Case management of TB With HIV/AIDS co
Case management of TB With HIV/AIDS co-infection Chris Nelson, Public Health Nurse Disclosures none Global TB/HIV 2011---13% TB cases are co-infected Estimated 400,000 people Leading cause of death among people with HIV Global Leading Causes of Death, 2008 SOURCE: http://who.int/mediacentre/factsheets/fs310/en/ 32 TB Case Rates in U.S.-born vs. Foreign-born Persons United States, 1993–2011* Cases per 100,000 HP 2020 GH-2 Target: 14.0 17.2 National Tuberculosis Surveillance System, data updated as of June 25, 2012. 47 HIV Co-infection Among TB Patients: U.S., 1993-2011 Percent 30 25-44 years 25 20 15 All ages 10 5 0 1993 1995 1997 1999 2001 2003 2005 SOURCE: National Tuberculosis Surveillance System Highlights from 2011, CDC/NCHHSTP. 2007 2009 2011 39 General Considerations About 10% of all TB cases in US are HIV-infected. Many are unaware of their HIV status and do not acknowledge their risk factors Clinical presentation of TB in the HIV-infected may differ from other immunocompetent clients—especially if CD4 counts <200 CXR may be normal (usual cornerstone to diagnosis) Extra pulmonary TB is more frequent (so signs and symptoms vary per site of infection) With extra pulmonary TB-must r/o pulmonary TB Wisconsin Numbers 2012 – 71 TB disease cases with 4 being co-infected 2013 – 50 TB cases with 2 co-infected LTBI – # unknown as we do not record this data 2012—new HIV recorded-241 plus 157 more that moved into WI Current cumulative +HIV known cases in WI: ◦ At the end of 2012-- 6,547 individuals presumed to be alive and living. ◦ 76% of this +HIV 2012 number were diagnosed in WI ◦ 18% of +HIV are unaware of their diagnosis-per CDC Issues to Consider Current IGRA tests are not currently licensed to be used with immune compromised such as HIV/AIDS. TST may not be accurate if: ◦ low CD-4 count, ◦ concurrent bacterial, fungal or viral infection ◦ TB disease is present Do 2-step if never tested. ◦ If 0mm TST repeat if CD4 is 200 or over. Clients with HIV have a 7-10% risk of progressing from LTBI to TB disease per year. (Contrast to 10% for others over a life time) For HIV+, TB disease must be ruled out prior to LTBI treatment Meds used to treat TB and HIV have many potential drug interactions and over lapping toxicities-this complicates treatment. Possibilities: ◦ treatment failure for either TB disease or HIV or both ◦ Possible: paradoxical reactions during treatment for both Other overlapping risks may exist: ◦ Hep B/C, chronic liver disease, ETOH use, pregnancy, age and other offending OTC agents (Tylenol) Potential Daily Living Issues Mental, Emotional, and Cognitive status Access to transportation Usual places of residence, where and how to locate the client, impending plans to relocate, travel, housing needs and living situation Cultural and religious beliefs that may impact adherence Language and literacy barriers Substance abuse Ability to pay for medical care Work history/income source Support systems Family dynamics Treatment LTBI tx should be daily and all options may be used if not on ART Length of TB disease tx is similar for those that are HIV+ and those who are not +HIV (6-9 months) +HIV with drug-susceptible TB respond well to standard treatment TB disease tx should be daily-not intermittent (some studies from NY confirm rifamycin containing regimens given intermittently caused resistance) TB disease--potential for immune reconstitution inflammatory syndrome (IRIS) if both TB medications and ART are started at the same time. Medical experts should guide treatment (esp. drug-drug interaction and clinical response to therapy is slow) Treatment Options For clients that have not started ART- at the time of TB diagnosis, many MD’s defer the initiation of ART until the intensive 1st phase (first 2-months) of TB treatment is completed. MD’s can manage the med side effects from TB drugs without the complications of ART. This also minimizes the likelihood of immune reconstitution syndrome(IRIS) Pill burden is also more tolerable If TB is diagnosed after client is on ART, their ART regimen may need to be changed to be compatible with TB treatment. Anti-TB regimens may be modified to not contain any rifamycins. Pregnant women are challenging-as ART regimens are difficult when rifabutin is not an available option Monitoring Therapy Common baseline blood tests: LFT’s, CBC with differential, CD4 counts Client should be seen by MD monthly-at minimum Sputum for smear/culture monthly until #2 consecutive neg cultures If initially smear +, test more frequently (q 2 weeks to assess Tx response Repeat CXR after 2 months of Tx End of Tx CXR Repeat drug susceptibility testing if culture + after 3 months of Tx Daily DOT Always assess for OTC meds, diet issues, weight loss, GI upset, alcohol and other substance use. Report: vomiting-as this may require addition of meds to control and be given before meds are taken. Assess for peripheral neuropathyIf on EMB-baseline eye exam (acuity/color)-monthly while on this med Therapeutic Drug Monitoring Need to be considered in clients who are slow to respond to Tx or have complex Drug-drug interactions. Consider this when on cycloserine Symptom Concerns Risk of adverse reactions to TB tx is higher in HIV+ occurring about 25% and 13% respectively Hepatotoxicity is common in tx of TB for HIV+ esp. if on ART, antibiotics, or co-infected with HepB/C Symptoms can be subtle and mimic drug effects, indigestion or another infectious process (decreased energy or appetite, fatigue, indigestion, abdominal discomfort, nausea, vomiting, myalgia and rash Evaluating a Rash Early: it can be maculopapular. If this rash does not resolve in 24 hours or have a likely cause-refer to provider. LFT’s may be needed. Some of the antiretrovirals (abacavir) can cause this and it maybe life threatening. Rashes warrant a thorough and prompt evaluation by the medical provider. Drug and Food Interactions Multiply significant Drug-Drug interactions especially with TB/ART meds. Also INH-may increase hepatotoxicity, may cause problems with many seizure and psych meds Rifampin-decrease many other medication effects Food/Drug interactions: ◦ Some TB meds need to be taken 1-2 hr before a meal (INH, Rif,) ◦ Some meds may to be taken with food (ethambutal, PZA, ethioamide, amikacin, capriomycin, para-aminosalicylic(PAS), linezolid) ◦ Some meds may require increased fluid intake (amikacin, streptomycin, capreomycin, PAS ) Need to avoid alcohol Client may need vitamin supplements with some meds Diet becomes very important-need for weight checks on regular basis Indicators Needing Attention DOT failure Slow sputum conversion or delayed clinical improvement Marginal or no acceptance of TB diagnosis Clinical deterioration while on TB therapy Failure to attend medical appointments Pregnancy Substance abuse Malabsorption of TB medications Complaints that TB medications taste bad or make the client sick. Final words Case management requires good communication with all providers of care Client education to ensure compliance Support of other systems if problems arise during tx Problems will arise
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