[activity type]

Tell your mentee that you will review case studies and ask some questions to assess his or her knowledge in Isoniazid Preventive Therapy for adults and children.

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Inosizi is a 24 year old HIV+ woman who is 30 weeks pregnant. She has been taking EFV/TDF/3TC = FDC since she learned she was positive at her first ANC visit about 3 months ago. She reports not missing any of her medication and feeling well. She was not due in clinic today but is very upset since her husband just told her he was being treated for TB at a clinic near his work. He was home last month for his annual leave and was coughing, but he told her that it was from the chemicals he uses at work. He seemed very tired and she noticed that he was not eating very much. She never expected that he had TB; otherwise, she would have told him to come to her clinic right away. She is crying and saying that she does not want to take any more medicine, but she is very afraid that not only she will get TB but also her baby will. She is also concerned about her mother, who has diabetes and a heart condition, who is staying with her. Recently her mother began coughing but said she caught a cold from one of their neighbours and was feeling fine.

1. What can you tell Inosizi to help her understand about IPT and pregnancy?
   • The medication to prevent TB has been found to be safe in pregnant women.
   • The benefits of IPT outweigh the risks since having TB while pregnant can result in harm to you and your baby.
   • You will also be able breastfeed your baby as you continue your medication to prevent TB.
2. What additional medical information do you need to determine if Inosizi is eligible for IPT?
   • History of liver disease or symptoms of active hepatitis.
   • History of convulsions, moderately severe peripheral neuropathy.
   • Previous history of INH hypersensitivity inducing hepatitis.
3. What additional psychosocial information do you need to determine if Inosizi is eligible for IPT?
   • Psychosocial history.
   • History of psychosis.
   • Current alcohol use using the CAGE questionnaire.
   • Patient shows basic understanding of the rationale behind INH.
   • No identified risk factors for non adherence.
4. What additional screening information do you need to determine if Inosizi is eligible for IPT?

   
   TB Screening

   • Do you have a current cough?
   • Do you have any fever?
   • Have you had any weight loss?
   • Do you have drenching night sweats?
5. What medication will you prescribe for Inosizi? Provide the dose for each medication.
   • INH 300 mg once daily.
   • Pyridoxine 25mg once daily (pyridoxine can be increased to 100mg/day if the peripheral neuropathy is severe).
6. Are there increased risks, side-effects, or drug-drug interactions associated with taking ART and IPT?
   • There does not seem to be an increased risk of developing hepatitis from taking ART and IPT as long as the health care worker takes a thorough history of prior liver disease, current nausea/vomiting, right upper quadrant pain, dark urine or pale stools, current alcohol use, and also conducts a physical exam to assess for jaundice and abdominal pain.
   • Nevirapine (NVP) may increase the risk of liver toxicity, but this is not one of the medications in her regimen.
   • She is also not on ART medications that would increase her risk of peripheral neuropathy such as Stavudine (d4T) or Didanosine (ddI).
7. What will you tell Inosizi about her mother and her risk of TB?
   • Isonizi’s mother needs to be screened for TB and evaluated for IPT as soon as possible.

[activity type]

Explain to the mentee that you are going to engage in a role play to help him or her learn how to improve TB prevention skills. He or she will play the role of health care provider and you will be the patient.

Show the mentee the instructions below for the health worker. Then tap on the box for the patient instructions. Do not show this to the mentee.

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Part 1

Mrs. Mponda completed her TB treatment last month and is in clinic today for her ART medication and cotrimoxazole. She was started on ART by you approximately 8 months ago but developed TB IRIS 5 weeks after she began taking EFV/TDF/3TC (FDC). She was very ill and was hospitalized for a week to stabilize her and begin TB treatment. Since then she has been feeling much stronger and has gained the weight she lost when she was so sick.

You note in her clinic record that she has not had any problems with her medications, and her adherence has been 95% – 100% consistently. Her most recent CD4 count is 156 cells/mm³ (her baseline CD4 count was 82 cells/mm³).

You received information from your supervisor that your clinic will begin screening patients for IPT. You attended training a few weeks ago and received copies of the National guidelines and screening algorithm, but you have not initiated any of your patients yet.

• Patient instructions (mentor). Do not show this to the mentee.

  Your task is to act the role of Mrs. Mponda. You are here to pick up your medication, and in fact, you are happy because the health care worker last month told you that since you are doing so well, you will be given a 2 month supply of medication so you do not have to come back to the clinic every month. Since you have returned to work, it has been very hard to keep your appointments and not anger your boss, who does not know your diagnosis. You managed to hide how uncomfortable you are when standing on your feet too long (your shoes feel tight and your feet feel hot). Your boss told you it was OK for you to have a chair near your workstation after you got out of the hospital, but he does not like it if you sit too much during your shift. You were never told about the need to take more medication to prevent you from getting TB again. In fact, you thought that because you already had TB you were protected for life!

  Your job is to listen carefully during the role play so that you can comment on what was done well and what could be improved.

  Check the boxes below to indicate whether the mentee provided a clear explanation about the importance and need for IPT following TB treatment, the medication she will be taking, length of time and possible side-effects. Did the mentee allow you to ask questions and give you the opportunity to go home and think about the information, or did she write the prescription and send you home? At the end of the role play, review any problem areas with the mentee.

  Did the mentee

  Provide a detailed explanation about IPT and why it is important even after TB treatment?

  Use probing questions to assess patient understanding of IPT?

  Allow time for discussion and questions before prescriptions were written?

  Review patient’s medical history, specifically assessing for liver disease, viral hepatitis, and symptoms of peripheral neuropathy?

  Review current medications, specifically looking for the use of potentially hepatotoxic medications including herbs or traditional medications?

  Perform TB screen using the four screening questions?

  Use the CAGE questionnaire for assessing alcohol use?

  Perform PE with attention to abdominal exam?

  Discuss assessment and plan of care?

  Obtain verbal agreement to the plan of care and commitment to the addition of INH and pyridoxine daily for the next 6 months?

  Provide patient with prescription for INH 300mg once daily and pyridoxine 25 mg once daily and instructions on dosing and possible side effects?

  Allow for questions about the medication instructions or any other information provided?

  Instruct patient to return in one month?

Part 2: Return visit

• Patient instructions (mentor). Do not show this to the mentee.

  You started IPT about 2 weeks ago. Within a few days of starting the medication, you noticed that your feet really were bothering you. Your shoes were definitely too tight. The bottom of your feet felt like someone was holding a hot iron. At night your legs and feet ached so much that even your bedsheet caused you increased pain. You have not been able to sleep well and you are having trouble keeping up with your work during the day. Your boss came to you yesterday and asked if you need to go back to the hospital and was visibly angry when you told him you were OK. He says, “You are obviously not OK and either you pick up your workload or I am going to have to let you go!”

  You return to the clinic without an appointment to find out why you are having this trouble with your feet and legs. If it is due to the new medication, you want to stop immediately! You are also fearful that the new medication may have caused permanent damage to your feet. You are walking slowly and limping due to the pain in your feet.

  Your job is to listen carefully during the role play so that you can comment on what was done well and what could be improved.

  Check the boxes below to indicate whether the mentee provided a complete and accurate assessment of your current complaints, performed a targeted physical examination to evaluate the extent of the peripheral neuropathy symptoms, and provide you with a plan of care that addresses the problem. Was there a clear explanation about the possible causes of the current symptoms and medication prescribed to manage your pain? At the end of the role play, review any problem areas with the mentee.

  Did the mentee

  Review the timeline of the current symptoms and any changes in lifestyle, e.g., alcohol use?

  Assess the degree of pain reported, e.g., mild, moderate, or severe, and the extent of interference with daily activities.

  Review current medications, dose, and timing with particular attention to the daily pyridoxine?

  Perform a targeted physical examination focusing on a neurological examination that includes vibratory and pinprick examination to evaluate the degree of peripheral neuropathy and extent of the current problem?

  Review current medications specifically looking for the use of potentially neurotoxic medications including herbs or traditional medications?

  Follow the guidelines for management of INH associated peripheral neuropathy?

  Stop INH and increase the pyridoxine to 100mg daily?

  Schedule a follow-up appointment in one week or sooner if the symptoms increase?

The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used method of screening for alcoholism.

Two "yes" responses indicate that the possibility of alcoholism should be investigated further.

The questionnaire asks the following questions:

1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Item responses on the CAGE are scored 0 or 1. A higher score is an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.

NB: Developed by Dr. John Ewing, founding Director of the Bowles Centre for Alcohol Studies, University of North Carolina at Chapel Hill.

If an adult or adolescent develops active TB while on IPT: they should be started on TB treatment according to the National guidelines. Meanwhile specimens should be collected and sent for exclusion of drug resistant TB.

Children developing active TB while on IPT: they should be started on TB treatment according to the National TB guidelines. If possible, it is advisable to obtain a specimen (sputum or other) and sent for culture and DST, although it should be noted that the risk of a child developing drug-resistant TB in this scenario is much less compared to an adult.