Session 9: Tuberculosis and HIV Co-Management

Integrated TB-HIV Care and Treatment

This session will focus on a discussion of approaches to take to integrate TB and HIV efforts in a way that will provide clients with seamless care for both infections under one roof.

Learning Objectives

By the end of this session, you will be able to:

Describe TB/HIV collaborative framework.
Describe how to reduce the burden of TB among PLHIV.
Describe five methods of decreasing the burden of HIV in TB clients.
Describe the one-stop-shop model for TB/HIV care.

Learning Activities

TB/HIV Collaborative Framework (5 min)

TB is the most common opportunistic infection for PLHIV and accounts for one third of all deaths among this population. In Zimbabwe, the national TB/HIV co-infection rate stands at 67% (Global TB report, 2017). HIV infection increases the risk of developing TB and PLHIV have a 10% annual risk of developing TB, compared to a 10% lifetime risk in the general population. Clients with TB-HIV co-infections are at risk of poor treatment outcomes and thus require close clinical monitoring.

To support efforts of addressing the needs of this special population, the WHO recommends integration of TB and HIV activities through various areas of collaboration.

A. Establish and strengthen the mechanisms for delivering integrated TB and HIV services
Set up and strengthen a coordinating body for collaborative TB/HIV activities functional at all levels.
Determine HIV prevalence among TB patients and TB prevalence among people living with HIV.
Carry out joint TB/HIV planning to integrate the delivery of TB and HIV services
Monitor and evaluate collaborative TB/HIV activities
B. Reduce the burden of TB in people living with HIV and initiate early antiretroviral therapy (the three I's for TB/HIV)
Intensify TB case finding and ensure high-quality antituberculosis treatment.
Initiate TB prevention with isoniazide preventive therapy and early antiretroviral therapy.
Ensure control of TB infection in health care facilities and congregate settings.
C. Reduce the burden of HIV in patients with presumptive and diagnosed TB
Provide HIV testing and counselling to patients with presumptive and diagnosed TB.
Provide HIV prevention for patients with presumptive and diagnosed TB.
Provide co-trimoxazole preventive therapy for TB patients living with HIV.
Ensure HIV prevention interventions, treatment and care for TB patients living with HIV.
Provide antiretroviral therapy for TB patients living with HIV.

The recommendations consist of 12 components that are divided into three categories. For the purposes of this session, we are going to focus on the last two categories— B. Reduce the burden of TB in PLHIV and initiate ART early and C. Reduce the burden of HIV in clients with presumptive and diagnosed TB.

PLHIV are a major risk group for contracting active TB disease and thus need special attention to ensure that those with TB are diagnosed early and initiated on appropriate treatment. For PLHIV who do not have active TB, appropriate preventive therapy needs to be given to reduce the risk of developing the disease. Lastly, the health facilities where most of the PLHIV can potentially get infected need to adhere to high quality infection control practices. To reduce the burden of TB among PHLIV, the WHO recommended approach of preventing TB in PLHIV is called the ‘Three Is’ for HIV/TB. We will cover each of these ‘Three Is’ in the next few readings.

Intensified Case Findings (5 min)
TB is curable. A key to addressing the burden of TB among PLHIV if to find TB cases among PLHIV and start them on appropriate treatment. In support of this strategy, the following practice standards are recommended:
1. At every encounter with a healthcare worker, all PLHIV should be screened for active TB using the symptom checklist enquiry and measuring their BMI (≤ 17).
2. All PLHIV with a positive enquiry to any one of the symptoms on the checklist and/or a BMI of less than 17 kg/m² should have a CXR taken (unless it is unavailable)
3. All PLHIV with an abnormal CXR should have one sputum sample collected and submitted to the laboratory for TB testing using the GeneXpert. Where the CXR is unavailable, a sputum sample should be taken in any PLHIV who has a positive symptom screen and/or a BMI of less than 17.
4. Where resources are available, all newly diagnosed HIV positive clients may submit one spot sputum sample for Xpert MTB/Rif to rule out active TB disease even if they have a negative symptom screen and or a BMI of > 17.
5. All PLHIV who are seriously ill and/or have a CD4 T cell count of equal or less than 100 can submit their urine and have a Lateral Flow - Lipoarabinomannan Assay (LF-LAM) done.

IPT (10 min)

TB preventive therapy (TBPT) should be offered to all PLHIV who do not test positive for TB. In Zimbabwe, the recommended regimen is IPT given as 6 month daily dose of INH plus low dose pyridoxine. IPT has been shown to reduce the incidence of TB disease in HIV-infected people with latent TB by 33 - 64%. No tuberculin skin test (TST) is required before someone is initiated on IPT. Below are the inclusion and exclusion criteria for initiating PLHIV on IPT.

Inclusion and exclusion criteria

Tap on each tab to read about the inclusion and exclusion criteria for IPT.

Inclusion criteria
Exclusion criteria

Inclusion criteria

Isoniazid Preventive Therapy (IPT) for children (<15 years)

Negative TB screening (no current cough, no fever, good weight gain) or evaluation has not found active TB.

And child fits into one of the following categories:

Routinely: All HIV exposed and HIV-infected children between the ages of 12 months and 15 years, regardless of contact history.
After any contact with TB: All HIV exposed and HIV-infected children <15 years of age, and HIV-uninfected children <5 years, having had contact with any case of TB.
Post TB treatment: All HIV exposed and HIV-infected children <15 years of age, immediately following the successful completion of TB treatment.

Caregiver demonstrates a good understanding of IPT, and no known risk factors for non-adherence are identified.

NB: Investigations for TB should be done acording to national guidelines.

Isoniazid Preventive Therapy (IPT) for adolescents and adults (≤15 years)

All confirmed HIV-infected adults who are:

Not in need of ART, or
On ART for more than 3 months or
Post-TB treatment (immediately following the successful completion of TB treatment)
Contacts of PTB

No signs or symptoms of Tuberculosis (Based on the adult TB screening criteria)

Good understanding of IPT and willing to adhere.

Exclusion criteria

Isoniazid Preventive Therapy (IPT) for children (<15 years)

Symptoms and signs suggestive of active TB.
Client on treatment for TB.
Completion of IPT in the past 3 years.
Clients who have been on ART for 3 months or less.
Clients who have been on ART for 3 years or more and are doing well (CD4% > 25%).
Contacts of confirmed or suspected DRTB clients.
Clients who successfully completed DRTB treatment.
Signs of active liver disease or history of INH-induced hepatitis.
Poor compliance/adherence.

Isoniazid Preventive Therapy (IPT) for adolescents and adults

Symptoms and signs suggestive of active TB.
Client on treatment for TB.
Commpletion of IPT in the past 3 years.
Clients who have been on ART for 3 months or less.
Clients who have been on ART for 3 years or more and are doing well (CD4% > 450%).
Contacts of confirmed or suspected DRTB clients.
Clients who successfully completed DRTB treatment.
Signs of active liver disease or history of INH-induced hepatitis or heavy alcohol abuse.
Poor compliance/adherence.

Practice recommendations

In support of this strategy, the following practice standards are recommended:

Measure BMI and conduct a chest x-ray (where available) for all PLHIV who have active TB excluded on symptom enquiry. Also provide TBPT to these clients. Adult clients should receive 300 mg INH given once daily for six months. Children clients should receive 10 mg/kg/day up to a maximum of 300 mg daily.
Provide pyridoxine supplementation, 25 mg daily, to reduce peripheral neuropathy caused by IPT.
Some clients may develop adverse events from IPT and will require close clinical monitoring.

Clients on IPT need to be supported to ensure that they adhere to their medications and complete the entire course. If TB is missed at the initiation of treatment, it’s possible for someone on IPT to develop TB. In such cases, the client should stop taking IPT and instead they should be put on the appropriate TB treatment based on the GeneXpert result. It’s important to note that giving IPT does not cause the emergence of MDR-TB and clinicians should not withhold IPT on that basis. Only in cases where the client experiences severe adverse events from IPT should one consider stopping it before completion of treatment.

The following are the doses of IPT by weight band:

Weight range (kg)	Number of 100mg tablets of INH per dose	Dose given (mg)
<5	½	50
5.1 - 9.9	1	100
10 - 13.9	1½	150
14 - 19.9	2	200
20 - 24.9	2½	250
>25	3 tablets or one adult tablet	300

Possible adverse effects of INH

Clients taking IPT commonly report minor side effects, mostly in the first month of treatment, which may include increased appetite, headache, itchy skin, joint pains, diarrhoea, nausea, stomach pains, and/or decreased libido or energy. Though uncommon, there are potentially serious side effects that may result from INH use which may include hepatitis, hypersensitivity rash, psychosis, and convulsions. Severe hepatotoxicity and death are rare if INH is stopped immediately when clients develop symptoms suggestive of hepatitis.

The most common adverse events are asymptomatic elevation of serum liver enzymes concentrations, clinical hepatitis, and peripheral neuropathy.

Asymptomatic elevation of serum liver enzymes concentrations occurs in 10-20% of clients, but levels may return to normal even when treatment is continued. It is generally recommended that INH be discontinued if a client’s serum liver enzymes concentration levels exceed 3 times the upper limit of normal if associated with symptoms or 5 times the upper limit of normal if the client is asymptomatic.

Clinical hepatitis occurs in about 0.1% of people taking INH and is more common when INH is combined with other hepatotoxic agents including some ART drugs. Consumption of alcohol, underlying liver disease, and concomitant use of other medicines that are metabolized in the liver will increase the severity of hepatitis.

Peripheral neuropathy occurs in less than 0.2% of people taking INH at conventional doses. It is more likely in the presence of other conditions that cause neuropathy such as diabetes, HIV, renal failure, and alcoholism. Pyridoxine supplementation is recommended only in such conditions or to prevent neuropathy in pregnant or breastfeeding women. For more information on IPT, refer to the IPT guidelines in the resources section of this training.

Infection Control (5 min)

TB infection control programme is based on a three-level hierarchy of control measures. Each hierarchical level of control is designed to achieve a specific aim in reducing the risk of exposure to infectious aerosols to healthcare workers, clients, and visitors.

Reducing Burden of HIV in Clients with Presumptive and Diagnosed TB (5 min)

As mentioned in previous sections, TB clients are at high risk for becoming infected with HIV. For this reason, it’s vital to provide HIV testing and counselling to all presumptive and diagnosed TB clients. For clients who test negative, link them to HIV prevention methods to keep them from becoming infected in the future. Clients who test positive for HIV must be initiated on cotrimoxazole preventive therapy (CPT) immediately. ART initiation should be done between two-eight weeks after starting TB treatment. Like other PLHIV, TB-HIV co-infected client should be linked to appropriate care and treatment services.

Considerations for ART and TB treatment regimen

Drug-drug interactions can complicate TB and HIV treatment. The rifamycins used in TB treatment, such as rifampicin, rifabutin, and rifapentine, are hepatic enzyme inducers and will lower the serum concentration of many medicines used to treat HIV. This effect is most pronounced with protease inhibitors (PIs) and rifampicin. In order to reduce possible drug-drug interactions, clients who are receiving PIs for the treatment of HIV and rifampicin given at a dose of 150 mg once daily should be treated with rifabutin instead of rifampicin. If rifabutin is not available, the doses of ritonavir boosted lopinavir (LPV/r) can be doubled or the doses of ritonavir can be increased to 400 mg twice daily. This is referred to as super boosting. Clinicians should be aware that both double dosing and super boosting are associated with increased risk of adverse drug reactions. The following table shows weight adjusted dosing for TB/HIV co-infected clients on ATZ/r:

Weight (Kilograms)	Intensive Phase (2 months)	Continuation Phase (4 months)
40 - 54 kg	RFB* 150 mg x 1 (3 times a week) Isoniazid 300 mg x 1 daily Ethambutol 400 mg x 2 daily Pyrazinamide 400 mg x 2 daily	RFB 150 mg x 1 (3 times a week) Isoniazid 300 mg x 1 daily
55 - 70 kg	RFB 150 mg x 1 (3 times a week) Isoniazid 300 mg x 1 daily Ethambutol 400 mg x 3 daily Pyrazinamide 400 mg x 3 daily	RFB 150 mg x 1 (3 times a week) Isoniazid 300 mg x 1 daily
Above 70 kg	RFB 150 mg x 1 (3 times a week) Isoniazid 300 mg x 1 daily Ethambutol 400 mg x 4 daily Pyrazinamide 400 mg x 4 daily	RFB 150 mg x 1 (3 times a week) Isoniazid 300 mg x 1 daily

Weight (Kilograms)

Intensive Phase (2 months)

Continuation Phase (4 months)

40 - 54 kg

RFB* 150 mg x 1 (3 times a week)

Isoniazid 300 mg x 1 daily

Ethambutol 400 mg x 2 daily

Pyrazinamide 400 mg x 2 daily