tuberculosis cases by country in 2000.

Copyright 2012 American Medical

Date of download: 12/1/2013
Association. All rights reserved.
From: The Growing Burden of Tuberculosis: Global Trends and Interactions With the HIV Epidemic

Arch Intern Med. 2003;163(9):1009-1021. doi:10.1001/archinte.163.9.1009

Figure Legend:
Estimated numbers of human immunodeficiency virusinfected tuberculosis cases per 100000 population (all ages) by country in
2000.

Copyright 2012 American Medical

Date of download: 12/1/2013
Association. All rights reserved.
TB IN CHILDHOOD
IMPACT OF HIV ON CHILDHOOD TB

10 time risk for TB in children born from HIV+ mother

HIV co infection 5% (in industrial countryies) to 50% (in developing
countries)
Present of multiple pathogens in HIV-TB coinfection
MYCOBACTERIUM COMPLEXES
INFECTION IN INDONESIA

M.Tuberculosis 22%, M.bovis 3%, M.africanum 3%, M.unknown 11% and

atypical mycobacteria 61% which species is: M.kansasii11%, M.szulgai
9%, M.simiae 4%, M.haemophylum 3%, M.marinum 4% M.gordonae 2%,
M.chelonae 1%, M.aviumintracellulare 1% and other 1%.
Burden of HIV infection
No country is really free of HIV infection or
AIDS

HOW BIG IS THE PROBLEMS (Burden of

disease and burden of health problems)
at moment?
How the virus spread from one to other?
Could we protect the spreading ?
How effective are our treatment ?
How the disease epidemyimpact the
people / nation?
 Better to know about

Indonesia Reported HIV+ cases by gender up to march 2010

HIV+ AIDS/IDU
Male 15.168 7480
Female 5.306 611
Un known
Total 20.564 8.091

The problems are in here ! Not just out there

We are religious nation, we could stop the enemy

by our belief,
We need acts to fight HIV-AIDS, God surely will help
s
Mode of transmission (HIV)

Hetero sexual 10.335

Homo-bisexual 679
IDU 8.091
Blood transfusion 20
Perinatal 534
Un-known 905
SIMPLE CONCEPT OF HIV DISEASE
PROGRESSION

IF THE PATTERN OF INFECTIONS GROWTH ALMOST ALWAYS IN

THAT WAY , AN EFFORT SHOULD BE DONE BY EVERY ONE IN
THIS COUNTRY
IF THE DISEASE IMPACT ARE LIKE THE FEATURE BELOW:

WHAT YOU SUPPOSE TO DO ?

MCTB strain distribution world wide
GLOBAL PHYLOGENY OF MCTB
HIV-TB interaction, A deadly
Synergism
HIV INFECTION TB
INFECTION
INDUCE IMMUNOCOMPROMIZE INCREASE DEATH RISK OF
CONDITION HIV INFECTED PERSONS BY
COMPLEX CLINICAL FORMS
INCREASE RISK OF TB
INFECTION REDUCE HIV TREATMENT
SUCCESS?
IMPLICATE CLINICAL FORMS
OF TB AND DIGNOSTIC INCREASE RISK OF anti
PROBLEM TB- ARV DRUCS
INTERACTIONS AND
INCREASE BACTERIAL ADVERSE EFFECTS
RESISTANCE

REDUCE TB TREATMENT
SUCCESS
HIV- TB CO INFECTION IN INDONESIA
(STUDY IN WEST PAPUA)
IMPACT OF CD4 COUNT (IMMUNE STATUS)
ON BACTERIOLOGICAL AND HISTOLOGICAL
STUDY OF HIV-ASSOCIATED TB
TREATMENT OUT COME ON HIV-TB CO-INFECTIONS
IMPACT ON VIROLOGIC SUCCESS OF HAART
TREATED HIV PATIENTS WITH AND
WITHOUT TB CO-INFECTION
ANTI TB ANTI - HIV DRUGS
INTERACTION
1. Drugs intolerance :

The most frequent drug intolerance is observed with rifampicin

(10%), followed by isoniazid (36%) and, more rarely,
ethambutol and pyrazinamide

Drug intolerance may present as:

a febrile skin rash

digestive disorders

liver toxicity, especially in patients coinfected chronically with

hepatitis B or C, or isolated fever
Some secondary effects can be increased by HAART, such as:

peripheral polyneuropathysecondary to isoniazid in

combination with didanosine (ddI), zalcitabine (ddC) or stavudine
(d4T)

Hepatotoxicity related to isoniazid and or pyrazinamide

in combination with nevirapine, efavirenz or PIs
2. Interaction in drugs co-
administration
Practical approach on anti TB and ARV
therapy
PARADOXICAL REACTION DURING HAART
AND ANTI TB THERAPY

A paradoxical worsening of signs and symptoms of TB may occur

when HIV-infected patients are treated effectively for their TB and
have commenced HAART

Paradoxs reaction :

hectic fever
the occurrence or enlargement of lymphadenopathies
worsening of chest infiltrates
increase of pre-existing TB lesions (cutaneous and
peritoneal)
Paradoxs reaction :
36 % of anti TB and ARV combination
7% anti TB alone
 INTERVENTION TO REDUCE TB
MORBIDITY
AND MORTALITY ASSOCIATED WITH HIV
REDUCING RISK OF HIV INFECTION
CONDOM USE AND STID CONTROL
AVAILABLE VCT (VOLUNTARY COUNSELING AND TESTING)
SAVE NEEDLE FOR INJECTING DRUGS
REDUCING TB TRANSMISSION EVENTS
CONTROL OF NOSSOCOMIAL AND COMMUNITY TB
TRANSMISSION
REDUCING RISK OF TB AMONG HIV INFECTED PERSONS
TREATMENT OF LATENT TB INFECTION
TREATMENT OF IMMUNOSUPPRESSION WITH ARV
REDUCING THE CASE FATALITY RATE OF HIV PATIENTS WITH
TB
PROMPT DIAGNOSIS
USE RIFAMPICIN-CONTAINING SHORT-COURSE REGIMEN
CONCURRENT ADMINISTRATION OF PROPHYLACTIC
COTRIMOXAZOLE
TREATMENT OF IMMUNOSUPPRESION WITH ARV
FUTURE CHALLENGE IN HIV-TB
CONTROL
IMPACT OF HIV-TB CO-INFECTION ON COST OF
PROGRAM
SCALE UP HIV-TB PROBLEMS
 WE MAY LEARN FROM OTHER S IN
MANAGEMENT OF HIV-TB CO- INFECTIONS
 FIELD PROBLEMS:
BARRIER IN HIV TESTING FOR TB PATIENTS

Patients' and providers' knowledge regarding HIV

was poor.
The main barriers perceived by patients were:
burden for accessing VCT and fear of knowing the
test results.

Stigma caused concerns among providers, but did

not play much role in patients' attitude towards
VCT.

The main barriers perceived by providers were

communication, patients feeling offended,
stigmatization and additional burden.
(Mahendradataet al., 2008)
Could TB patients ready for HIV VCT?

22 not interested ,24 no negative

feeling
9Frankly,
clearly feltI was
that time offended
offended. From the beginning, it was
already explained that HIV is transmitted by this and that, not
all drug users get it, also not all 'others [risk groups] get it. And
then all the sudden they
offered me HIV test? 23-year-old, male, university student,
attended VCT

Well what can I say? That HIV is not scary. It's just another
disease. It can be cured. 29-year-old, female, employee, not
interested in VCT
Misconceptions regarding transmission of HIV/AIDS were
common:
You can get infected through having a [sexual] relationship or
through drugs or through smoking cigarettes, that's all I know. I
heard it before from stories, you know, on TV. 26-year-old,
male, unemployed,
attended VCT

A few patients (7) accepted that they could be at risk and were
interested in VCT:
I've never done anything wrong [risky], or had a [sexual] relationship
with someone with HIV. I've never received blood transfusion, never. I
don't believe I can get HIV but, there's a possibility I get it because of
TB,
they say that can make you get infected easily. 45-yearold, male,
construction worker, attended VCTNo, I was already told [by the health
worker] that from ...from the lungs it can lead to HIV.

So I already knew beforehand. 24-year-old, female, self-employed,

attended VCT