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RNTCP guidelines Sep 2016
Index
The burden of HIV TB Interactions between TB & HIV Treatment of TB & HIV in HIV-TB Impact of ART
Drug interactions & toxicity IRIS
3 ‘I’s approach
The burden of HIV - TB
2.1 million PLHIV in India
10% global burden of HIV+TB
0.27% prevalence in population
6-8% prevalence : PLHIV visiting ART centre
Incidence relatively high despite ART
5% of TB : HIV + : >1 lakh/year
TB : 25% deaths in PLHIV
HIV : Effects on TB
Risk increases after seroconversion : 2x within the first year (rapid depletion of TB-specific T helper cells) & increases with time.
Latent to active TB : 12-20 x Risk of new TB : 5-10% / year : 8x risk Rapid progression : outbreaks of MDR,XDR Recurrence after successful treatment : Usually
exogenous re infection
HIV : Effects on TB
Atypical presentation Extra pulmonary : 4x Smear negative Normal CXR 20% Lower lobe
involvement
TB : Effect on HIV
Increases risk of progression to AIDS or death TB infection : significantly increased plasma
HIV viremia Generalized immune activation due to TB :
increased CD4 : targets for HIV Increased expression of HIV coreceptors CCR5
& CXCR4 in TB-HIV
Rx of TB in HIV -TB
Cat,Rx, followup & testing as for HIV neg Check for DST before initiation Drug sensitive TB & second line ART
Rifabutin 300mg x 3/7 or 150mg OD Rifampicin suppresses bio availability of Ritonavir
boosted Atazanavir/Lopinavir/Darunavir ART 2w-8w + CPT to prevent OI
Rx of HIV in HIV-TB
First line : TLE as per NACP Second line :
T/L/Pi Z/L/Pi St/L/Pi Ab/L/Pi
Impact of ART
Reduces the risk of developing TB Relative risk remains high Reduces mortality & morbidity
Impact of ART
Drug interactions Shared toxicity High pill burden Paradoxical IRIS
Drug interactions & toxicity
Rifampicin decreases [Efavirenz] concn : Use 600mg/day ( 800mg in >50kg)
OCP decrease [Efavirenz],[Rifampicin] Hepatotoxicity of both
INH,RIF,PZA,MOX,PAS NVP ( Fatal hepatic necrosis), PI
TB associated IRIS
Paradoxical worsening after ART Biphasic : 3-6 m CD4 memory, exp of naive
CD4 from thymus, total CD8 initially inc, memory CD8 later declines
Inc markers of immune activation, pathogen sp delayed hypersensitivity, almost 3x inducible lymphocyte proliferation ( Ifn y, TNF a, CRP, IL-2,6 & 7)
TB associated IRIS
33% HIV/TB 5d – 3m on ART especially CD4<50/uL Fever, worsening of LN/resp disease,stridor Self limited usually
Criteria & treatment
Criteria Low CD4 (<100) exception TB + virological & immunological response R/O DR infection, bacterial super infection, allergy, non
compliance, reduced drug levels, abacavir hypersensitivity Temporal association Inflammatory response
Predn (1.0 mg/kg, max 80mg/d) or dexa 8-16 mg/d divided in twice daily doses; tapered/1-2m adjunct to AKT & CART
Single Window approach & 3 ‘I’s
Intensified TB case finding Isoniazid Preventive Therapy Airborne Infection Control
Intensified case finding
Adult : 1)Current cough2)Fever3)Weight loss4)Night sweats
Children : 1)Current cough2)Fever3)Lack of weight gain4)Contact with a TB
case4-S screening (a) 85% sens(b) 98% NPV(c) Meta analysis of 12 studies & 8,148 PLHIV
Approach to presumptive TB
Priority CBNAAT ( 84% sens comp to 53% smear)
Daily FDCs ( switch to daily if prev. on 3/w) 2HRZE + 4HRE 2HRZES + IHRZE + 5HRE ( previously treated)
LTBI
Infection without signs/ symptoms/ radiographic/bacteriological evidence
Endemic : TST / IgRA 6m INH/ 9m INH/ 3m Rifp + hi dose INH / week
are equivalent IPT 6m recommended
IPT
Indications 1) 4S neg2)LTBI in adult & children ( +TST unnecessary)3)Children post Rx4)Previously / Recently Rx TB
With ART : safePregnancy & lactation : safe
IPT
CI Active TB/hepatitis PN Poor adherence to Septran preventive therapy Contact with MDR TB Completed DRTB therapy
IPT
Dose Adult H 300 + B6 50mg Children > 12m : H 10/kg + B6 25mg
Duration : 6m Less chance of H res in LTBI
IPT Spl Sit
Children born to Micr. + TB : IPT if active TB
TB during IPT : DST & if S Cat I ( if IPT < 1m &
Rx naive), else II IPT LFU/toxicity :
restart if gap <3m; else don’t
Thank you
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