TB plus HIV

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Transcript of TB plus HIV

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Sources

RNTCP guidelines Sep 2016

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Index

The burden of HIV TB Interactions between TB & HIV Treatment of TB & HIV in HIV-TB Impact of ART

Drug interactions & toxicity IRIS

3 ‘I’s approach

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The burden of HIV - TB

2.1 million PLHIV in India

10% global burden of HIV+TB

0.27% prevalence in population

6-8% prevalence : PLHIV visiting ART centre

Incidence relatively high despite ART

5% of TB : HIV + : >1 lakh/year

TB : 25% deaths in PLHIV

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HIV : Effects on TB

Risk increases after seroconversion : 2x within the first year (rapid depletion of TB-specific T helper cells) & increases with time.

Latent to active TB : 12-20 x Risk of new TB : 5-10% / year : 8x risk Rapid progression : outbreaks of MDR,XDR Recurrence after successful treatment : Usually

exogenous re infection

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HIV : Effects on TB

Atypical presentation Extra pulmonary : 4x Smear negative Normal CXR 20% Lower lobe

involvement

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TB : Effect on HIV

Increases risk of progression to AIDS or death TB infection : significantly increased plasma

HIV viremia Generalized immune activation due to TB :

increased CD4 : targets for HIV Increased expression of HIV coreceptors CCR5

& CXCR4 in TB-HIV

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Rx of TB in HIV -TB

Cat,Rx, followup & testing as for HIV neg Check for DST before initiation Drug sensitive TB & second line ART

Rifabutin 300mg x 3/7 or 150mg OD Rifampicin suppresses bio availability of Ritonavir

boosted Atazanavir/Lopinavir/Darunavir ART 2w-8w + CPT to prevent OI

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Rx of HIV in HIV-TB

First line : TLE as per NACP Second line :

T/L/Pi Z/L/Pi St/L/Pi Ab/L/Pi

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Impact of ART

Reduces the risk of developing TB Relative risk remains high Reduces mortality & morbidity

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Impact of ART

Drug interactions Shared toxicity High pill burden Paradoxical IRIS

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Drug interactions & toxicity

Rifampicin decreases [Efavirenz] concn : Use 600mg/day ( 800mg in >50kg)

OCP decrease [Efavirenz],[Rifampicin] Hepatotoxicity of both

INH,RIF,PZA,MOX,PAS NVP ( Fatal hepatic necrosis), PI

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TB associated IRIS

Paradoxical worsening after ART Biphasic : 3-6 m CD4 memory, exp of naive

CD4 from thymus, total CD8 initially inc, memory CD8 later declines

Inc markers of immune activation, pathogen sp delayed hypersensitivity, almost 3x inducible lymphocyte proliferation ( Ifn y, TNF a, CRP, IL-2,6 & 7)

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TB associated IRIS

33% HIV/TB 5d – 3m on ART especially CD4<50/uL Fever, worsening of LN/resp disease,stridor Self limited usually

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Criteria & treatment

Criteria Low CD4 (<100) exception TB + virological & immunological response R/O DR infection, bacterial super infection, allergy, non

compliance, reduced drug levels, abacavir hypersensitivity Temporal association Inflammatory response

Predn (1.0 mg/kg, max 80mg/d) or dexa 8-16 mg/d divided in twice daily doses; tapered/1-2m adjunct to AKT & CART

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Single Window approach & 3 ‘I’s

Intensified TB case finding Isoniazid Preventive Therapy Airborne Infection Control

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Intensified case finding

Adult : 1)Current cough2)Fever3)Weight loss4)Night sweats

Children : 1)Current cough2)Fever3)Lack of weight gain4)Contact with a TB

case4-S screening (a) 85% sens(b) 98% NPV(c) Meta analysis of 12 studies & 8,148 PLHIV

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Approach to presumptive TB

Priority CBNAAT ( 84% sens comp to 53% smear)

Daily FDCs ( switch to daily if prev. on 3/w) 2HRZE + 4HRE 2HRZES + IHRZE + 5HRE ( previously treated)

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LTBI

Infection without signs/ symptoms/ radiographic/bacteriological evidence

Endemic : TST / IgRA 6m INH/ 9m INH/ 3m Rifp + hi dose INH / week

are equivalent IPT 6m recommended

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IPT

Indications 1) 4S neg2)LTBI in adult & children ( +TST unnecessary)3)Children post Rx4)Previously / Recently Rx TB

With ART : safePregnancy & lactation : safe

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IPT

CI Active TB/hepatitis PN Poor adherence to Septran preventive therapy Contact with MDR TB Completed DRTB therapy

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IPT

Dose Adult H 300 + B6 50mg Children > 12m : H 10/kg + B6 25mg

Duration : 6m Less chance of H res in LTBI

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IPT Spl Sit

Children born to Micr. + TB : IPT if active TB

TB during IPT : DST & if S Cat I ( if IPT < 1m &

Rx naive), else II IPT LFU/toxicity :

restart if gap <3m; else don’t

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Thank you