Case management of TB
With HIV/AIDS co-infection
Chris Nelson, Public Health Nurse
Disclosures
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none
Global TB/HIV
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2011---13% TB cases are co-infected
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Estimated 400,000 people
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Leading cause of death among people
with HIV
Global Leading Causes of Death, 2008
SOURCE: http://who.int/mediacentre/factsheets/fs310/en/
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TB Case Rates in U.S.-born vs. Foreign-born Persons
United States, 1993–2011*
Cases per 100,000
HP 2020 GH-2 Target: 14.0
17.2
National Tuberculosis Surveillance System, data updated as of June 25, 2012.
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HIV Co-infection Among TB Patients:
U.S.,
1993-2011
Percent
30
25-44 years
25
20
15
All ages
10
5
0
1993
1995
1997
1999
2001
2003
2005
SOURCE: National Tuberculosis Surveillance System Highlights from 2011, CDC/NCHHSTP.
2007
2009
2011
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General Considerations
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About 10% of all TB cases in US are HIV-infected.
Many are unaware of their HIV status and do not
acknowledge their risk factors
Clinical presentation of TB in the HIV-infected
may differ from other immunocompetent
clients—especially if CD4 counts <200
CXR may be normal (usual cornerstone to
diagnosis)
Extra pulmonary TB is more frequent (so signs
and symptoms vary per site of infection)
With extra pulmonary TB-must r/o pulmonary TB
Wisconsin Numbers
2012 – 71 TB disease cases with 4 being co-infected
 2013 – 50 TB cases with 2 co-infected
 LTBI – # unknown as we do not record this data
 2012—new HIV recorded-241 plus 157 more that moved
into WI
 Current cumulative +HIV known cases in WI:
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◦ At the end of 2012-- 6,547 individuals presumed to be alive and
living.
◦ 76% of this +HIV 2012 number were diagnosed in WI
◦ 18% of +HIV are unaware of their diagnosis-per CDC
Issues to Consider
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Current IGRA tests are not currently licensed to be used with
immune compromised such as HIV/AIDS.
TST may not be accurate if:
◦ low CD-4 count,
◦ concurrent bacterial, fungal or viral infection
◦ TB disease is present
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Do 2-step if never tested.
◦ If 0mm TST repeat if CD4 is 200 or over.
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Clients with HIV have a 7-10% risk of progressing from LTBI to TB
disease per year. (Contrast to 10% for others over a life time)
For HIV+, TB disease must be ruled out prior to LTBI treatment
Meds used to treat TB and HIV have many potential drug interactions
and over lapping toxicities-this complicates treatment.
Possibilities:
◦ treatment failure for either TB disease or HIV or both
◦ Possible: paradoxical reactions during treatment for both
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Other overlapping risks may exist:
◦ Hep B/C, chronic liver disease, ETOH use, pregnancy, age and other offending OTC agents
(Tylenol)
Potential Daily Living Issues
Mental, Emotional, and Cognitive status
 Access to transportation
 Usual places of residence, where and how to locate the
client, impending plans to relocate, travel, housing needs
and living situation
 Cultural and religious beliefs that may impact adherence
 Language and literacy barriers
 Substance abuse
 Ability to pay for medical care
 Work history/income source
 Support systems
 Family dynamics
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Treatment
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LTBI tx should be daily and all options may be used if not on ART
Length of TB disease tx is similar for those that are HIV+ and those
who are not +HIV (6-9 months)
+HIV with drug-susceptible TB respond well to standard treatment
TB disease tx should be daily-not intermittent (some studies from
NY confirm rifamycin containing regimens given intermittently caused
resistance)
TB disease--potential for immune reconstitution inflammatory
syndrome (IRIS) if both TB medications and ART are started at the
same time.
Medical experts should guide treatment (esp. drug-drug interaction
and clinical response to therapy is slow)
Treatment Options
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For clients that have not started ART- at the time of TB diagnosis,
many MD’s defer the initiation of ART until the intensive 1st phase
(first 2-months) of TB treatment is completed. MD’s can manage the
med side effects from TB drugs without the complications of ART.
This also minimizes the likelihood of immune reconstitution
syndrome(IRIS)
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Pill burden is also more tolerable
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If TB is diagnosed after client is on ART, their ART regimen may need
to be changed to be compatible with TB treatment.
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Anti-TB regimens may be modified to not contain any rifamycins.
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Pregnant women are challenging-as ART regimens are difficult when
rifabutin is not an available option
Monitoring Therapy
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Common baseline blood tests: LFT’s, CBC with differential, CD4
counts
Client should be seen by MD monthly-at minimum
Sputum for smear/culture monthly until #2 consecutive neg cultures
If initially smear +, test more frequently (q 2 weeks to assess Tx
response
Repeat CXR after 2 months of Tx
End of Tx CXR
Repeat drug susceptibility testing if culture + after 3 months of Tx
Daily DOT
Always assess for OTC meds, diet issues, weight loss, GI upset,
alcohol and other substance use.
Report: vomiting-as this may require addition of meds to control and
be given before meds are taken.
Assess for peripheral neuropathyIf on EMB-baseline eye exam (acuity/color)-monthly while on this
med
Therapeutic Drug Monitoring
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Need to be considered in clients who are slow to respond to Tx or
have complex Drug-drug interactions.
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Consider this when on cycloserine
Symptom Concerns
Risk of adverse reactions to TB tx is higher in HIV+ occurring about
25% and 13% respectively
 Hepatotoxicity is common in tx of TB for HIV+ esp. if on ART,
antibiotics, or co-infected with HepB/C
 Symptoms can be subtle and mimic drug effects, indigestion or
another infectious process (decreased energy or appetite, fatigue,
indigestion, abdominal discomfort, nausea, vomiting, myalgia and rash
Evaluating a Rash
 Early: it can be maculopapular. If this rash does not resolve in 24
hours or have a likely cause-refer to provider. LFT’s may be needed.
 Some of the antiretrovirals (abacavir) can cause this and it maybe life
threatening.
 Rashes warrant a thorough and prompt evaluation by the medical
provider.
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Drug and Food Interactions
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Multiply significant Drug-Drug interactions especially with TB/ART
meds.
Also
INH-may increase hepatotoxicity, may cause problems with many
seizure and psych meds
Rifampin-decrease many other medication effects
Food/Drug interactions:
◦ Some TB meds need to be taken 1-2 hr before a meal (INH, Rif,)
◦ Some meds may to be taken with food (ethambutal, PZA, ethioamide, amikacin,
capriomycin, para-aminosalicylic(PAS), linezolid)
◦ Some meds may require increased fluid intake (amikacin, streptomycin, capreomycin,
PAS )
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Need to avoid alcohol
Client may need vitamin supplements with some meds
Diet becomes very important-need for weight checks on regular basis
Indicators Needing Attention
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DOT failure
Slow sputum conversion or delayed clinical
improvement
Marginal or no acceptance of TB diagnosis
Clinical deterioration while on TB therapy
Failure to attend medical appointments
Pregnancy
Substance abuse
Malabsorption of TB medications
Complaints that TB medications taste bad or
make the client sick.
Final words
Case management requires good
communication with all providers of care
 Client education to ensure compliance
 Support of other systems if problems
arise during tx
 Problems will arise
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