Tuberculosis and HIV potx

1 Tuberculosis and HIV VCHAP Vietnam-CDC-Harvard Medical School AIDS Partnership 2 Learning Objectives   •   •    !" • #$ % •   3 Outline of Talk • & • ' ()* • ( +%()*!*, /# • ( +%()* •  4 TB/HIV co-infection: HIV prevalence among TB patients in some provinces • 0$ 5 Incidence of Active TB in Persons with Positive Tuberculin Skin Test Am J Resp Crit Care Med 2000 Apr;161 (4 Pt 2 ): S221-47 Risk Factor TB Cases/1000 person-years TB infection < 1 year ago 12.9 TB infection 1-7 years ago 1.6 HIV/AIDS 35 – 162 HIV + Injection Drug User 76 HIV – Injection Drug User 10 6 OI distribution in 100 HIV/AIDS patients at Tropical Disease Hospital (HCMC) - 2000  Oral thrush  Tuberculosis  Wasting syndrome*  Respiratory infections  Cryptococcosis  Penicilliosis  PCP  Septicemia 53% 37% 34% 13% 9% 7% 5% 4% Louie JK, Nguyen HC et al. Inter Jrnl of STD & AIDS 2004;15:758 - 761 *50% of pts with this diagnosis, grew + cultures for MTB 7 OI distribution in 220 HIV/AIDS inpatients at NIITD (Hanoi) 2001-2002  Oral thrush 43 %  Wasting syndrome 33%  Tuberculosis 28%  Penicilliosis 11%  Shingles 5%  Septicemia 5%  Cerebral toxoplasmosis 3%  MAC infection 3%  PCP 2%  Leishmaniasis 0,5%  Aspergillosis 0,5% Le Dang Ha et al.2001-2002 Clinical Presentation of the PLWHA with Tuberculosis 9 The effect of HIV infection on signs and symptoms of TB Symptom/sign HIV positive (%) HIV negative (%) Dyspnea Fever Sweats Weight loss Diarrhea Hepatomegaly Splenomegaly Lymphadenopathy 97 79 83 89 23 41 40 35 81 62 64 83 4 21 15 13 Chest 1994;106:1471-6 10 Clinical presentation and CD4 • ( 1'23 4 56  " – cough with or without bloody sputum – upper lobe disease, cavitations – pleural effusions – fever, weight loss etc [...]... extrapulmonary TB and Laboratory confirmation of HIV infection OR • • Strong clinical evidence of HIV infection and A decision by a clinician to treat with a full course of anti-TB chemotherapy 18 Evaluation and Management of the PLWHA suspected to have Tuberculosis New WHO Perspectives on the Evaluation and Management of the PLWHA suspected to have TB • Now, a setting with high HIV prevalence determines... An HIV prevalent setting is defined as: – Adult HIV prevalence rate among pregnant women is ≥1% or HIV prevalence among TB patients is ≥5% – Setting : country, sub-national administration unit (e.g., district, county), selected facility (e.g., referral hospital, drug rehabilitation centre) • For countries with national HIV prevalence < 1%, national TB and HIV authorities should identify and define HIV. .. response to a course of broad spectrum antibiotics and • Decision by a clinician to treat with a full course of anti-TB chemotherapy HIV prevalent settings-NEW • At least two negative sputum specimens for AFB and • Radiographic abnormalities consistent with active TB and • Laboratory confirmation of HIV infection OR • Strong clinical evidence of HIV infection and • Decision by a clinician to treat with a... of HIV (CD4 < 200) • pulmonary cavities absent • infiltrates in middle and lower lobes • nodular infiltrates • effusions can be pleural and pericardial • mediastinal lymphadenopathy with no pulmonary infiltrates • normal CXR 13 Diagnosing Tuberculosis in the PLWHA WHO 2006 Case Definitions for Tuberculosis New Perspectives on the Case Definition of Tuberculosis • In the 2006 WHO guidelines, the HIV. .. positive for AFB and • One sputum smear positive for AFB PLUS sputum culture positive for M tuberculosis • Strong clinical evidence of HIV infection • Laboratory confirmation of HIV infection or 16 2006 WHO case definition Smear negative pulmonary TB (SNPTB) Non -HIV settings • At least three negative sputum specimens for AFB and • Radiographic abnormalities consistent with active TB and • No response...Clinical presentation and CD4 • Patients with advanced immunosuppression (CD4 < 200) have more atypical symptoms: – fever, weight loss with minimal cough – AIDS wasting syndrome – extrapulmonary disease – atypical chest radiographs – smear negative tuberculosis 11 Sputum smear and HIV status Tubercle Lung Dis 1993;75:191-4 12 Chest XRAY findings in patients with TB /HIV Early stages of HIV (CD4 > 500) •... months *Often HIV+ patients are given Ethambutol instead of SM in the first 2 months This is because of high rates of SM resistance in new patients (29%) and, to avoid the need for injections Guidelines for the Diagnosis and Treatment of HIV/ AIDS Ministry of Health, Vietnam March, 2005 Quy HT et al 2006 30 Tuberculosis: National Re-Treatment Protocol 2 SHRZE / 1 HRZE / 5 H3R3E3 Months 1 and 2: • Streptomycin... the Diagnosis and Treatment of HIV/ AIDS Ministry of Health, Vietnam March, 2005 31 TB /HIV Treatment Guidelines-2000 Vietnam Ministry of Health • Direct observation by MD in initial 2 months • Avoid thiacetazone in HIV/ AIDS patients • Smear remains + >4 mo, consider as Rx failure • Diagnose and treat other OIs 32 Some recent data suggesting superiority of HR for continuation phase • First randomized controlled... condition (Ambulatory & seriously ill patients) • HIV testing to TB suspects along with AFB • Acceptable number of visits established • CXR and Culture to be done earlier 23 Key WHO recommendations in 2006 • Vigilance and flexibility to start empiric treatment for suspected extrapulmonary TB in peripheral health facilities • TB care should include HIV care – HIV staging (clinical , immunological) – PCP... patients randomized to HRZE x 2 months followed by either HE (x 6 months) or HR (x4 mos) • 12 months after completion of therapy patients who had received HE were 2.86 times more likely to relapse • Of 68 patients co-infected with HIV 1 patient in HR group had unfavourable outcome vs 13 in the HE group (P=.08) Jindani A et al Lancet 364: 1244-1251, 2004 33 Tuberculosis meningitis and Dexamethasone • Randomized, . Presentation of the PLWHA with Tuberculosis 9 The effect of HIV infection on signs and symptoms of TB Symptom/sign HIV positive (%) HIV negative (%) Dyspnea Fever Sweats Weight. negative tuberculosis 12 Sputum smear and HIV status Tubercle Lung Dis 1993;75:191-4 13 Chest XRAY findings in patients with TB /HIV Early stages of HIV (CD4