TREATMENT OF OPPORTUNISTIC INFECTIONS OF HIV WITH REFERENCE TO TB ...

TREATMENT OF OPPORTUNISTIC INFECTIONS OF HIV WITH REFERENCE TO TB MANAGEMENT BY DR. J. A. OSHO MEDICAL ADVISOR DAMIEN FOUNDATION BELGIUM WHAT ARE OPPORTUNISTIC INFECTIONS IN HIV  These are infections or disease conditions, which takes advantage of the depressed immunity of HIV infected person.  List of common OIs / Conditions in Nigeria:  The common opportunistic infections are due mainly to: viral, fungal, bacterial and parasitic/ protozoa organisms. These include: Viral –Herpes Simplex Herpes Zooster, Multiple bluish nodules (Kaposi sarcoma) Human papiloma virus (vaginal warts) Viral upper respiratory tract infection. Fungal – Ringworm, Nail infections Candida infections OIS CONTD • Bacterial – Papulo-pruritic eruptions, Pneumonia, Diarrhoea diseases, Urinary tract infection TB is the commonest opportunistic infection among PLWHA. • Protozoal / Parasitic - Scabies, Diarrhoeal diseases Malaria Compared with an individual who is not infected with HIV, a person infected with HIV has a 10 times increased risk of developing TB. Epidemiology - An HIV prevalence of 10% in a community will cause an excess of 49% in TB cases (van Cleef 1995). Proportion of new TB cases attributable to HIV co-infection (Dolin 1994): 4% in 1990 8% in 1995 14% in 2000 - 1 in 7 cases of TB globally is attributed to HIV in 2000 (Pozniak 1999). In Sub-Saharan Africa >30% of TB cases are associated with HIV, with figures as high as 70% in some countries e.g. Malawi and Zambia. In a 1994 study in Shashemene, Ethiopia, 44% of 450 TB patients when screened were HIV positive (Gellete 1997).  Lifetime risk of developing disease in a person with latent TB infection HIV-negative: 5 - 10% HIV-positive: 50 - 80% (with a 10% annual risk in the early years post-infection with TB) HIV and the diagnosis of TB - Requires high index of suspicion and, sometimes, supportive radiological investigation. But sputum smear examination remains the main tool of investigation - Clinical presentation of TB patients with HIV co-infection depends on the stage of the HIV-infection and can be broadly classified as early and late presentation - Smear positivity rates among HIV+ve TB patients are the same as among HIV-ve TB cases - In the early stages of HIV-infection, the clinical presentation is almost indistinguishable for that in other TB patients - In the terminal stages, the presentation can be atypical and extrapulmonary forms like TB pleurisy, miliary TB etc occur  HIV is known to increase the burden of TB; according to the 2001 sentinel survey in Nigeria the prevalence of HIV among TB patients is 19.1%. Current WHO estimate in 2005 IS 27%.  On the other hand, it is estimated that TB is the most common cause of death among People Living With HIV/AIDS (PLWHA) and is responsible for 30-40% HIV/AIDS death globally.  Therefore it is imperative that health workers be alert to the interaction between these two diseases and learn to manage conditions arising from them competently. Presentation in early and late stages of HIV infection Stage of HIV-infection Early stage Clinical picture 1. cough > 3 weeks 2. productive cough Late stage / clinical AIDS 1.dry cough, not productive X-ray picture 1.upper lobe infiltrates 2.cavitation 3.nodular or patchy shadows 1.lower lobe infiltrates, no cavitation 2.mediastinal lymphadenopathy often and/or pleural effusion 3.sometimes miliary or interstitial pneumonia 1. often negative (<50%) Sputum smear 1.often positive (>80%) Nigerian HIV Prevalence Trend (1991-2005) 7 6 5 4 3 2 1 0 1991 1993 1996 1999 2001 2003 2005 5.4 4.5 3.8 5.8 5.0 4.4 1.8 Prevalence of HIV among TB patients from 1991 - 2001 20 18 16 14 12 10 8 6 4 2 0 1991 1993 1995 . 2001 TB MANAGEMENT  GLOBALLY A STRATEGY HAS BEEN ADOPTED FOR THE MANAGEMENT OF TUBERCULOSIS CALLED DIRECTLY OBSERVED TREATMENT SHORTCOURSE (DOTS) DOTS HAS 5 COMPONENTS History of DOTS expansion 1991: WHA establishes the 70/85 targets for 2000 1993: TB as a global emergency 1994: New TB control framework 1995: DOTS launched as a brand 1996: Global monitoring established 1998: London committee assesses constraints 1998: StopTB Partnership launched 2000: Amsterdam declaration; targets in 2005; DEWG 2001: GDEP and GDF launched 2001: GPSTB and Washington Commitment (+GFATM) World Health Organization COMPONENTS OF DOTS 1. Government Commitment COMPONENTS OF DOTS 2. Case Detection by Sputum Microscopy COMPONENTS OF DOTS 3. Direct Observation of TB Treatment by Health worker COMPONENTS OF DOTS 4. Provision of un-interrupted supply of anti-TB drugs for 8 month COMPONENTS OF DOTS 5. Standardised recording and reporting system Management of TB suspect Cough ≥ 3 wks – Collect 3 sputum specimen Sputum AFB Microscopy AFB +ve AFB doubtful AFB -ve Broad-spectrum anti-biotics x 7/7, Review in 2/52 Repeat 3 specimen No improvement Improved ≥ 1 +ve All -ve Its not TB! ESTABLISH DIAGNOSIS AND TREAT ACCORDINGLY! TREAT AS TB! REVIEW AND ORDER CHEST X-RAY! TB features No TB features Criteria for assigning treatment Information needed: Age History of previous anti-TB exposure Other medical conditions Pregnancy HIV status Other contra-indications Pre-treatment weight Drugs used in TB treatment Rifampicin (R) Isoniazid (H) Ethambutol (E) Pyrazinamide (Z) Streptomycin (S) Thiacetazone (T) Drug Development Timeline 1940s Selman Waksman cultivated actinomycin and streptothricin, which were toxic. The cultures used were Actinomycetes, Aspergillus, and Mycotorula. Finally, streptomycin was created. 1944 Streptomycin was first administered to a human patient on November 20. This is an effective treatment of TB. 1947 Streptomycin resistance. 1948 The drug p-aminosalicylic acid (PAS) is created. 1949 Streptomycin and PAS used together. 1951 A new drug, Isoniazid (INH) is created. Used with PAS, it is more effective than streptomycin and PAS. 1954 The drug Pyrazinamide is created. 1955 Cycloserine is produced. 1962 Ethambutol is created. 1963 Rifampicin is used to treat tuberculosis. ** The drugs in bold are commonly used today as a multiple against MDR TB. Theoretical model of drug action B= semi-dormant bacilli (Persisters) existing in relatively hypoxic environ of caseous tissue which undergo occasional spurts of metabolism. B® A= Metabolically active and dividing bacilli growing inside well oxygenated walls of cavities. A(RHS) D D= dormant bacilli which die on their own and or cleaned up by immune system c (Z) C= semi-dormant bacilli existing in an acidic environ either intracellular (inside macrophages) or extra-cellular Treatment Regimen Type of TB patients All new cases (i.e. smear positive/negative or EPTB) Cat. 2 Cases of Relapse, 2SRHZE/1RHZE/5RHZ Failures, RAD and others E Cat. 1 2RHZE/6EH TB Monitoring When? 1st patient’s visit (diagnosis) What do I do? 3 sputum specimen Result? Positive Conclusion? TB case Action! Start DOTS! Negative May be not TB REFER! End of 2 months 2 sputum specimen Positive Intensive Rx not enough Intensive Rx enough Treatment failed Patient improving Extend 1 month! Negative Start Continuation End of 5 months 2 sputum specimen Positive Start CAT II Rx Negative Continue Rx End of 7 months 2 sputum specimen Positive Treatment failed Excellent! Start CAT II Rx Give last Rx DECLARE CURED! Negative ARV regimen:  1st line drugs:  Nevarapine (NVP) 200mg o.d  Lamivudine (3TC) 150mg b.d  Stavudine D4t/Effavirenz 300mg b.d/600mg o.d 2nd line drugs  Indinavir  didanosine (Ddl)  Zidovudine (AZT) When to start ARV for TB patient with HIV Situation Action PTB patient & CD4 Start DOTS. Start ARV count <50mm3 or EPTB as soon as TB treatment is tolerated PTB with CD4 count of 50-200mm3 PTB & CD4 count >200mm3 Start DOTS. Start ARV after 2 months of TB treatment is tolerated Treat TB, monitor CD4 count. Start ARV when indicated. Steps for administering ARV & DOTS Situation New TB case( cat 1) & HIV + ve ( stable) Recommended Actions Provide counseling Start DOTS Complete intensive phase (IP) Commence ART not early than 2 weeks after IP TB patient already on DOTS & Provide counseling tested +ve for HIV Complete IP DOTS Commence ART not early than 2 weeks after IP If pt was in continuation phase, Commence ART Steps for administering ARV & DOTS Cont: Situation New TB case ( cat 1) & HIV + ve ( stable) Recommended Actions Provide counseling Start DOTS Complete intensive phase (IP) Commence ART not early than 2 weeks after IP TB patient already on DOTS & tested +ve for HIV Provide counseling Complete IP DOTS Commence ART not early than 2 weeks after IP If pt was in continuation phase, Commence ART Overall impact of HIV on TB control  increased overall numbers of TB cases  drug reactions and interactions are more common  mortality rate, whilst on treatment, is higher (mostly attributed to other HIV-related diseases)  higher relapse rate and worse response to standard chemotherapy  over-diagnosis of smear-negative PTB Overall impact of HIV on TB control Cont:  under-diagnosis of smear-positive PTB  inadequate supervision of anti-TB chemotherapy  low cure rates  high default rates because of adverse drug reactions  delayed reporting of patients because of the fear of having HIV-infection  when diagnosed as TB  increased emergence of drug resistance THE STOP TB STRATEGY VISION GOAL OBJECTIVES A TB FREE WORLD To dramatically reduce the global burden of tb by 2015 in line with the Millenium Development Goals and Stop TB Partnership targets Achieve universal access to quality diagnosis and patientcentred treatment Reduce human suffering and socioeconomic burden associated with TB. Protect vulnerable population from TB, TB/HIV and multiple drug resistance Support the development ofnew tools and enable their timely & effective use. MDG 6, Target 8: Halt and begin to reverse the incidence of TB by 2015 -2005: detect at least 70% of infectious TB cases and cure at least 85% of them - 2015: Reduce prevalence of & death due TB by 50% relative to 1990 TARGETS Components of the Stop TB Strategy 1. Pursue quality DOTS expansion and enhancement.- 5 components of DOTS. 2. Address TB/HIV, MDR-TB and other challenges.- TB/HIV collaborative activities. 3. Contribute to health system strengthening 4. Engage all care givers- PPM DOTS 5. Empower people with TB, and communitiesAdvocacy Communication &Social Mobilisation 6. Enable and promote research 1. ESTABLISH THE MECHANISM FOR TB/HIV COLLABORATION AT NATIONAL LEVEL A. National TB/HIV working group inaugurated on 22nd June 2006.  4 Sub Committees. - Technical. - Resource Mobilization and Coordination - Research and M&E - ACSM TOR – TWG 1. Facilitate collaboration between TB and HIV/AIDS programmes at all levels.  2. Support Government to Coordinate activities of partners – both individuals and institutions which have recognized experience in controlling TB/HIV  3. To review periodically National TB/HIV strategic framework guidelines and any other documents to guide all stakeholders for better TB control among HIVinfected people and effective HIV prevention and care among TB patients. TOR Contd. 4. Support in the dissemination of the Technical Guidelines. 5. Mobilize Financial and Technical Resources for implementing Collaborative TB/HIV activities. 6. Promotion of National Research in TB/HIV control State Working group  6 States – Adamawa, Benue, Ebonyi, Ogun, Rivers and Sokoto. Health workers from ART sites and Community support group in 6 states trained on implementation of joint TB/HIV activities. Funding from USAID to implement the plan in 6 states.  State TWG – Gombe  What of my State. B. SURVEILLNACE OF HIV PREVALENCE AMONG TB PATIENTS  Sentinel Survey. Routine Collection of Data New TB Reporting format. - Patient Treatment Card. - LGA Central Register. - Case Finding. - Treatment Outcome. - Referral/Transfer forms. C. JOINT PLANNING. SASCP S.M.O.H STBLCP What Can I do in my state to enhance Joint Planning? 2. DECREASE THE BURDEN OF TB AMONG PEOPLE LIVING WITH HIV/AIDS. A. Establish Intensified TB case finding. 25 FGN ART sites trained to implement DOTS. ABU Teaching Hospital Zaria, FMC, Gombe. FMC, Markurdi UMTH, Maiduguri. JUTH, Jos, FMC Azare, FMC, Owerri., FMC, Uyo. FMC, Asaba. FMC, Umuhaia, Abia , UPTH, Port Harcourt. UNNTH, Enugu. Military Hospital, LUTH, Lagos. FMC, Abeokuta. UITH, Ilorin. UCH, Ibadan, State House Clinic, Abuja. CBN, Abuja. FMC, Katsina, Federal Staff Hospital, Abuja. FMC, Lokoja , FMC Bida and FMC, Keffi Action Point - To know If activities has fully commenced in these facilities and if not, what to do to kick start. Health Facilities.  3 LGAS/State X 6 states = 18 LGAs.  2 DOTS clinic/LGAs = 36 DOTS sites.  1 ART facilities per state.  1 Support group per state. KM KM DECREASE THE BURDEN OF HIV AMONG TB PATIENTS. A. Provide HCT.  A situational analysis visit was conducted A total of 18 LGAs, 36 DOTS centers, were identified to implement collaborative TB/HIV activities. Health workers from the DOTS sites trained on implementation of collaborative TB activities and capacity build to offer basic counseling for TB patients and Suspects attending the DOTS clinics.  Laboratory Personnel trained.  Free Testing Kits – 32,500 TB Suspects and patients  Parallel test – Determine and Stat park.  15,000 Cappilus and Determine B. Introduce co-trimoxazole preventive therapy  Ensure HIV/AIDS care and support D. Introduce antiretroviral therapy Recommended Collaborative activities. A. Establish the mechanisms for collaboration  A.1 Set up a coordinating body for TB/HIV activities effective at all levels  A.2 Conduct surveillance of HIV prevalence among tuberculosis patients  A.3 Carry out joint TB/HIV planning  A.4 Conduct monitoring and evaluation B. Decrease the burden of tuberculosis in people living with HIV/AIDS  B.1 Establish intensified tuberculosis case-finding  B.2 Introduce isoniazid preventive therapy  B.3 Ensure tuberculosis infection control in health care and congregate settings Contd. C. Decrease the burden of HIV in tuberculosis patients C.1 Provide HIV testing and counseling C.2 Introduce HIV prevention methods C.3 Introduce co-trimoxazole preventive therapy C.4 Ensure HIV/AIDS care and support C.5 Introduce antiretroviral therapy IPT (ISONIAZID PROPHYLAXIS THERAPY  IPT CONTROVERSY  Use since 50-60 to prevent infection in contacts  HIV and TB are common in Nigeria  HIV is a major catalyst for activating TB  Studies in various HIV populations show  INH protective (SA,Botswana,Senegal) and other parts of the world Use is evidence based  11 pooled studies showed 62% protection against active TB in mantoux positive and 33% in those without disease  Rio-de Janeiro: protection is most marked when IPT is used with ARV (Toronto 2006) succeed, we must try… and try again. e must believe in what we are doing. e must not give up. e must be patient. e must keep pushing. Only those who persevere succeed handle with care Parting Statement When the right hand washes the left and the left washes the right , both hands become clean. You can only beat our chest with a full palm. Nigérian proverbes. The bridge is generally repaired only We can only win this battle against after someone falls two water.. he the ambush by thesein thediseases if bridge is generally repaired only after all involved in the control programme someone falls in the water.. are united. THANKS FOR YOUR PATIENCE.