Case management of TBCase management of TBWith HIV/AIDS co-infectionWith HIV/AIDS co-infection

Chris Nelson, Public Health Nurse

DisclosuresDisclosuresnone

Global TB/HIVGlobal TB/HIV2011---13% TB cases are co-

infected

Estimated 400,000 people

Leading cause of death among people with HIV

32

Global Leading Causes of Death, 2008Global Leading Causes of Death, 2008

SOURCE: http://who.int/mediacentre/factsheets/fs310/en/

47

TB Case Rates in U.S.-born vs. Foreign-born Persons United States, 1993–2011*

National Tuberculosis Surveillance System, data updated as of June 25, 2012.

Cases per 100,000

HP 2020 GH-2 Target: 14.0

17.2

10

5

0

15

25

20

30

1993 1995 1997 1999 2001 2003 2005 2007 2009 2011

39

HIV Co-infection Among TB Patients: U.S., 1993-2011

SOURCE: National Tuberculosis Surveillance System Highlights from 2011, CDC/NCHHSTP.

All ages

25-44 yearsPercent

General ConsiderationsGeneral Considerations

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 NumbersWisconsin Numbers

2012 – 71 TB disease cases with 4 being co-infected

2013 – 50 TB cases with 2 co-infectedLTBI – # unknown as we do not record this

data 2012—new HIV recorded-241 plus 157 more

that moved into WICurrent cumulative +HIV known cases in WI:

◦ 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 Issues to Consider 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

Do 2-step if never tested.◦ If 0mm TST repeat if CD4 is 200 or over.

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

Other overlapping risks may exist:◦ Hep B/C, chronic liver disease, ETOH use, pregnancy, age and other offending OTC

agents (Tylenol)

Potential Daily Living IssuesPotential Daily Living Issues

Mental, Emotional, and Cognitive statusAccess to transportationUsual 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 barriersSubstance abuseAbility to pay for medical careWork history/income sourceSupport systemsFamily dynamics

TreatmentTreatment

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 OptionsTreatment Options 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)

Pill burden is also more tolerable

If TB is diagnosed after client is on ART, their ART regimen may need to be changed to be compatible with TB treatment.

Anti-TB regimens may be modified to not contain any rifamycins.

Pregnant women are challenging-as ART regimens are difficult when rifabutin is not an available option

Monitoring Therapy Monitoring Therapy 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 neuropathy- If on EMB-baseline eye exam (acuity/color)-monthly

while on this med

Therapeutic Drug MonitoringTherapeutic Drug Monitoring

Need to be considered in clients who are slow to respond to Tx or have complex Drug-drug interactions.

Consider this when on cycloserine

Symptom ConcernsSymptom 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.

Drug and Food InteractionsDrug and Food Interactions 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 )

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 AttentionIndicators Needing AttentionDOT failureSlow sputum conversion or delayed

clinical improvementMarginal or no acceptance of TB

diagnosisClinical deterioration while on TB therapyFailure to attend medical appointmentsPregnancySubstance abuseMalabsorption of TB medicationsComplaints that TB medications taste

bad or make the client sick.

Final wordsFinal wordsCase 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