Tuberculose et SIDA

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Tuberculosis and AIDS
Ibrahima NDIAYE, Bernard Marcel DIOP, Papa Salif
SOW Infectious Diseases ClinicFann UHC, Dakar
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Introduction

• Characteristics of tuberculosis and AIDS
• Very frequent opportunistic infection
• Interactions with the two endemic diseases
• Risk of nosocomial transmission
• Non stereotypical clinical manifestations
• Drug interactions with ARV
• Problem of tuberculosis prophylaxis
• Association of tuberculosis and aids challenge

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Introduction

• HIV factor which is currently causing an
  increase in TB
• Direct route with PWHIV
• Indirect increase in transmission
• Year 2000 1 case of TB/7 were attributed to HIV
• TB Incidence 143 to 163/100.000 (90 - 00)
• HIV upsurge in multiresistant cases
• The problem immunity deficit
• Vulnerability of PWHIV Tuberculosis

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Natural HIV history Role of TB
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PWHIV Tuberculosisprevalance AIDS 2001

• Rwanda 41
• Burundi 49
• Ivory Coast 61
• Tanzania 65
• Ethiopia 42
• Burkina Faso 46

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Opportunistic Infections (n 1095, Mal.Infect.
Dakar)

• Tuberculosis 318 37.9
• Bact.et parasit.diarrohea 268 32
• Pneumopathy 171 20.5
• Bacteriaemia 44 5.2
• Purulent meningitis 18 2.1
• Kaposis sarcoma 9 1.1
• Cryptococcus meningitis 7 0.8
• Cerebral toxoplasmosis 3 0.4

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Infectious pnemopathyResearch project ANRS -
Senegal

• 589 patients recruited (Fann and HPD)
• Tuberculosis 1st HIV and HIV- infection
• Bacterial pneumopathy (HIV vs HIV-)
• Low pneumocystosis prevalence
• Strong HIV pneumo.bacterial lethality
• Need for a prophylaxis for these O.I.

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Clinical characteristics

• HIV patient with CD4 gt 200
• Non specific clinical signs
• Mainly pulmonary localisations
• HIV patient with CD4 lt 200
• Disseminated forms of the disease ganglionic,
  meningitis, hepatic
• Positive haemoculture

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Radiographic appearances

• Uni or bilateral infiltrates, localised /-
• Alveolar focus /- systematised
• Miliary bronchogenes
• Caverns on tops of lungs (rarely)
• Hilar or mediastinal adenopathy
• Normal chest image (AFB )

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Paraclinical diagnosis

• Positive IDR tuberculin test 30
• AFB sputum ve in 40 to 50
• Other respiratory samples
• Gastric tubages
• Broncho-alveolar lavage
• Fibro-aspiration
• Biopsy (positive liver biopsy in 40)
• Significance of culture expectorations
• Amplification of chain polymerisation

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Risk factors for negative sputum acid-fast
bacilli smears in pulmonary tuberculosis results
from Dakar, Senegal, a city with low HIV
seroprevalence

• B.Samb, P.S.Sow, S.Kony, M.Maynart, G.Diouf, S.
• Cissokho, M.Sané, A.A.Hane, F.Klotz et al.
• Int J Tuberc Lung Dis 1999 3 (4) 330 - 336

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Tuberculosis and HIV infection

• HIV Tuberculosis predictive factors
• Buccal candiasis
• A low level of CD4
• Cutaneous anergy
• Negative bacilloscopy is more frequent in HIV
• Different radiological images in HIV vs HIV-

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Tuberculosis and HIV infections

• Frequent opacity and caverns in HIV-
• Mediastinal adenopathy HIV
• Tuberculosis is immunosuppressive and accelerates
  the progression of HIV infection

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Treatment strategies

• Sensitivity to classic antituberculosis agents
• But
• Problematic multiresistant forms
• Alternative strategies fluoroquinolones
• Interaction with antiprotease and non nucleosidic
  inhibitors
• Reduction of bioavailability with Rifampicin

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Tuberculosis and HIV/AIDS

• Negative Bacilloscopy
• HIV Tuberculosis 14/40 (35.0)
• HIV - Tuberculosis 71/410 (17.3)
• HIV versus HIV- 35.0 vs 17.3 RR
  2.02 1.26-3.24, P 0.01.
• Multivariate analysis

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Antiretroviral treatment and Tuberculosis

• Three treatment strategies proposed
• Delay ARV treatment until the end of
  antituberculosis treatment
• Immediate treatment with 2 NRTI 1 NNRTI
  (efavirenz 800 mg if rifampicin) or with3 NRTI
• Delay ARV treatment by 2 months at time of change
  to maintenance treatment and use Isoniazide
  Ethambutol

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Recommendations

• Individual specific decision
• WHO/CD4
• Combined treatment CD4lt 50
• Delay ARV treatment by 2 months 50lt CD4lt 200
• TB treatment then ARV treatment CD4gt 200

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Chemoprophylaxis arguments

• TB is a first opportunistic infection
• Tuberculosis accelerates HIV progression
• Increase in TB incidence due to HIV
• Prophylaxis with Isoniazide for 1 year
• Reduction in TB risk by a factor of 2 to 4
• Reduction in TB risk by 27 over 5 year follow-up

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TB and HIV chemoprophylaxis

• HIV patient IDR tuberculin test gt 10 mm
• Isoniazide for 12 months
• Isoniazide 2 times/week 9 months
• Rifampicin Pyrazinamide for 2 months
• Pyrazinamide Rifabutin for 2 months
• Isoniaside Rifampicin Pyra 3 months
• Senegal no recommendations

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Conclusion

• HIV pandemic aggravates TB situation
• Morbidity and mortality linked to CD4 deficit
• Need for NPFA and NPT to collaborate
• Best combined treatment strategies of ARV and
  antituberculosis agents must be better defined