HIV / TB

COLLABORATION
 TB HIV CO-ORDINATION
RNTCP AND NACO –
“JOINT ACTION PLAN”
OBJECTIVE=
TO REDUCE TB ASSOCIATED MORBIDITY AND
MORTALITY IN TB-HIV PATIENTS
FOR EFFECTIVE PREVETION AND CONTROL OF BOTH THE
DISEASES
PHASE I=
2OOI
IN 6 HIGH HIV PREVALENT STATES ( AP, KARNATAKA,
MAHARASHTRA, MANIPUR, NAGALAND, TN)
PHASE II
2003

8 ADDITIONAL STATES (DELHI, GUJARAT, HP,

KERALA, ORISSA, PUNJAB, RAJASTHAN, WB).

PLAN TO BE EXTENDED TO ALL OTHER STATES IN

DUE COURSE.
 TB/HIV

Two Diseases

One Patient
 TB: A Growing Concern for
PLWHA
 Approximately 1/3 of
the world population is HIV
infected with TB
 Globally, 1/3 of PLWHA
are co-infected with TB HIV & TB
 TB is one of the leading
causes of death in
people with HIV, TB
particularly in low-
income countries
 HIV- ASSOCIATED TB AND
MORTALITY
 TB is the leading cause of Death in

HIV-infected patients globally.

 Case fatality rate is about 40% or higher.

 Estimated 456,000 HIV-TB deaths in 2007. This

number represents:
• 33% of the estimated 1.4 million incident HIV-
TB cases
• 23% of estimated 1.8 million TB deaths
 People living with HIV (PLWH) are
6 times more likely to die during TB
treatment.
 TB is the "Achilles heel" of HIV care
and treatment (major cause of death and
can undermine the effectiveness of ART
outcomes).
HIV/TB: Profound Effect on Individuals

The annual risk of TB

in HIV infected approximates the lifetime risk of
HIV uninfected
 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

9
 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
 HIV viral load decreases with successful TB therapy
 TB therapy when combined with ARV has potential for drug-
drug interactions and side effects

10
 Impact of TB on HIV replication

TB

T-cell T-cell HIV Viral

Replication
(inactive) (active)

11
 Clinical Presentation of
HIV-related TB
 CD4 counts >350
• Disease usually limited to the lungs.
• Often presents like TB in HIV-
uninfected persons.
• “typical” chest X-ray findings with
upper lobe infiltrates with or without
cavities
 CD4 counts <50-100
• Extrapulmonary disease is common.
• Disseminated disease with high fevers
and rapid progression is seen
• Chest X-ray findings often look like
“primary TB” with adenopathy,
effusions, interstitial or miliary
 Pulmonary TB in Early and Late
HIV Infection
Features of Early Stage Late Stage
pulmonary TB HIV infection HIV infection
Clinical picture often resembles often resembles
post-primary primary PTB
PTB
Sputum smear often positive more likely to
result be negative
Chest X-ray upper lobe infiltrates any
appearance infiltrates with or lung zone, no
without cavitation cavitation;
miliary; normal
 Diagnosing TB in Persons with HIV
 In HIV-positive or suspect patients:
• 2 sputum samples for microscopy are indicated for
any symptoms of TB regardless of duration or
sputum characteristics
• Fever and weight loss can be important symptoms
• If Sputum smear is +, a chest X-ray is not required
to confirm the diagnosis PTB.
 Smear-negative Pulmonary TB
 TB sputum culture is the gold standard for TB
diagnosis.
 If sputum smears are negative:
• Obtain sputum culture if available
• Culture will improve the quality of care and assist the
confirmation of the diagnosis
• A CXR can help with earlier diagnosis, i.e., if findings
show intrathoracic adenopathy, miliary changes, or
upper lobe infiltrates
 Post – Primary
TB : Consolidation
HIV & TB :
Adenitis
AFB Stain
 People with Tuberculosis and
HIV Co-infection
WHO recommends that people with both TB and HIV
complete their TB therapy prior to beginning ARV
treatment unless there is high risk of HIV Disease
progression and Death during the period of TB
treatment, defined as
• a CD4 count < 200/mm3
or
• Presence of disseminated TB
 Treatment of TB for
HIV-Positive Persons
 Rifampicin-based regimens generally
recommended for persons
• Who have not started antiretroviral therapy
• For whom Rifampicin-incompatible Pis or NNRTI
based regimens are not essential
 Initial treatment phase should consist of:
• Isoniazid (INH)
• Rifampicin (RIF)
• Pyrazinamide (PZA)
• Ethambutol (EMB)
 Drug-drug interactions
Absorption
TB/HIV

Metabolism CYP3A4

PIs
NNRTIs
Metabolism

Elimination
 Drug-drug interactions
Absorption
TB/HIV

Metabolism RIFAMPICIN
CYP3A4

Metabolism
PIs
NNRTIs

Elimination
 For Patients Receiving PIs or
NNRTIs, initial treatment phase may
consist of:
• Isoniazid (INH)
• Rifabutin (RFB)
• Pyrazinamide (PZA)
• Ethambutol (EMB)
 HAART and Rifampicin- Based
TB Therapy
 Recommended regimen:
Efavirenz plus 2 nucleosides
• Use EFV for adults and children >3 years old
• Avoid 1st trimester of pregnancy
 Choice of nucleosides
• Usual adult first line therapy: Zidovudine +
Lamivudine (AZT/3TC)
– Alternate in case of anaemia: stavudine + lamivudine
(d4T/3TC)
• For children stavudine +lamivudine (d4T/3TC)
– Alternate: zidovudine + lamivudine (AZT/3TC)
 When to Start ART During TB
Therapy?
 HIV-infected TB patients should be evaluated for
ART immediately
• CD4 <200 - start ART between 2-8 weeks after start of
anti-TB therapy
• CD4 >200 but <350 - start ART 8 weeks after start of
anti-TB therapy
• CD4 >350 - defer ART but re-evaluate at 8 wks and
at end of anti-TB therapy
 HIV-infected patients already on ARVs who
develop TB should begin anti-TB meds
immediately .
 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, pathogen-
specific immune response
 Not ART treatment failURE
27
 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 .

28
TB IRS
 BENEFITS of TB/HIV
integrated services
 For Patients (TB and HIV)
• Improved access to prevention, diagnosis and treatment
services.
• Improved adherence and outcome of treatment.

 For Health services

• Decentralise services ( to periphery and low cadre HCW).
• Integrated and pooled staff training.
• Maximise synergy and Partnership between stakeholders.
• Effective use of resources.
Working together….

ART
CTXp
ICF

IC

IPT