TREATMENT OF OPPORTUNISTIC INFECTIONS OF HIV WITH REFERENCE TO TB MANAGEMENT BY DR' J' A' OSHO MEDIC

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TREATMENT OF OPPORTUNISTIC INFECTIONS OF HIV WITH
REFERENCE TO TB MANAGEMENTBYDR. J. A.
OSHOMEDICAL ADVISORDAMIEN FOUNDATION BELGIUM
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WHAT ARE OPPORTUNISTIC INFECTIONS IN HIV

• These are infections or disease conditions, which
  takes advantage
• of the depressed immunity of HIV infected
  person.
• List of common OIs / Conditions in Nigeria
• The common opportunistic infections are due
  mainly to viral, fungal,
• bacterial and parasitic/ protozoa
  organisms.
• These include Viral Herpes Simplex Herpes
  Zooster,
• Multiple
  bluish nodules (Kaposi sarcoma)
• Human
  papiloma virus (vaginal warts)
• Viral
  upper respiratory tract infection.
• Fungal Ringworm,
  Nail infections
• 
  Candida infections

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OIS CONTD

• Bacterial Papulo-pruritic eruptions, Pneumonia,
  
• Diarrhoea diseases, Urinary tract infection
• TB is the commonest opportunistic infection among
  PLWHA.
• Protozoal / Parasitic - Scabies, Diarrhoeal
  diseases
• Malaria
• Compared with an individual who is not infected
  with HIV, a person infected with HIV has a 10
  times increased risk of developing TB.

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Epidemiology - An HIV prevalence of 10 in a
community will cause an excess of 49 in TB
cases (van Cleef 1995). Proportion of new TB
cases attributable to HIV co-infection (Dolin
1994) 4 in 1990 8 in 1995 14 in
2000 - 1 in 7 cases of TB globally is attributed
to HIV in 2000 (Pozniak 1999). In Sub-Saharan
Africa gt30 of TB cases are associated with HIV,
with figures as high as 70 in some countries
e.g. Malawi and Zambia. In a 1994 study in
Shashemene, Ethiopia, 44 of 450 TB patients when
screened were HIV positive (Gellete 1997).
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• Lifetime risk of developing disease in a person
  with latent TB infection
• HIV-negative 5 - 10
• HIV-positive 50 - 80
• (with a 10 annual risk in the early years
  post-infection with TB)

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HIV and the diagnosis of TB - Requires high
index of suspicion and, sometimes, supportive
radiological investigation. But sputum smear
examination remains the main tool of
investigation - Clinical presentation of TB
patients with HIV co-infection depends on the
stage of the HIV-infection and can be broadly
classified as early and late presentation -
Smear positivity rates among HIVve TB patients
are the same as among HIV-ve TB cases - In the
early stages of HIV-infection, the clinical
presentation is almost indistinguishable for that
in other TB patients - In the terminal stages,
the presentation can be atypical and extra-
pulmonary forms like TB pleurisy, miliary TB etc
occur
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• HIV is known to increase the burden of TB
  according to the 2001 sentinel survey in Nigeria
  the prevalence of HIV among TB patients is 19.1.
  Current WHO estimate in 2005 IS 27.
• On the other hand, it is estimated that TB is the
  most common cause of death among People Living
  With HIV/AIDS (PLWHA) and is responsible for
  30-40 HIV/AIDS death globally.
• Therefore it is imperative that health workers be
  alert to the interaction between these two
  diseases and learn to manage conditions arising
  from them competently.

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Presentation in early and late stages of HIV
infection
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Nigerian HIV Prevalence Trend (1991-2005)
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Prevalence of HIV among TB patients from 1991 -
2001.
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TB MANAGEMENT

• GLOBALLY A STRATEGY HAS BEEN ADOPTED FOR THE
  MANAGEMENT
• OF TUBERCULOSIS
• CALLED
• DIRECTLY OBSERVED TREATMENT SHORTCOURSE
• (DOTS)
• DOTS HAS 5 COMPONENTS

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History of DOTS expansion
1991 WHA establishes the 70/85 targets for
2000 1993 TB as a global emergency 1994 New TB
control framework 1995 DOTS launched as a
brand 1996 Global monitoring established 1998
London committee assesses constraints 1998
StopTB Partnership launched 2000 Amsterdam
declaration targets in 2005 DEWG 2001 GDEP and
GDF launched 2001 GPSTB and Washington
Commitment (GFATM)
World Health Organization
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COMPONENTS OF DOTS1. Government Commitment
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COMPONENTS OF DOTS2. Case Detection by Sputum
Microscopy
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COMPONENTS OF DOTS3. Direct Observation of TB
Treatment by Health worker
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COMPONENTS OF DOTS4. Provision of un-interrupted
supply of anti-TB drugs for 8 month
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COMPONENTS OF DOTS5. Standardised recording and
reporting system
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Management of TB suspect
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(No Transcript)
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Criteria for assigning treatment

• Information needed
• Age
• History of previous anti-TB exposure
• Other medical conditions
• Pregnancy
• HIV status
• Other contra-indications
• Pre-treatment weight

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Drugs used in TB treatment

• Rifampicin (R)
• Isoniazid (H)
• Ethambutol (E)
• Pyrazinamide (Z)
• Streptomycin (S)
• Thiacetazone (T)

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Drug Development Timeline

• 1940s Selman Waksman cultivated actinomycin and
  streptothricin, which
• were toxic. The cultures used were
  Actinomycetes, Aspergillus,
• and Mycotorula. Finally,
  streptomycin was created.
• 1944 Streptomycin was first administered to a
  human patient on November 20. This is an
  effective treatment of TB.
• 1947 Streptomycin resistance.
• 1948 The drug p-aminosalicylic acid (PAS) is
  created.
• 1949 Streptomycin and PAS used together.
• 1951 A new drug, Isoniazid (INH) is created. Used
  with PAS, it is more effective than
  streptomycin and PAS.
• 1954 The drug Pyrazinamide is created.
• 1955 Cycloserine is produced.
• 1962 Ethambutol is created.
• 1963 Rifampicin is used to treat tuberculosis.
• The drugs in bold are commonly used today as a
  multiple against MDR TB.

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Theoretical model of drug action
B semi-dormant bacilli (Persisters) existing in
relatively hypoxic environ of caseous tissue
which undergo occasional spurts of metabolism.
A Metabolically active and dividing bacilli
growing inside well oxygenated walls of cavities.

C semi-dormant bacilli existing in an acidic
environ either intra-cellular (inside
macrophages) or extra-cellular
D dormant bacilli which die on their own and or
cleaned up by immune system
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Treatment Regimen
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TB Monitoring
When?
Result?
What do I do?
Action!
Conclusion?
Start DOTS!
Positive
TB case
1st patients visit (diagnosis)
3 sputum specimen
REFER!
Negative
May be not TB
Extend 1 month!
Intensive Rx not enough
Positive
End of 2 months
2 sputum specimen
Intensive Rx enough
Start Continuation
Negative
Treatment failed
Positive
Start CAT II Rx
End of 5 months
2 sputum specimen
Negative
Patient improving
Continue Rx
Treatment failed
Start CAT II Rx
Positive
End of 7 months
2 sputum specimen
Give last Rx DECLARE CURED!
Excellent!
Negative
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ARV regimen

• 1st line drugs
• Nevarapine (NVP) 200mg o.d
• Lamivudine (3TC) 150mg b.d
• Stavudine D4t/Effavirenz 300mg b.d/600mg o.d
• 2nd line drugs
• Indinavir
• didanosine (Ddl)
• Zidovudine (AZT)

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When to start ARV for TB patient with HIV
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Steps for administering ARV DOTS
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Steps for administering ARV DOTS Cont
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Overall impact of HIV on TB control

• increased overall numbers of TB cases
• drug reactions and interactions are more common
• mortality rate, whilst on treatment, is higher
  (mostly attributed to other HIV-related diseases)
• higher relapse rate and worse response to
  standard chemotherapy
• over-diagnosis of smear-negative PTB

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Overall impact of HIV on TB control Cont

• under-diagnosis of smear-positive PTB
• inadequate supervision of anti-TB chemotherapy
• low cure rates
• high default rates because of adverse drug
  reactions
• delayed reporting of patients because of the fear
  of having HIV-infection
• when diagnosed as TB
• increased emergence of drug resistance

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THE STOP TB STRATEGY
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Components of the Stop TB Strategy

• Pursue quality DOTS expansion and enhancement.- 5
  components of DOTS.
• Address TB/HIV, MDR-TB and other challenges.-
  TB/HIV collaborative activities.
• Contribute to health system strengthening
• Engage all care givers- PPM DOTS
• Empower people with TB, and communities-Advocacy
  Communication Social Mobilisation
• Enable and promote research

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1. ESTABLISH THE MECHANISM FOR TB/HIV
COLLABORATION AT NATIONAL LEVEL

• National TB/HIV working group inaugurated on 22nd
  June 2006.
• 4 Sub Committees.
• - Technical.
• - Resource Mobilization and Coordination
• - Research and ME - ACSM

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TOR TWG

• 1. Facilitate collaboration between TB and
  HIV/AIDS programmes at all levels.
• 2.   Support Government to Coordinate activities
  of partners both individuals and institutions
  which have recognized experience in controlling
  TB/HIV
• 3. To review periodically National TB/HIV
  strategic framework guidelines and any other
  documents to guide all stakeholders for better TB
  control among HIV-infected people and effective
  HIV prevention and care among TB patients.

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TOR Contd.

• 4.    Support in the dissemination of the
  Technical Guidelines.
• 5.    Mobilize Financial and Technical Resources
  for implementing Collaborative TB/HIV activities.
• 6. Promotion of National Research in TB/HIV
  control

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State Working group

• 6 States Adamawa, Benue, Ebonyi,
• Ogun, Rivers and Sokoto.
• Health workers from ART sites and Community
  support group in 6 states trained on
  implementation of joint TB/HIV activities.
• Funding from USAID to implement the plan in 6
  states.
• State TWG Gombe
• What of my State.

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B. SURVEILLNACE OF HIV PREVALENCE AMONG TB
PATIENTS

• Sentinel Survey.
• Routine Collection of Data
• New TB Reporting format.
• - Patient Treatment Card.
• - LGA Central Register.
• - Case Finding.
• - Treatment Outcome.
• - Referral/Transfer forms.

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C. JOINT PLANNING.
S.M.O.H
SASCP
STBLCP
What Can I do in my state to enhance Joint
Planning?
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2. DECREASE THE BURDEN OF TB AMONG PEOPLE
LIVING WITH HIV/AIDS.

• A. Establish Intensified TB case finding.
• 25 FGN ART sites trained to implement DOTS.
• ABU Teaching Hospital Zaria, FMC, Gombe. FMC,
  Markurdi UMTH, Maiduguri. JUTH, Jos, FMC Azare,
  FMC, Owerri., FMC, Uyo. FMC, Asaba. FMC, Umuhaia,
  Abia , UPTH, Port Harcourt. UNNTH, Enugu.
  Military Hospital, LUTH, Lagos. FMC, Abeokuta.
  UITH, Ilorin. UCH, Ibadan, State House Clinic,
  Abuja. CBN, Abuja. FMC, Katsina, Federal Staff
  Hospital, Abuja. FMC, Lokoja , FMC Bida and
  FMC, Keffi
• Action Point - To know If activities has fully
  commenced in these facilities and if not, what to
  do to kick start.

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Health Facilities.

• 3 LGAS/State X 6 states 18 LGAs.
• 2 DOTS clinic/LGAs 36 DOTS sites.
• 1 ART facilities per state.
• 1 Support group per state.

KM
KM
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DECREASE THE BURDEN OF HIV AMONG TB PATIENTS.

• A. Provide HCT.
• A situational analysis visit was conducted A
  total of 18 LGAs, 36 DOTS centers, were
  identified to implement collaborative TB/HIV
  activities. Health workers from the DOTS sites
  trained on implementation of collaborative TB
  activities and capacity build to offer basic
  counseling for TB patients and Suspects attending
  the DOTS clinics.
• Laboratory Personnel trained.
• Free Testing Kits 32,500 TB Suspects and
  patients
• Parallel test Determine and Stat park.
• 15,000 Cappilus and Determine

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• B. Introduce co-trimoxazole preventive therapy
• Ensure HIV/AIDS care and support
• D. Introduce antiretroviral therapy

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Recommended Collaborative activities.

• A. Establish the mechanisms for collaboration
• A.1 Set up a coordinating body for TB/HIV
  activities effective at all levels
• A.2 Conduct surveillance of HIV prevalence among
  tuberculosis patients
• A.3 Carry out joint TB/HIV planning
• A.4 Conduct monitoring and evaluation
• B. Decrease the burden of tuberculosis in people
  living with HIV/AIDS
• B.1 Establish intensified tuberculosis
  case-finding
• B.2 Introduce isoniazid preventive therapy
• B.3 Ensure tuberculosis infection control in
  health care and congregate settings

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Contd.

• C. Decrease the burden of HIV in tuberculosis
  patients
• C.1 Provide HIV testing and counseling
• C.2 Introduce HIV prevention methods
• C.3 Introduce co-trimoxazole preventive therapy
• C.4 Ensure HIV/AIDS care and support
• C.5 Introduce antiretroviral therapy

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IPT (ISONIAZID PROPHYLAXIS THERAPY

• IPT CONTROVERSY

• Use is evidence based

• Use since 50-60 to prevent infection in contacts
• HIV and TB are common in Nigeria
• HIV is a major catalyst for activating TB
• Studies in various HIV populations show
• INH protective (SA,Botswana,Senegal) and other
  parts of the world

• 11 pooled studies showed 62 protection against
  active TB in mantoux positive and 33 in those
  without disease
• Rio-de Janeiro protection is most marked when
  IPT is used with ARV (Toronto 2006)

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To succeed, we must try and try again.We must
believe in what we are doing.We must not give
up.We must be patient.We must keep pushing.

• Only those who persevere succeed

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Parting Statement
When the right hand washes the left and the left
washes the right , both hands become clean. You
can only beat our chest with a full palm.
Nigérian proverbes.
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We can only win this battle against the ambush by
these two diseases if all involved in the control
programme are united.

• The bridge is generally repaired only after
  someone falls in the water.. he bridge is
  generally repaired only after someone falls in
  the water..

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• THANKS
• FOR
• YOUR
• 
  PATIENCE.