TB treatment for HIV patients by stephan2

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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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