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TB and HIV Co-infectionApproach to treatment
Dr. Elsa BaltTB directorate
NTCP
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Key points: TB is a common co-morbid illness with HIV.
It is important to investigate patients for TB
before starting ART.
Patients should be counseled before starting ART
If TB is diagnosed, there are 2 possibilities to
consider : 1.TB developed while on ART2.Patient on TB treatment who needs
ART.
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Investigate all patients for TBbefore starting ART.
Suspect TB if 2 or more of the
following are present:Observed weight loss of >1.5kg over past 4 w.
Cough > 2 weeks.
Night sweats > 2 weeks
Fever > 2 weeks
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1.TB develops while on ART Continue ART throughout TB treatment
Patients on first line therapy containing
Nevirapine should be changed to Efavirenz.
1st line therapy:
Stavudine 40mg (or 30 mg if ,40kg) 12hourly.Lamivudine 150mg 12 hourly.
Efavirenz 600mg at night.
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Second line therapySecond line therapy should be changed to a
regimen compatible with TB therapy.
Zidovudine (AZT) 300mg 12 hourly.
Didanosine 400mg once a day.
Lopinavir/ritonavir 400/400 mg every 12hours
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2.TB disease present before
starting ART2.1 CD4 > 200 cells/mm and no history of
WHO stage 4, no need for ART
Reassess on completion of TB treatment.
2.2 History of WHO stage IV disease, and/ ora CD4 count of less than 200 cells/mm.
Complete 2 months of TB therapy beforecommencing ART
Start first line therapy as above.
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2.3 CD4 count of less than 50 cells/mm, or
other serious HIV related illnesses make
sure the patient is tolerant to TB treatment
before initiating ART.
The patient should complete 2 weeks of TB
treatment before starting ART.
Start 1st line anti-retroviral therapy;
Stavudine, Lamivudine and Efavirenz
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Initiation of ARV therapy for TB
patients. Reasons to start ART
ARV decrease morbidity and mortality related
to HIV/AIDS
Reasons to delay ART.
Side-effects of the drugs.Paradoxical immune reaction.
Difficulties with adherence
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Councel patients before
starting ART: Large number of tablets will be involve
which may make adherence difficult.
TB symptoms may temporarily worsen
when ART is started
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Side effects of TB drugs and
ARVSide effect ART TB drugs
Nausea Didanosine,
Zidovodine,Ritonavir
PZA
Hepatitis Nevirapine
Efavirenz
Rimf. INH, PZA
Peripharal
neuropathy
Stavudine
Didanosine
INH
Rash Nevirapine,
Efavirenz
Rif. INH, PZA
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Inflamatory syndrome
Hectic fever
New or worsening adenitis.
New or worsening pulmonary infiltrates,
including respiratory failure
New or worsening pleuritis, pericarditis or ascites
Intracranial tuberculomas, meningitis
Disseminated skin lesions
Epididymitis,Hepato-splenomegaly, abscessess
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INH prophylaxis for HIV patients HIV counselling and testing available
Effective screening for TB.
Monthly follow-up
Do not interfere with TB CP.
Local AIDS program takes responsibilityfor management of the Preventative
therapy.
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Eligibility for TB preventative
therapy in HIV-positive patients .
Only HIV-positive patients with no
symptoms of TB and a normal chest X-ray.
If tuberculin test is positive, no symptomsof TB and normal chest x-ray.
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Summary Give INH 5mgkg Maximum300mg) for 6
months.
See the patient on a monthly basis.
If TB symptoms develop, stop TB
preventative therapy
If the patient develops hepatitis, stop
therapy.
