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TB treatment for HIV patients
Capacity Building for Tuberculosis control,
with a specific focus on TB/HIV in CAREC
Member Countries
Pan American
Health
Organization
First line anti-TB drugs
Mode of Potency Recommended dose (mg/kg
action of body weight)
Daily Intermittent (3
times a week)
Isoniazid (I) Bactericidal High 5 10
Rifampicin (R) Bactericidal High 10 10
Pyrazinamide (P) Bactericidal Low 25 35
Streptomicycin (S) Bactericidal Low 15 15
Ethambutol (E) Bacteriostatic Low 15 (30)?
Thioacetazone (T) Bacteriostatic Low Not aplicable
Pan American
Health
Organization
Population of TB bacilli
• Metabolically active I
• Bacilli inside cells (macrophages) P
• Semidormant bacilli (persisters) R
• Dormant bacilli
Pan American
Health
Organization
Standardized regimens
Diagnostic TB Patients Initial Phase Continuation
Category Daily or 3x/wk Phase
Daily or 3x/wk
I New ssm+
New ssm- (extensive)
2HRZE 4HR or
6HE daily
Severe HIV disease or
severe forms of EP
II Previously treated ssm+:
relapse
2HRZES / 5HRE
Rx after failure
1HRZE
Rx after interruption
III New ssm- (other than
category I)
2HRZE 4HR or
Less severe EP
6HE daily
IV Chronic and MDR-TB
(still ssm+ after
Specially designed standardized or
individualized regimens
supervised re-Rx)
Pan American
Health
Organization
Monitoring of patients with SS (+)
When to monitor 8-month 6-month
treatment regimen treatment regimen
At time of diagnosis Sputum smear Sputum smear
At the end of initial phase Sputum smear Sputum smear
In continuation phase Sputum smear Sputum smear
(month 5) (month 5)
During last month of treatment Sputum smear (month Sputum smear
8) (month 6)
Pan American
Health
Organization
Action in interruption of TB treatment
Interruption for less than 1 month
•Trace patient
•Solve the cause of interruption
•Continue treatment and prolong it to compensate for the missed dose
Interruption for 1-2 months
Action 1 Action 2
•Trace patient If smears (-) or Continue treatment and prolong it to
•Solve the cause of EPTB compensate for the missed dose
interruption Treatment Continue treatment and
If one or more
•Do 3 ss. Continue smears (+) received: less prolong it to compensate
treatment while waiting than 5 months for the missed dose
for results
more than 5 Cat I: start Cat II
months
Cat II: refer
Pan American
Health
Organization
Action in interruption of TB treatment
Interruption for 2 months (DEFAULTER)
•Trace patient If smears (-) or Clinical decission on individual basis
•Solve the cause of EPTB whether to restart or continue the
interruption treatment, or no further treatment
•Do 3 ss. Continue
treatment while aaiting
for results If one o more Category i Start Category II
smears (+)
Category II Refer
Pan American
Health
Organization
GDF standard treatment kit
Pan American
Health
Organization
Sample regimens with fixed dose combination of anti
TB drugs in adults
Weight in Kg
30-39 40-54 55-70 +70
Initial phase (daily)
HRZE 75mg+150mg+400mg+275mg 2 3 4 5
or HRZ (75mg+150mg+400mg) 2 3 4 5
Continuation phase (daily)
HR 75mg+150mg 2 3 4 5
or HE 75mg+400mg 1.5 2 3 3
Continuation phase 3 times weekly
HR 75mg+150mg 2 3 4 5
Pan American
Health
Organization
Calculation of drug requirements
1. Calculate drug requirements to treat ONE
patient for each category
2. Multiply by the number of patients you are
expecting this year for each category
3. Multiply by 2 for 1 year of reserve stock
4. Subtract current stock
5. Amounts needed after subtracting current
stock
Pan American
Health
Organization
Calculation of drug requirements
Weight in Kg
Drug Tablets Multiply by 2 Stock as the last Amounts
needed to for reserve day of the needed
treat * stock previous quarter
HR
H 100mg
R150mg
Z 500mg
E 400 mg
*Tablets needed to treat:
Category I: a patients x b tablets
Category II: c patients x d tablets
Pan American
Category III: e patients x f tablets
Health
Organization
TB treatment for PLWHA
Pan American
Health
Organization
PERU: decrease of the fatality rate in co-infected
patients.
Early detection and DOTS
1996 2000
PLWHA All TB cases PLWHA All TB cases
(HIV-) (HIV-)
Total 118 22 926 339 21 390
Deaths 73 596 131 449
Percent 61,9% 2,6% 38,6% 2,1%
RR 23,9 18,9
Pan American
Health Fuente: Ministerio de Salud, PNCT Perú.
Organization
TB treatment for PLWHA
The same categories for TB patients
irrespective HIV status
Pan American
Health
Organization
Standardized regimens
Diagnostic TB Patients Initial Phase Continuation
Category Daily or 3x/wk Phase
Daily or 3x/wk
I New ssm+
New ssm- (extensive)
2HRZE 4HR or
6HE daily
Severe HIV disease or
severe forms of EP
II Previously treated ssm+:
relapse
2HRZES/ 5HRE
Rx after failure
1HRZE
Rx after interruption
III New ssm- (other than
category I)
2HRZE 4HR or
Less severe EP
6HE daily
IV Chronic and MDR-TB
(still ssm+ after
Specially designed standardized or
individualized regimens
supervised re-Rx)
Pan American
Health
Organization
Implications of HIV for TB treatment
in PLWHA
• Treatment is the same, except for the use of
Thioacetazone
• Increased risk of adverse drug reactions
• Monitor to identify and treat O I during TB treatment
• Increased case fatality rate, but response in survivors
is similar to HIV (-) patients
• Recurrence of TB after completion of treatment is
higher in HIV (+): 5-10%
• Risk of developing resistance to R, if CD4 < 100
/mm3
• Drug interactions: R with ARV
Pan American
Health
Organization
Drug interactions: R with ARV
• Mechanism: R stimulates the activity of
cytochrome P450 liver enzyme system.
• P450 liver enzyme system metabolizes
PIs and NNRTIs
– PIs: SQV, RTV, IDV, NFV
– NNRTIs: NVP, EFV, DLV
Pan American
Health
Organization
When start ARV treatment in TB
patients?
TB patient
HIV (-) HIV (+)
CD4 CD4
CD4< 200 / mm3 CD4>350 / mm3
200-350/mm3 No available
Start ARV Start ARV
Delay ARV
2weeks-2months After initial phase
Pan American
Health
Organization
Immune reconstitution syndrome
• Developed in up to 36% of patients if ART
» 7% if no ART
• Fever, worsening chest infiltrates in X Ray and
peripheral and mediastinal lymphadenopathy.
• Lower VL, increase reactivity to PPD
• Generally, self-limited, and last 10 - 40 days.
• If the reaction is severe: short course of
corticoid
Pan American Source: Havlir et Barnes, 1999. NEJM
Health
Organization
Thank you!
Pan American
Health
Organization
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