Seminar:

Tuberculosis with HIV Infection

Andria Amanda P - 1106127784
Bondan Winarno - 1106064700
Ditha AR Pratiwi - 1106127595
Karin Nadia U - 1106127765
Kenneth Johan - 1106064631
Putri Luthfiyah - 1106008864
 Tuberculosis
• Infection transmitted via airborne; caused by
Mycobacterium tuberculosis
• TB infection can develop gradually in both
immunocompetent and immunocompromised patient
• Worldwide, TB is known to be one of the leading
mortality rates in people living with HIV
• Included as a true AIDS-defining illness in HIV patients
– Besides Pneumocyctis carinii pneumonia, cerebral
toxoplasmosis or extrapulmonary systemic mycoses
• The presence of TB in patients with HIV usually occurs
in early stage of HIV infection  TB may influence the
prognosis of HIV infection
 Epidemiology
• 1997: at least 10.7 million people who were infected by both HIV
and TB in the world
• 1992, WHO: approximately 4 milllion people were infected by both
TB and HIV worldwide and 95% of them were lived in developing
countries
• 2014, WHO: 1.2 million out of 9.6 million new cases of TB are
people living with HIV
• Men more prone to get TB infection during HIV infection
• People who lived in sub-Saharan countries and southern Asia, in
which malnutrition is one of the factors
• People living with HIV have a greater risk to develop TB infection up
to 30 times greater as compared to those who live without HIV
infection
• Pedoman Teknis Tatalaksana Ko-infeksi HIV pada TB: 60% of people
living with HIV that will be infected as well to TB infection
 Coordination of TB-HIV
• Indonesia  high rate of TB infection
• The spreading coinfection of TB-HIV is a new challenge in Indonesia
– Low integrated service or facility of TB-HIV
– Coordination of TB-HIV generally should be strengthen
• According to Strategi Nasional Pengendalian TB guideline, there are
several things that are still needed to be evaluated:
– Many hospitals have not been involved in the national TB control
program
– TB screening has not been fully managed
– Isoniazid preventive therapy has not been included in national
collaboration of TB-HIV authorization
– TB-HIV program in prison is still limited
– Low understading in the community and also the access to TB-HIV
materials
 Coordination of TB-HIV
• Integrated TB-HIV service is focused on high
risk community in health care facility,
including in prisons, which aims:
– To improve treatment compliance and patient
visits
– To activate TB screening for people living with HIV
– To expand HIV testing for suspected TB infection
– To provide antiretroviral therapy (ART) for patients
with co-infection of TB-HIV
Pathophysiology of TB in Patients with
HIV
• Infection by M. Tuberculosis
– Penetrates respiratory tract  initiation of
inflammatory response
– Increased number of macrophages and dendritic cells
on infected lung tissue
– Activation of CD4+  production of IFN-γ
– Activation of macrophages  inhibits the growth of
intracellular bacteria
• Tuberculosis: when immune system is weakened,
and becomes insufficient to limit the growth of
bacteria
Pathophysiology of TB in Patients with
HIV

• Patients with HIV infection:

– Reduction in number of CD4+  decreased IFN-γ
production

– Increased risk of reactivation and reinfection of M.
tuberculosis
 Clinical Manifestation of TB
Respiratory Systemic
• Cough lasting more than 3 • Fever
weeks • Malaise
• Coughing blood • Sweating at night
• Shortness of breath • Anorexia
• Chest pain • Weight loss
Risk Factors of TB
Screening for TB among people living
with HIV
• Patients who answer at least 1 symptom
should undergo a diagnostic evaluation
– Smear microscopy and liquid culture of at least 2
sputum specimens
– Liquid culture of a lymph node aspirate is there is
enlarged lymph nodes
 Radiological
Findings

Gooze L, Daley CL.

Tuberculosis. Dikutip pada
27 November 2014.
Diunduh dari:
http://www.hiv.va.gov/pro
 HIV Testing on TB Patients
• Rapid test or lab assay -> finger prick or oral
specimen

Aaron L, Saadoun D, Calatroni I, Launay O,

Memain N, Vincent V. Tuberculosis in HIV-
infected patients: a comprehensive
review. Clin Micribiol Infect.
2004;(10):388–98.
 TB-HIV Treatment Principle
• same principle as in other TB patients.
• TB patients with HIV  increased number of
mortality and morbidity  given ARV and OAT.
• ARV treatment should be initiated immediately
within the first 2-8 weeks after the start of TB
treatment and well tolerated.
• If the patient is in the treatment of ARV , TB
treatment should be referred to hospitals for ARV
treatment referral.
• If found to be HIV-positive at TB patients, refer
the patient to the unit with HIV or ARV referral
hospitals to prepare for the commencement
of HIV treatment.
• ARV treatment should be given in the service
PDP, which is capable for delivering the
treatment of HIV-related complications ARV
referral hospitals or satellites.
 ARV drugs dosage
Golongan Obat
Nukleosida RTI (NsRTI)
· Abakavir (ABC)
· Didanosin (ddl)
· Lamivudin (3TC)
· Stavudin (d4T)
· Zidovudin (ZDV)
Nukleotida RTI
· TDF
Non nukleosid RTI (NNRTI)
· Efavirenz (EFV)
· Nevirapine (NVP)
Protease inhibitor (PI)
· Indinavir/ritonavir (IDV/r)
· Lopinavir/ritonavir (LPV/r)
· Nelfinavir (NFV)
· Saquinavir/ritonavir (SQV/r)
· Ritonavir (RTV/r)
Dosis
300 mg 2x/hari atau 400 mg 1x/hari
250 mg 1x/hari (BB<60 Kg)
150 mg 2x/hari atau 300 mg 1x/hari
40 mg 2x/hari (30 mg 2x/hari bila BB<60 Kg)
300 mg 2x/hari
300 mg 1x/hari
600 mg 1x/hari
200 mg 1x/hari untuk 14 hari kemudian 200 mg 2x/hari
800 mg/100 mg 2x/hari
400 mg/100 mg 2x/hari
1250 mg 2x/hari
1000mg/ 100 mg 2x/hari atau 1600 mg/200 mg 1x/hari
Kapsul 100 mg, larutan oral 400 mg/5 ml.
ARV treatment to HIV-TB
 The provision of isoniazid (INH) as a
prophylaxis.
• INH preventive treatment aimed at preventing
active tuberculosis in people living with HIV
(PLHIV) .
• If PLHIV is not proven TB and no
contraindications, then INH given at a dose of
300 mg / day and B6 at a dose of 25 mg / day
dose of 180 or 7 months.
 The provision of co-trimoxazole as
prophylaxis.
• PLHIV decreased immune system  that
patients are more susceptible to any infection.
• co-trimoxazole usually given to PLHIV as a
prophylaxis of infectious pneumonia,
Pneumocystis pneumonia, toxoplasmosis,
isospora belli, salmonella, and others.
 Drug interactions
• Giving rifampicin will reduce levels of NNRTIs and
protease inhibitors because it induces the P450
enzymes work on the day.
• Efavirenz is a NNRTI’s drug of choice for the
treatment of HIV-TB because it interaction with
TB drugs is minimal. EFV standard dose is 600mg
/ day.
• NVP (nevapirenz) can also be given, and levels
also decreased if given together with rifampicin.
 TB-HIV drug side effects
• Unique to each individual
• Can be mild or severe
• Target symptomatic relief
Management of side effects to patient
in TB-HIV therapy
• Anorexia, nausea, and stomachache – treat symptomatic
complaint, consume drug after meal, and suggests frequent
small portion food with soft consistency.
• Joint pain – give analgesics such as aspirin or paracetamol
• Pins and needle feeling on foot – give B6 vitamin 100mg
per day, otherwise consult to specialized hospital.
• Orange urine – explain to patient.
• Tiredness – tiredness usually occurred for 4 to 6 weeks
after ZDV started. If not resolved after 6 weeks, consider to
refer.
• Changes in fat distribution – educate the patient that this
cannot be avoided.
• Pruritus – might be allergic reaction or Steven
Johnson Syndrome, consider to refer.
• Hearing problem – stop streptomycin.
• Anemia – check hemoglobin level, in pregnant
women, swap ZDV with d4T.
• Headache – give analgesics such as aspirin or
paracetamol.
• Diarrhea- give oralit or substitutional fluids,
encourage patient that the diarrhea will
resolve. If not resolved within two weeks, then
refer
 References
• Aaron L, Saadoun D, Calatroni I, Launay O, Memain N, et al. Tuberculosis in HIV-infected patients: a comprehensive
review. Clin Microbiol Infect. 2004; 10: 388-398.
• Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan Kementrian Kesehatan Republik Indonesia.
Petunjuk Teknis Tatalaksana Klinis Ko-infeksi TB-HIV. 2012.
• Narain JP, Raviglione MC, Kochi A. HIV-associated tuberculosis in developing countries: epidemiology and
strategies for prevention. Tubercle and Lung Disease. 1992; 73(6): 311-321.
• World Health Organization. Tuberculosis and HIV. [Online on the Internet]. 2016. Available on:
http://www.who.int/hiv/topics/tb/en/
• Kementerian Kesehatan Republik Indonesia: Direktorat Jenderal Pengendalian Penyakit dan Penyehatan
Lingkungan. Strategi Nasional Pengendalian TB di Indonesia 2010-2014. 2011.
• Pawlowski A, Jansson M, Sköld M, Rottenberg ME, Källenius G. Tuberculosis and HIV co-infection. PLoS Pathog
8(2): e1002464. doi:10.1371/journal.ppat.1002464
• Konsensus TB. Pedoman diagnosis dan penatalaksanaan Tuberkulosis di Indonesia. 2012 [cited 2016 Apr 20].
• Centers for disease control and prevention.A new approach for TB disease screening and diagnosis in people with
HIV/AIDS. 2012 [Cited 2016 April]. Available from: http://www.cdc.gov/tb/topic/globaltb/screening.htm.
• Arunkumar N, Chandrasekhar S, Kumar SR, Menon PA, Narendran G, Padmapriyadarsini C, et al. Impact of HIV
infection on radiographic features in patients with pulmonary tuberculosis. Indian J Chest Dis Allied Sci 2007; 49:
133-6
• Gooze L, Daley CL. Tuberculosis. Cited on 27 November 2014. Available from:
http://www.hiv.va.gov/provider/image-library/tb.asp?post=1&slide=45.
• Perhimpunan dokter paru indonesia. Tuberkulosis: pedoman diagnosis dan penatalaksaaan di Indonesia. Revisi
pertama. Jakarta: PHPI, 2011