Numbers of people developing active TB 1990-1993* · most national TB programmes (see page 15). BCG vaccination BCG vaccine protects children against the most severe and life-threatening

HIV infection -are no longer infectiousafter two to three weeks and almost allare cured after taking appropriate drugsfor at least six months. Withouttreatment more than half of those withTB disease are likely to die. Propertreatment also prevents the spread of TBbecause it makes people non-infectious.

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SPECIAL ISSUETB and HIV

TB preventionand treatment

HIV and TB links

Education and

training

Current issues:

.drug resistance

.preventive TB

therapy

Community projects for HIV-positive people, likein Kampala can provide support and encouragemEhelp individuals complete their TB treatment.

A third of the world's population is infectedwith tuberculosis (TB). Every year three

million people die from TB, mostly in developingcountries where it kills one in five adults. Despitethe development of effective anti-tuberculosisdrugs, TB causes more deaths than any otherinfectious disease. It is now one of the maincauses of death in people with HIV infection and,since the mid-I 980s, has increased dramatically indeveloping and industrialised countries. Like HIV,having TB is associated with poverty and oftenresults in discrimination and stigma, and abuse ofhuman rights.

But TB can be cured. With correct treatment,people with TB -including those who also have

Published by

AHRTAGAppropriate Health Resources& Technologies Action Group

What ;s TB?Tuberculosis is usually caused byinfection with the bacillus Mycobacteriumtuberculosis. TB normally affects the lungs

-this is called pulmonary TB. Sometimesthe TB germs enter the bloodstream and

spread to other organs in the body -thisis called extra-pulmonary TB. PulmonaryTB is much more common than

extra-pulmonary TB.When a person is exposed to TB

germs and becomes infected, they haveTB infection (or latent TB). Sometimesthe infection progresses to TB disease

(tuberculosis, active tuberculosis oractive disease).

Once infected with TB a personremains infected for the rest of their life.But most people do not become ill withTB disease and infectious to others. A

healthy immune system can stop the.germs from multiplying enough to causethis

one illness. But the TB germs may continue!nt to I . I d d h I .

to mu tip y an estroy t e ung tissues,leading to active TB disease, particularly

if a person is in poor health, or has HIVinfection. The symptoms of pulmonary TB diseaseare cough for more than three weeks (sometimeswith bloody sputum) and chest pain. Exhaustion,

night sweats, fever and weight loss are symptomsof both pulmonary and extra-pulmonary TB.

Active pulmonary TB is the only form of thedisease which is infectious, spreading from personto person via the air. The lungs of a person with

active disease develop cavities (spaces) which arefull of TB germs. When the person coughs or

sneezes large numbers of TB germs from thelungs are sprayed into the air in tiny droplets.Family, friends and health workers who haveclose contact with a person who has infectious

Continued from page I

TB are at greatest risk. TB spreadsmost easily in over-crowded and badlyventilated places.

Sputum smear tests are used to findout if a person has active TB and isinfectious. A positive sputum smeartest means that a person is coughingup TB germs and should be treated.

Numbers of people developing active TB 1990-1993*

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A growing crisisWHO has predicted a global TB epid-emic, causing 30 million deaths duringthe I 990s. The number of new TBcases worldwide each year is expectedto increase from around seven millionin 1990 to over ten million by 2000.There are two main reasons why TB is

a growing problem: neglect of TB

programmes and the spread of HIV.Effective TB control requires a

properly functioning health servicewith good management, diagnosticfacilities, trained staff and regular drug

supplies including reserve stocks. Butfinancing TB programmes has not beena priority.

There has also been little commun-ity education to tell people about TB

symptoms, reduce discrimination andto encourage them to seek treatment.

In some places there has alwaysbeen a stigma attached to TB. People

risk losing their jobs and housing if itbecomes known that they have TB.The stigma and stress may be worsefor women. In some cultures, havingTB may make it difficult to find ahusband or result in divorce. linksbetween HIV and TB are worsening

the stigma.Worldwide the number of people

infected with both HIV and TB is risingand will reach four million by the year2000. About half of TB patients in sub-Saharan Africa are also infected withHIV. In Tanzania, TB cases doubled

between 1983 and 1991, a third ofthem related to HIV. In Asia, TB is al-

ready one of the most important lifethreatening opportunistic infections

associated with HIV. In Europe andNorth America the rise in TB casessince the mid-1980s is due partly toHIV, but also to other factors such asincreasing homelessness and poverty,and worsening public health systems.

,

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Rates (per 100,000).> 100.25 to 1000

..rlnclp

Treatment and supervisionAnti-tuberculosis drug treatment is 95per cent effective only when it is usedcorrectly, so it is most important thatTB patients complete their treatment.The treatment is based on a combinat-ion of drugs taken for at least sixmonths, in two phases: an initial phaseand a continuation phase. The comb-inadon of drugs varies as does thelength of treatment (see pages 8-9).

People may find it difficult to takeanti-tuberculosis drugs for a longperiod of dme. But they can be helpedby a well supervised programme anduse of DOT (directly observedtherapy) which means watching theperson take their drugs (see page II).It is especially important that padentstake their treatment during the inidalphase to make them non-infectious.

Proper detection and treatmentPeople can only spread TB to otherswhen they have active TB disease. The

key to TB care and prevention is to

identify people who are infectious andto provide prompt and effective

treatment to make them non-infectious and cure them.

Case finding should prioritise

identifying people with smear positiveactive TB because they are the most

important source of infection in thecommunity. Passive case finding meansdiagnosing infectious smear positivepeople who come to health facilitieswith symptoms of TB.

Active case finding means trying toreach all those in a community whomay have infectious TB disease. It isimportant to check children under fivein a patient's family. However, in

general active case finding is moreexpensive than passive case finding andstudies have shown that fewer people

may complete treatment.

including those who may be HIVpositive, and only withheld from infantswith symptomatic HIV disease.

Preventive chemotherapyPreventive therapy (or chemoprophy-laxis) means giving anti-tuberculosisdrugs to an individual with TB infection(or at very high risk of being infected)to prevent progression to activedisease. In developing countriespreventive therapy is only usuallyrecommended for young infants whosemothers have active pulmonary TB,and children under five who are livingwith a person with infectious TB.

Chemoprophylaxis is also beneficialfor individuals with HIV and TBinfections, to preventing them fromdeveloping active TB disease. However,there are still many unansweredquestions, and providing preventivetherapy is not a feasible option formost national TB programmes (see

page 15).

BCG vaccinationBCG vaccine protects children againstthe most severe and life-threateningforms of TB disease in childhood, suchas tuberculous meningitis. BCG doesnot reduce the risk of being infected

with TB, and its impact on preventing

pulmonary disease is limited. So BCGhas a very restricted role in TB controlbecause it does not prevent

transmission of infection in the

community.BCG vaccination should be given to

young children as early in life as poss-

ible, preferably immediately after birth.The only exception is if the mother is

sputum smear positive when the babyis born. In this situation the infantshould be given preventive therapy forsix months. At six months a tuberculintest should be done. If it is negativeBCG vaccination should be given.

Giving BCG vaccine to HIV-positiveinfants may increase complications ordisseminated BCG disease (illnesscaused by the vaccine itself) in infantswith severe immunodeficiency. How-ever, the benefits of BCG vaccination

outweigh the possible risks to HIVpositive infants. Therefore BCGvaccine should be given to all infants,

People with TB symptoms should beasked to provide a sputum sample tobe examined for TB bacilli.

AIDS ACTION Issue 31 December 1 99S-February 1996 Published by AHRTAG in the UK

A TB programme should facilitate linksbetween primary, district, regional andnational levels and with HIV/STD pro-grammes too. Health workers shouldalways follow national TB programmeguidelines. If there is no functioning TBprogramme in your area, use WHOTB treatment guidelines.

.a recording and reportingsystem that provides informationabout case categories and treatmentresults

.to train staff to screen, diagnoseand treat patients

.a reliable sputum smearmicroscopy service, withadequate equipment and trainedlaboratory personnel

.treatment services which providedirectly supervised short coursechemotherapy and health education

.a reliable supply of drugs anddiagnostic materials.

T B control requires a well organis-ed national programme. A poor

programme is worse than none at all,because of the risk of large numbers ofpeople being given inadequate treat-ment. This means they will continue tobe infectious to others and this canlead to the development of TB strainsresistant to available drugs. WHO andIUA TLD (the International UnionAgainst TB and Lung Disease) havedeveloped standard guidelines fornational TB programmes, which areresponsible for planning, policy,budgets, supervision and training. Aneffective programme needs:

Collaboration between TBand HIV/AIDS programmesPeople with HIVand TB face similarproblems of stigma and fear, and haveneeds for care and support, and forcounselling and confidentiality. Closercollaboration between TB control andAIDS programmes in these areas couldbe useful. For example, more integrat-ed approaches to community educat-ion could help to change attitudes toboth infections and reduce stigma.Collaboration in home care and followup of patients with TB and with HIV/AIDS could help to increase adherenceto TB treatment and identification ofpeople with active TB..Nurses in Kenya, trained in HIV

counselling and who plan care forpeople with AIDS after dischargefrom hospital, are extending theirservices to patients on TB wards.

.In Ghana a peer support group forpeople with HIV, working withhealth staff, discusses TB prevent-ion, early TB recognition, and treat-ment adherence during home visits

.Hospital community outreach teamsin South Africa visit people with HIVand TB at home. Many patients haveboth infections and the integratedapproach helps to share limitedresources such as transport, toreduce stigma and to increase

community acceptance.

What can NGOs do?NGOs should make sure that theiractivities complement the national TBprogramme and discuss what role theycan play to support the national prog-ramme with the district TB officer.Local AIDS organisations are playing avital role in community education andcare including:

AIDS ACTION Issue 31 December 1995-February 1996 Published by AHRTAG in the UK

.ossible Ijnks with H.V..-

jCentral TB unit, MOH.plan, monitor and supervise national activities;.

liaise with HIV/AIDSfSTD and essential drugs programm~.co-ordinate training, drugs and diagnostic supplies

Regional TB co-ordinatOrs.liaise with central TB unit.ensure effective co-ordination of above activities in region, and liaise with HIV services.regu1ar technical supervision of district TB officers.revIew case finding and treatment reportsI

District TB officer (with DMQ)i. supervise and visit primary facilitiesI. collect data for and maintain district TB register, with quarterly reports on new cases,

relapses and treatment results.support case finding activities.supervise effective microscopy service and records.arrange training and supervisory activities, including HIV-related issues.ensure referral possible if necessary.maintain drugs and equipment.make a ro 'riate..finkswith district AIDS committee and AtDS team at hos ital.eMou;e~ommu~ni. ;;education and!inks with AIDS NGOs rovidin home care andeducati;on--~.".I;; ...PrImary health facilitIes.identify people with possible TB symptoms and trace contacts.take sputum samples and liaise with laboratory.provide efficient referral and treatment services: appropriate regimens and sputumtesting, counsellin health education,10cal 0 anisation of DOT clinic visits, communiworkers AIDS home care services.keep TB treatme6t cards and records up to date I ;;111;; ;0.; c; c.follow up defaulting patients and discharge patients who are cured or have completedtreatment.car out communi education with HIV services if a ro riate

I.report regularly to district level.ensure staff understand HIV and TB links, and area~re of needs for counsellin etc

.Ensuring that community membersrecognise TB symptoms, andunderstand that it can be cured

.Encouraging people with symptomsincluding those who may have HIV

to be screened for TB and to seektreatment

.Encouraging people to take theirtreatment using DOTS systems

.Countering misbeliefs and stigmaabout AI DS and TB

.Educating people about the ways inwhich TB is spread and encouragingthem to cover the mouth whencoughing and to spit into a containerand dispose of sputum carefully

.Providing home care and support topeople with TB and HIV.

People who are sick with AIDS-related TB need care and support from familyand health workers in their community.

What can health workers do?Health workers need to be friendlyand aware of the person's needs forconfidentiality, and to:.Ask about symptoms -if a person

has had a cough for more than threeweeks and chest pain, get a sputumtest done

.Make sure that the person under-stands that the full course oftreatment is needed even if the

symptoms soon go, and discuss theperson's fears and worries about TB

(and HIV).Be aware of the possibility that the

person may have HIV, and offer HIVcounselling and testing if it isappropriate and available

.Help them to take their full course

of treatment.Make sure they understand that they

are no longer infectious after 2-3

weeks.Examine family and household con-

tacts for TB, especially if they are ill.Keep proper records and visit the

person at home if they don't comefor their appointment or drugs

.Ensure that supplies of anti- TB drugs

are available and do not run out.Refer difficult cases to a centre with

a physician or TB specialist.Check HIV patients for TB and make

sure that people with both infections

do not receive thiacetazone.

AIDS ACTION Issue 31 December 1995-February 1996Published by AHRTAG in the UK

Keeping recordsRecords are needed for a TB programme to work effectively. The recording systemshould enable health workers and TB programme staff to plan, monitor and evaluateservices and drug supplies and to:.see how many cases are being detected.ensure that all potentially infectious cases are being properly screened.monitor patients' progress and adherence to treatment.make sure all patients are fully treated.assess the effectiveness of treatment.distinguish new cases from those that have previously received treatment.prevent the development of drug resistance.identify problems and where more training or supervision is needed

For each person records need to be kept of:.diagnostic examinations.treatment including the initial phase of treatment, patient adherence and follow

up.follow up sputum smear results, smear conversion and treatment outcomes for

those initially smear positive

A record system usually includes the following:.Patient TB card (kept by the person).TB treatment card (kept at the health facility).clinic TB register (kept at the health facility).TB laboratory register.district TB register

H ealth workers should suspect TBif patients present with the

following symptoms and history:

Adults.cough for more than three weeks.blood in the sputum.chest pain for more than one month.increasing weakness and loss of

weight.had TB in the past or previously

treated for cough

Children.close contact with a smear positive

case.positive tuberculin test.wasting -decrease in weight with

no obvious reason.two or more episodes of fever with

no obvious cause such as malariaTB treatment should not be startedon the basis of clinical symptoms alone(unless non-pulmonary disease is

Sputum smear microscopySputum smear microscopy is the mostuseful diagnostic tool in low incomecountries. Sputum examination ischeaper, easier and more reliable thantaking x-rays, more reliable thantuberculin testing, and cheaper andeasier than culturing. It is possible todetect most smear positive cases ofpulmonary TB using sputum smearmicroscopic examination.

The method of collection of thesputum is important. It should beproduced away from other people,placed in a tightly covered labelled

CulturingA specimen of sputum is sent to aspecialised laboratory where TBbacilli, if they are present, can be'grown' or cultured. Culturing is moresensitive than sputum smearmicroscopy but in many countriesfacilities and personnel are notavailable. It is also expensive and theresults can take several weeks tocome back. This delays confirmationof the diagnosis and startingtreatment. Culturing is thereforeoften inappropriate as a diagnostictool but is used to test TB bacilli fordrug resistance and sensitivity where a

AIDS ACTION Issue 31 December 1995-February 1996 Published by AHRTAG in the UK

suspected when immediate referral container and delivered to theand treatment are very important). laboratory as soon as possible. If TB isThe main diagnostic tools are: suspected, ideally three sputum.sputum smear microscopy specimens should be collected within.culture of bacteria 24 hours: during the first consultation;.tuberculin skin testing by the person at home the next.chest radiography (x-ray) morning; and at the second

consultation..Two positive sputum smears are

enough to confirm the diagnosis ofTB.

.If the first smear is positive and thesecond is negative (or vice versa), athird smear needs to be examined.

.If the first smear is positive and theperson does not return for thesecond consultation they need to befollowed up and encouraged toreturn. Without treatment they willinfect others and their owncondition will get worse.

.Health workers in areas withoutsmear facilities need to look forclinical symptoms and historysuggesting TB and refer the personto a health facility for screening.

.One negative smear result is notenough to exclude a diagnosis of TB.

Smear microscopy requires well-trained laboratory workers andwell-maintained equipment. Poorlytrained staff or inadequate equipmentcan lead to over-diagnosis of smearnegative and under-diagnosis of smearpositive cases. Sputum smearmicroscopy is also used to check cure,which is based on smear conversionfrom positive to negative.

patient is not responding to treatment.Culturing is also used for sputumsmear negative cases where active TBis suspected.

Tuberculin skin testing

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Chest radiographyChest radiography or x-ray isexpensive and usually available only inhospitals. It is not the most reliableway of diagnosing TB, although it canbe a useful supportive tool to helpmedical officers to diagnose smearnegative TB. Chest abnormalitieswhich show up on x-ray may be dueto other conditions or previous TBdisease. Relying on x-ray results canlead to over-diagnosis of TB and un-necessary drug treatment. But chestradiography may not detect the earlystages of TB disease, and the signs ofpulmonary TB (such as cavitations)usually seen on x-ray are less commonin people with HIV.

Sputum smear microscopy is the best way to find out if a person has smearpositive TB and is infectious to others.

.The tuberculin skin test often failsto work in people who are HIV posi-tive because it relies on measuringthe response of a person's immunesystem. If the immune system hasbeen damaged by HIV, it may notrespond even though the person isinfected with TB. HIV positive

people with TB therefore have ahigher frequency of false negativetuberculin skin test results.

.Chest radiography may be less use-ful in people with HIV because theyhave less cavitation. Cavities (spacesin the lungs) usually develop becausethe immune response to the TBbacilli leads to some destruction oflung tissue. In people with HIV, whodo not have a fully functioningimmune system, there is less tissue

destruction and hence less lungcavitation.

.Cases of extra-pulmonary TB seemto be more common in people whoare co-infected.

The health worker may suspect HIVinfection because TB is difficult to diag-nose, and the person is sick with otherHIV-related infections. Offer confident-ial counselling and testing if availableand appropriate. However. it is not

Detection and diagnosis ofTB in people with HIVIn most people in the early stages ofHIV infection, symptoms of TB diseaseare the same as in people without HIVinfection.

In areas where many people haveHIV infection, TB programmes shouldcontinue to focus on identifying infect-

ious sputum smear positive cases

through microscopy. However, diag-nosis of TB in individual patients usingthe standard diagnostic tools can bemore difficult if they have advancedHIV infection.

.HIV positive people with pulmonaryTB may have a higher frequency ofnegative sputum smears. Confirming

the diagnosis may require sputumculture.

necessary to know the person's HIVstatus.

For people thought, or known tohave, HIV with TB symptoms:.Screen for TB using sputum smear

microscopy..If the result is positive start treatment..If the smear result is negative but it

is suspected that the patient has TB,sputum culture should be carriedwhere feasible to confirm the

diagnosis..Give TB treatment to those with

positive culture results.Alternatively, where culture cannot bedone, treatment can be given to thosejudged by a doctor to have active TBon the basis of x-ray and clinical

symptoms.Many HIV-infected smear negative

patients thought to have TB in facthave other diseases. It is important toexclude the possibility of otherinfections before starting TB treatment.Usually this is done by treating firstwith a regular antibiotic for two weeks,and repeating the smear tests at theend of the two weeks if the person stillhas symptoms. If smear positive, startanti- TB treatment, but refer if stillsmear negative.

AIDS ACTION Issue 31 December 1995-February 1996Published by AHRTAG in the UK

Tuberculin skin testing, which measur-es the body's response to TB, is alsoless useful in clinical diagnosis, exceptin children. An individual can producea positive tuberculin test result if theyare infe~ted with TB or have been

vaccinated with BCG. The tuberculintest cannot reliably differentiate

between TB infection and TB disease.The test may also give a 'false negative'

result if someone is infected with TBand HIV (see below).

The principles of treatment are:.an appropriate combination of drugs

to prevent development ofresistance;

.prescribed in the right dosage;

.taken regularly by the patient under

supervision;.for a sufficient period of time.

Drugs The most commonly used firstline anti-tuberculosis drugs are:isoniazid (H), rifampicin (R), etham-butol (E), pyrazinamide (Z), strepto-mycin (S), and thiacetazone (T). Someof these drugs are available in combin-ed preparations, for example isoniazidwith rifampicin (RH) and isoniazid withethambutol (EH). Treatment regimenswhich contain both isoniazid andrifampicin are the most effective.Because rifampicin is such a usefulanti- TB drug, its use in treatingdiseases other than TB should becarefully limited. It is important tosupervise treatment regimens

containing rifampicin.

0

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Pregnant or breastfeeding womencan be prescribed short courseregimens (without streptomycin).

sterilisation of needles and syringes.Thiacetazone is no longerrecommend- ed in areas where HIVinfection is common because of sideeffects (see page 10).

Intermittent therapy means takinganti-tuberculosis drugs three times aweek instead of daily. There is nodifference between intermittent anddaily regimens in terms of the lengthof time before sputum conversionfrom positive to negative, or the finaloutcome.

Length of treatment Until recentlythe standard treatment regimen was12-18 months. However, people arelikely not to complete such a longcourse of treatment, which meansthey are not cured and continue toinfect others in the community.Regimens can be shortened to 6-8months if they include rifampicin.These regimens are called ShortCourse Chemotherapy (SCC).

Since the late I 980s WHO hasencouraged national TB programmesto introduce SCC regimens whichinclude rifampicin. Because of financialconstraints many developing countriesare still using the old standard 12month course. However, the drugs forthe short treatment course are only alittle more expensive. Successfulcompletion of treatment is also higherand better cure rates are achieved.This means that SCC regimens are abetter use of resources. Whateverregimen is used, making sure that theperson takes the full course isessential (see page 12).

Treatment of people with smearpositive TB should always include:

an initial intensive phase -in thisphase a combination of four drugs isgiven daily, to eliminate as many TBbacilli as possible and prevent thedevelopment of drug resistance. Theinitial phase of therapy should be givenfor a minimum of two months andcontinues until the patient becomessmear negative. Most people will havebecome smear negative after twomonths of treatment.

a continuation phase -in this phasefewer drugs are given but thetreatment needs to be continued forlong enough (depending on the SCCregimen the continuation phase can befour or six months) to ensure that thepatient is permanently cured and doesnot relapse after completion oftreatment.

Some TB programmes are limitingthe use of streptomycin because it hasto be given by injection. This is moreexpensive and risks spreading HIVwhere it is difficult to guarantee proper

How to assess cure?To be sure that TB is cured, a patientwho is initially smear positive mustproduce a smear negative result aftertreatment. The change from sputumsmear positive to sputum smear negat-ive is called smear conversion. Patientsneed to be followed up to ensure thatinformation on sputum conversion andoutcome of treatment is obtained.

The patient's sputum should beexamined after the initial two monthsof treatment. If it is smear negative,they can start the continuation phase.The sputum should be examined againat the end of the fourth or fifth monthto identify people who have failedtreatment. During the last month oftreatment a final smear is taken toidentify cure, or treatment failure.

Patients cannot be classified ascured if there is no sputum conversionfrom positive to negative. This appliesto initially sputum negative patients, or

AIDS ACTION Issue 3 1 December 1 995-February 1996 Published by AHRTAG in the UK

to sputum smear positive cases whocompleted treatment. with negativesmears at the end of the initial phase,but with no or only one negativesputum examination in the continuat-ion phase and none at the end oftreatment. Sputum conversion is theonly way to be sure that a person iscured, even if they complete treatmentand have no clinical symptoms. If it isimpossible to examine the sputum,then the patient is classified as'treatment completed'.

Failure to respondPeople fail to respond to treatmenteither because:.they are not taking their drugs OR.they have drug resistant TB.

Not taking the drugs is the mostcommon reason for treatment failure.If a person continues to be sick, withpersistent cough, fails to gain weightand has persistent positive sputumafter treatment for some time, use theWHO recommended retreatmentregimen for both HIV positive and HIVnegative patients who:.remain sputum positive after five

months of treatment (failure case).interrupt treatment for more than 2

months and return smear positive(return after default case)

.return smear positive aftercompleting treatment and beingdeclared cured (relapse case).

The therapy for retreatment should befully supervised for at least threemonths, and longer if the patient is stillsputum smear positive after threemonths. If the patient still fails torespond they may have resistant TBbacilli and need to be referred.

REMEMBER:.if a patient fails to respond to the

treatment regimen, refer forassessment

.treatment should be supervised aspoor adherence is even more likelywith more toxic and longer regimens

.good record keeping is essential todistinguish between people with newactive TB, or who have failedtreatment, because the treatmentregimens are different.

Source: Treatment of TB, Guidelines forNational Programmes, WHO.

Published by AHRTAG in the UK AIDS ACTION Issue 31 December 1995-February 1996

Side effects of drug treatmentSerious side effects to TB drugs are rare. Minor side effects do not mean that treat-ment should be stopped, but people need reassurance and to be warned about possibleside effects in advance. Side effects which are associated with certain drugs include:.Skin rashes and itching -reaction to thiacetazone and other drugs..Shock and fever -can be caused by rifampicin, pyrazinamide and/or streptomycin..Problems with sight -can be caused by ethambutol. Patients should be warned to

report any problems with their vision. Ethambutol is not usually given to childrenwho are too young to be able to report visual problems.

.Hepatitis -liver disease where the patient develops jaundice. Commonly due toisoniazid but may also be caused by rifampicin and pyrazinamide.

.Dizziness -caused by streptomycin, most frequently in older individuals orchildren. Streptomycin should never be given to pregnant women because it cancause deafness in the unborn child.

.Reaction in the joints such as pain, swelling, heat -caused by pyrazinamide.

.Flu-like illness and/or abdominal pain -caused by rifampicin..Red/orange colour of body fluids such as tears or urine -caused by rifampicin.

If patients develop any of the following serious side effects stop the treatment and referthem to a doctor immediately:

.yellow jaundice.serious skin conditions (more common in people with HIV -see page 10).problems with urinating and possible renal failure.shock

sellors for voluntary testing. Somepeople would prefer not to knowtheir HIV status. The cost of testingall patients would also be very high.

.Using an SCC regimen that doesnot include thiacetazone is nowrecommended in places where HIVis common. In a district hospital inZambia a study found that HIVtesting and treating only those withHIV with more expensiveethambutol instead of thiacetazonecost the same as treating all patientswith the non-thiacetazone regimen.These regimens are now rapidlybecoming less expensive.

and sometimes fatal reactions in up to20 per cent of HIV positive TBpatients, including severe skin rasheswhere the skin peels off.

There is a danger that people willnot seek treatment because they areconcerned about side effects. InZambia, for example, it has beenreported that even people withoutHIV, who are not at risk of severe sideeffects, do not want the 'drug thatcauses the rash'.

What does this mean in placeswhere many people who need TBtreatment are infected with HIV?

.Educating staff and patients aboutside effects and continuing toprescribe thiacetazone is notacceptable given the seriousness ofthe adverse reactions and theproportion of patients with bothinfections who suffer from them.

.Testing all TB patients for HIV toexclude them from thiacetazoneregimens is not practical, as mostcountries do not have enough facil-ities, test kits and trained coun-

T he treatment of HIV infectedpeople with TB is the same as for

other TB patients with a few except-ions. HIV positive people with activeTB can be effectively treated using SCC.

There are two main issues to consider:

Uncertainty about HIV statusYou may suspect that a person whohas TB symptoms also has HIV

infection, but their HIV status is notconfirmed. It may be helpful to offeran HIV test, but only where voluntary

testing with pre- and post-testcounselling is available and confidential.However, it is not necessary for theperson to have an HIV test before

they begin TB treatment. Avoid

prescribing thiacetazone to anyonewith HIV or who may be at risk.

Adverse reactions and side effectsThe most important issue in treatingHIV positive patients for TB is adverse

drug reactions, especially to thiacet-azone. Thiacetazone, a sulphonamide,has been one of the main drugs usedfor TB treatment, in part because ofits low cost. However, it causes severe

~~

Sources: Dr Ricardo Barradas and Dr PaulaPerdigoo, Maputo Central Hospital,Mozambique, and WHO.

Thiacetazone can cause severe and sometimes fatal skin reactions in peoplewith HIV. Such reactions need prompt and rapid care.

Published by AHRTAG in the UKAIDS ACTION Issue 31 December 1995-February 1996

Skin reactions and careUnless the reaction is very mild, stop alldrugs until the person's conditionsettles down. Then restart the drugsone at a time, starting with those leastlikely to have caused the reaction. Adda new drug every few days if there is noreaction, until the person is on the fullregimen again, but without thiacetazone.If there is a fever and rash, give an

antihistamine drug if available..If there is a very severe reaction,

treat with steroids:40-60mg prednisolone daily in asingle oral dose, reducing the dosegradually every 2 days OR200mg hydrocortisone 3-4 timesdaily given intravenously, andintravenous fluids as required.

Severe reactions to thiacetazone andother drugs can cause most of the skinto blister and peel off. Hospital care isneeded, using similar principles as forthe management of burns. This means:.Protecting the exposed surface from

further damage..Cleaning the wound with normal

saline. After cleaning, the wound canbe left exposed, or covered with 0.5per cent chlorhexidine swabsmoistened and changed, or bathedwith potassium permanganate.

.Silver sulphadiazine cream, an anti-septic widely used in the treatmentof burns, should not be used.

.Control of infection is vital to avoid

sepsis..Nutritional support is important.

Feeding via a gastric tube issometimes needed.

T B programmes need to make surethat people with active TB take all

their drugs and complete their treat-ment (treatment adherence) whetherthey are being treated in hospital or athome.

Patients should only be hospitalisedif there is no alternative. T ransm issionof TB may be greater in over-crowdedhospitals than in a community setting.Some programmes hospitalise patientsfor the initial phase of therapy, if thereis no other way to guarantee

supervision.

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~~ci::a.

People with TB can choose their own 'treatment supporters' in the community.

approach, but only where there is aproperly functioning TB programme,with trained staff, good recordkeepingand guaranteed supplies of drugs. Ofthe 8 million people who develop TBdisease each year, only about 500,000have DOTS because of poor healthservices. Many people are still sentaway with six months prescription fordrugs, and often fail to take the comp-lete course. This unsupervised treat-ment also contributes to drug resistance.

.Enabling incentives such as travelexpenses or a meal

.Written or verbal agreementsbetween the person and healthprovider about treatment

.Setting up support groups, led bypeople cured of TB

.Making sure all members of theperson's family understand thetreatment and make sure theperson takes their medicine

.Explaining about TB and commonside effects of treatment, so that thepatient will not be worried and stoptaking the drugs if minor side effectsoccur

Encouraging treatment

What ;s DOTS?Ambulatory treatment (when theperson is well enough to be at homeand takes their medication on a dailyor intermittent basis) is the recom-mended approach, but it only workswhen the person is supervised takingtheir treatment by a health workerwhen they visit a clinic or during homevisits by an outreach or communityhealth worker.

This system, called Directly Observ-ed Therapy, Short course (DOTS) is amethod to ensure high levels of adher-ence and completion of TB treatment.It means setting up a system to ensurethat each person swallows every doseof their drugs. DOTS aims to help pat-ients complete their treatment -the'supervisor' can be a source of encour-agement and support for the patient.

The DOTS system works:.In Botswana TB patients attend thenearest primary health care facility totheir home for daily supervised treat-ment. People who fail to attend arefollowed up and traced by communityhealth workers, usually family welfareeducators, during home visits. Highadherence, of over 90 per cent, hasbeen achieved through intensiverepeated health education of patientsand their relatives, constant super-vision and followup and integrationinto PHC at the community level..A DOTS programme in New YorkCity uses outreach workers to reachpeople at home, in work places or liv-ing on the streets, and has achieved anincrease of 40 per cent in treatmentcompletion from 1989 to 1994.

WHO recommends that everycountry should adopt the DOTS

AIDS ACTION Issue 31 December 1995-February 1996Published by AHRTAG in the UK

These are ways to help people

complete treatment

.link TB with AIDS leading toadditional stigma.

People may self treat or use traditionalhealers instead of modern healthservices and drugs, if illness is believedto be caused by magic or witchcraft.Stigma means people may deny theirillness or try to hide it from theircommunity or family. Fear of rejectioncan be an important reason for not

.believe that TB cannot be cured anddo not know that with proper treat-ment people are no longer infectious

.think TB is a disease sent from god,or caused by magic or witchcraft

.be unaware of TB and its symptoms,how it is spread, and its seriousness

.think that TB only affects 'cursed' or'bad' people

.consider TB patients to be unclean

Published by AHRTAG in the UKAIDS ACTION Issue 31 December 1995-February 1996

E ncouraging people to seek andcomplete TB treatment is essent-

ial for successful TB care and control.

Understanding local beliefs, commun-ity education and health workertraining all play important roles.

Beliefs about TB and its causes are

important influences on people'sbehaviour. For example, studies havefound that people may:

"'"',' "'.c~ "

seeking help from health care servicesand for not completing a course oftreatment. Understanding theseattitudes and beliefs can help healthworkers to give more appropr- iateadvice and to provide more relevant!community health education.

Health worker attitudes andresources can cause people to delayseeking treatment and fail to completetheir therapy. In Nepal, games havebeen used during training to help healthworkers reconsider their attitudes.

A booklet developed inSouth Africa helpedpeople with TB andtheir families to dealwith the social impact ofTB as well as diagnosisand treatment.

TB educationIn South Africa a TB project found thatpoor communication between patientsand health workers and lack of educat-ional material were important reasonswhy people failed to complete theirtreatment. Health education materialin TB clinics was mostly not relevantto people's lives, covering clinical signsand symptoms and with pictures oflungs and bacteria. Health workerswere unaware of the concerns ofpeople with TB .

The project started by trainingnurses to run group discussions withpatients. The discussions revealed thatpeople with TB had low self esteem,experienced stigma, were afraid ofinfecting others, and stopped takingtreatment if they felt better after acouple of months to save time and

money.They needed clear information and

more support from health workers, soa booklet was developed using a storyand photographs based on the experi-ence of a woman with TB, showingtrue-to-life success, failures anddifficulties. The draft was pre-testedamong TB patients and received a verypositive response -many felt it couldhave been their story. At the back ofeach booklet is a treatment calendarwhich enables people to keep track oftheir treatment and encourages

completion.Evaluation has shown that patients

who are given a copy of the bookletare more likely to complete theirtreatment than those who are not, andthat the participatory research processhelped to improve nurses' under-standing and communication skills.Source: Judy Dick and Hester van de Walt,Medical Research Council, South Africa.

Adapted from:Where there's a will'a photonovella

developed by MRc,South Africa.

AIDS ACTION Issue 31 December 1995-February 1996Published by AHRTAG in the UK

0

~Advise people who may have infectious TB tocover their mouths when coughing.

0

~81:1--.~

An airy waiting area outside the clinic reducesthe risk of spreading TB infection.

AIDS ACTION Issue 31 December 1995-February 1996 Published by AHRTAG in the UK

Identify and treat people with infectious TB.If possible, keep potentially infectious patients separate and advise them tocover their mouth and nose when coughing if possible with a clean cloth.Surgical masks are not very effective, are expensive and increasestigmatisation of TB patients..All patients with TB symptoms, especially those with a cough, should bescreened for TB by sputum smear microscopy..Remember that the most infectious TB patients are those with pulmonarydisease who are sputum smear positive, and that people are no longer infectiousafter 2-3 weeks of treatment.

.Treatment should be in immediate a di nosis ofTB is confirmed.

Handle sputum safely.Sputum specimens should be collected away from general waiting rooms orhospital wards in a special receptacle or spittoon with a lid..Laboratories processing sputum specimens should follow guidelines toprevent transmission to laboratory workers. Preparing a smear is apotentially risky procedure and laboratory personnel should always wearmask and loves.

Care for people with infectious TB separately.Patients should only be hospitalised for TB treatment if absolutely necessary..Patients with smear positive pulmonary TB who are hospitalised should beaccommodated in separate wards, away from patients without TB, during theinitial phase of treatment until they are no longer infectious (smear negative).It is most important that infectious TB patients are separated from infantsand people with HIV, who may be more susceptible..HIV/AIDS patients suspected of having TB should not be admittedwards until the dia nosis is confirmed and treatment bun.

Ventilate wards and waiting areas.Proper ventilation is one of the most effective measures to reduce TB ..Waiting areas should be large, well ventilated or aired several times a day,with the windows open and uncurtained to allow sunlight in. Alternativelypatients can wait outside where there is more air circulating..Outpatient clinics where screening for TB takes place should also be wellventilated..TB wards with closed doors and windows open to the outside are ideal..Fans are useful for moving air from the wards to the outside..In colder climates where the windows need to be closed, it is important that airflow from TB wards is not directed to other arts of the ho ital.

Use natural UV light.Ultra Violet (UV) light kills TB germs. Sunlight is a good source of UV light..Special UV lights are not recommended because they have not been shown tobe effective. They are also expensive, require careful maintenance, and can beharmful if not installed ro rl.

Protect health care workers and others.If possible, health workers who know they are infected with HIV shouldavoid working with TB patients. Those who are not sure of their HIV statusneed counselling to help them decide whether or not they want to have anHtV test. In some places HIV positive health workers are offered preventiontherapy if they are working with infectious TB patients. The same principlesapply as to other HIV positive individuals (see page 15)..People with TB need to understand that they can transmit TB germs tostaff, other patients and visitors, and be encouraged to take the stepsdescribed above, to reduce the risk.Small children and infants who have to remain in hospital when theirmothers are being treated for TB should be given preventive treatment withisoniazid see e 8 .

Source: Control of tuberculosis transmissian in health care settings. Joint statement ofthe IUATLD and WHO TB Programme.

T B chemoprophylaxis meanstreating people with symptomless

TB infection to prevent the develop-ment of active disease. Preventivetherapy has been shown to be bene-ficial for people with both TB and HIVinfections who are at risk of rapidprogression to active TB disease. Dailyisoniazid (isoniazid preventive therapyor IPT) can reduce the incidence ofactive TB in HIV positive people.Before IPT can be considered, volun-tary HIV counselling and testing

facilities need to be available for peoplewho may have HIV.

There are still many questionsabout IPT. It is not clear at what stageof HIV disease chemoprophylaxis

should be given, or which drug regim-ens might be most effective. It is alsonot clear for how long people shouldcontinue to take preventive therapyand whether the benefits continueafter completing the recommendedperiod of therapy.

WHO recommendationsI. Isoniazid preventive therapy can beof value to individuals with both HIVand tuberculosis infection.2. Education about TB and its link toHIV infection should be part of HIVpre- and post-test counselling.3. People who are HIV positive:.should be screened for TB by

clinical examination..should receive a tuberculin skin test..if the tuberculin test is positive they

should receive a chest x-ray.4. People with symptoms consistentwith tuberculosis and/or an abnormalchest x-ray should have sputumcollected for bacteriologicalexamination culture.5. People with a positive skin test inwhom active TB has been excluded(by x-ray and culture) should be givenisoniazid at the daily dose of Smg/kgup to a maximum of 300 mg for 6-12months.6. Persons receiving preventive therapyshould be monitored monthly foradherence, toxicity and thedevelopment of active TB.Source: Preventive therapy for TB inHIV-infected persons, Lancet vol 345, 1995.

providing drugs for preventive therapyare not possible. Although IPT canprolong healthy life in individuals withHIV and TB infections, resourcesshould be prioritised for identifyingand treating smear positive patients.

Side effects Hepatoxicity (the risk ofhepatitis) is one of the most common

side effects of IPT and can be fatal. Therisk is higher in adults aged over 35

years. However in HIV positive peoplethe benefits of IPT generally outweighthe risk of toxicity, except in peoplewith chronic active hepatitis orpossibly those with more advancedHIV disease.

Drug resistance Preventive therapycould potentially increase drugresistance if it is wrongly given tothose who have active TB. The effectson the development of drug resistanceof large scale preventive therapy withone drug are not known.

Adherence Without good supportand supervision, there may beproblems in ensuring people take

preventive therapy for long periods oftime, especially if they do not have

symptoms of TB disease.

Drug resistance means that certainstrains or types of TB bacilli are notkilled by the anti-tuberculosis drugsgiven during treatment. Some strainscan be resistant to one or more drug.WHO defines a multi-drug resistant(MDR) strain as one that is at leastresistant to isoniazid and rifampicin. Aperson infected with MDR TB willtherefore not be cured by shortcourse chemotherapy which relies onthese two drugs.

common reasons for the developmentof resistance are:.incorrect prescription.irregular supply of drugs.lack of supervision and followup

There are two types of drugresistance:

Who should get IPI?IPT should only be given to HIV

positive people who have TB infect-ion but who do not have active TB.Those with active TB need full treat-ment. Giving only one drug to aperson with active TB can helpresistant strains of TB to develop.

Proper TB screening is essential to

ensure that preventive therapy is notgiven to patients with active TB. But itis not always easy to confirm whetherHIV positive individuals have active TB

disease or TB infection (see page?).The WHO guidelines for

tuberculosis preventive therapy in HIVpositive individuals should be followed

(see below). The guidelines emphasisethat IPT should only be considered for

HIV infected people with a positivetuberculin skin test who do not have

active TB.

Acquired resistance is whereresistance develops as a result ofinadequate treatment. Use of a singledrug is the most important cause ofacquired resistance. This is becausesome TB bacilli are naturally resistantto anti- TB drugs. If a single drug isused to treat a patient who is infectedwith a large number of TB bacilli onlythose which are sensitive to that drug

Why does drug resistance

develop?Drug resistance is caused byinadequate TB treatment and poor TBcontrol programmes. The most

Limitations of IPTResources In most developingcountries, voluntary counselling andtesting for HIV, screening all HIVpositive patients for TB infection, and

are killed, allowing the resistant bacillito multiply. This is the reason for using

several drugs during the initial intensivephase of treatment, until the number ofbacilli has been greatly reduced.

Primary resistance is when anindividual is infected by someone whoalready has drug resistant TB bacilli.The newly infected person will have

TB that is drug resistant from theoutset. The number of people withprimary resistance -who have drugresistant TB but who have not beentreated for TB before -is increasing.

is developing: for example. it has beenreported in Thailand. Drug resistanceis potentially a serious problem incountries where prescription ofanti- TB drugs by private physicians isnot well controlled.

WHO and IUATLD have developedguidelines to help countries detectstrains resistant to the main TB drugs

through national surveillanceprogrammes. Better information willhelp countries to decide which is the

most appropriate SCC drug regimenand the best strategies for

retreatment.

What are the dangers ofMDR TB?The most serious danger is that MDRTB is much more difficult to treat,even where second line drugs areavailable. Treatment of MDR TB cantake at least two years and the resultsare poor. Second line drugs cost 30-35times as much as drugs used in SCCtreatment of non-resistant TB. Patientswith MDR TB may need to be hospita-lised and isolated, which adds to thecost of treatment, to prevent trans-mission of primary resistant strains toothers. In the USA it is estimated thattreating one case of MDR TB costs tentimes as much as treating a case of TBsensitive to the usual drugs. Carefulprecautions are necessary to preventtransmission, especially to healthworkers caring for MDR TB patients.

Is MDR TB a major problem?In all countries and especially thosewhere the number of cases of TB is

rising rapidly because of the

association with HIV, the developmentof resistant strains of TB is a serious

concern.Between 50 and 100 million people

worldwide are thought to be infectedwith strains of resistant TB. Anaccurate picture of drug resistance is

not available because few countries

have a reliable drug resistance

surveillance system. Resistance varies,for example in Africa resistance toisoniazid is estimated at between 5 per

cent and I 0 per cent.Resistance to rifampicin, one of the

most effective TB drugs, is thought tobe low in Africa because the drug hasnot been widely available. But there

are signs that resistance to rifampicin

Clinical tuberculosis provides practicalinformation on all aspects of TB controland clinical care. Available for £3.00 in

English, French,'Spanish and Portuguese fromTALC, PO Box 49, St Albans, ALl 4AX, Hefts,

UK.Tuberculosis guide for low-incomecountries is a handbook providing infor-mation for staff involved in primary levelprevention and care. Single copies in English,French or Spanish free from IUATLD, 68Boulevard Saint-Michel, 75006 Paris, France.

TB and HIV: SidAlerte Supplement is

a quarterly magazine in French and Englishcovering good policy and practice in TB

and HIV care and prevention. For

subscription details write to SidAlerteInternational, 7 rue du Lac, 69003 Lyon,

France.

Childhood TB is a new briefing paperfrom AHRTAG. Available free to readers in

developing countries.

'Preventing infections in health-caresettings' provides practical guidelines onreducing the risk of blood and air-borneinfections. Available free to readers in

developing countries and for £5.00 elsewhere,

from AHRTAG.Please write to AHRTAG if you would like a full

list of the reference materials used for this

special TB and HIV issue.

I Articles were written by Kathy Attawell. withcontributions from Dr ET Maganu. Dr Rumisha.Dr Ian Smith. Dr Paul janssen. Sally Smith. DrDavid Wilkinson. Patricia Hudelson. S Chondoka,P Bwalya. Esther Sumatojo and others credited in

text. AA takes full responsibility for anyinaccuracies in the text.

Tackling TB and HIVWhat is TB?A growing crisisHow do TB and HIV interact?Numbers of people developing active TB 1990-1993*

Principles of TB controlProper detection and treatmentBCG vaccinationWomen and TBPreventive chemotherapy

TB programmesWays to work together: HIV and TB programmesTB programme activitiesCollaboration between TB and HIV/AIDS programmesWhat can NGOs do?What can health workers do?Keeping records

TB diagnosisDetection and diagnosisDefinitionsSputum smear microscopyCulturingTuberculin skin testingChest radiographyDetection and diagnosis of TB in people with HIV

TreatmentTreatment for TBPregnant women and young infantsHow to assess cure?Failure to respondTB SCC treatment for new cases, adults >50kgTB re-treatment for adults >50kgSide effects of drug treatment

Treatment issues for people with HIVCaring for people with HIV and TBSkin reactions and care

Supervising treatmentWhat is DOTS?Encouraging treatmentCommunity support

Education and trainingWorking with communitiesTB treatment gameTB education

Preventing TB in health facilitiesPreventitive therapyWho should get IPT?Limitations of IPTWHO recommendations

Drug resistanceWhy does drug resistance develop?Is MDR TB a major problem?What are the dangers of MDR TB?

Resources