HIV and TB Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health Program in Global Health, Division of Infectious Diseases David Geffen School of Medicine Fielding School of Public Health Special thanks to: Caitlin Reed MD, MPH Medical Director, Inpatient TB Unit, Olive View – UCLA Medical Center Los Angeles County Department of Health Services September 2014 African-American HIV University
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HIV and TB Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health Program in Global Health, Division of Infectious Diseases David Geffen.
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HIV and TB
Jeffrey D. Klausner, MD, MPHProfessor of Medicine and Public Health
Program in Global Health, Division of Infectious Diseases David Geffen School of MedicineFielding School of Public Health
Special thanks to: Caitlin Reed MD, MPHMedical Director, Inpatient TB Unit, Olive View – UCLA Medical Center
• Dr. Klausner is a faculty member of the University of California Los Angeles
• Dr. Klausner is a guest researcher with the US CDC Mycotics Diseases Branch
• Dr. Klausner is a member of the WHO STD Guidelines group
• Dr. Klausner is a board member of YTH, Inc, non-profit
• Dr. Klausner is medical advisor for Healthvana.com
• In the past 12 months, Dr. Klausner has received:
– Travel support for meeting coordination and speaking from Standard Diagnostics, Inc.
– Research funding or donated supplies from the NIH, CDC, Hologic, Inc., Alere, Inc., Chembio, Inc. Cepheid, Standard Diagnostics, Inc., and MedMira, Inc.
*WHO Stop TB Diagnostics Working Group Strategic Plan 2006-2015
Mycobacterial Culture
• Reference Standard for diagnosis of TB
• Can send from any body site• Solid or liquid culture medium
• Limitation:– Slow (mean: 24 days for positives)– Resource intensive, costly
Drug Susceptibility Culture Testing
• Diagnosis of drug-resistant TB• Conventional Methods:
– Grow TB in culture – Assess for growth (resistant)
or absence of growth (susceptible)
at 4 weeks
Nucleic Acid Amplification Tests
– Amplify nucleic acid segments specific for M. tuberculosis
– Rapid: Results in 24-48 hours
– Commercially Available:• Mycobacterium Tuberculosis Direct
(MTD)• Amplicor M.Tb Test (Amplicor)• Cepheid GeneXpert MTB Rif
Cepheid GeneXpert MTB Rif
Case 2
• 66 yo homeless man with abnormal chest xray, weight loss, chronic cough
• Smear positive for AFB• HIV-infected• Treatment?
– 4 drug regimen: Rifampin, INH, PZA, Ethambutol– May stop PZA after 2 months– May stop Ethambutol if no resistance – For 6 to 9 months total duration
TB and HIV infection
• Difficult to diagnosis (low amount of TB)• Drug-drug interactions• Immune reconstitution inflammatory syndrome (IRIS)
– Delay antiretroviral therapy until on TB treatment• If CD4 < 50 delay 2 weeks• If CD4 > 50 and stable, delay 8 weeks
– Monitor for worsening– Consider addition of steroids
New developments in TB
• Ongoing search for point of care test– Urine LAM: antigen detection; potentially
useful, in HIV-infected patients with CD4 <50
• Reports of ‘Totally Drug Resistant’ TB • Finally, new drugs for drug-resistant TB
– Bedaquiline (Sirturo)– FDA approved Dec 2012 for MDR-TB
– Delaminid – phase III trial
Olive View Inpatient TB Unit
TB Unit15 beds (10 staffed currently)Patients must be stable with lab-confirmed TB
Categories of patients• Infectious, need prolonged isolation• Drug resistant TB requiring special management• TB drug adverse reactions• Public health detention
Group questions & dilemmas
Group 1
The patient has HIV infection but his TB skin test is negative
What are 3 possible explanations?
Group 2
A patient has been started on TB medicines. He initially gets better and then gets worse.
What are 3 possible explanations?
Group 3
• Name 3 groups that are high risk for TB
• Describe 3 ways the risk for TB might be decreased in those groups?
Group 4
• TB is a public health condition that gets reported to the health department.
• Name 3 other “reportable” conditions
• Describe what the health department does with that information