TB and HIV Overview for World TB Day March 2022
TB and HIV Overview for World
TB Day March 2022
James Sunstrum, M.D.
Wayne County TB Clinic
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B
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V
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2
Disclosure
Denise
Parr
Isagenix
International
(Sales)
Western
Michigan
University Homer
Stryker
M.D.
School of
Medicine adheres
to the
ACCME’s Standards
for Integrity
and Independence
in Accredited Continuing
Education.
Any
individuals
in
a
position
to
control
the
content
of
a
CE
activity,
including
faculty,
planners,
reviewers
or
others
are
required
to
disclose
all
relevant
financial
relationships
with
ineligible
entities
(commercial
interests).
All
relevant
conflicts
of
interest
have
been
mitigated
prior
to
the
commencement
of
the
activity.
Accreditation
In
support
of
improving
patient
care,
this
activity
has
been
planned
and
implemented
by
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
and
Michigan
Department
of
Health
and
Human
Services.
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
is
jointly
accredited
by
the
Accreditation
Council
for
Continuing
Medical
Education
(ACCME),
the
Accreditation
Council
for
Pharmacy
Education
(ACPE),
and
the
American
Nurses
Credentialing
Center
(ANCC),
to
provide
continuing
education
for
the
healthcare
team.
Credit
amount
subject
to
change.
Interprofessional
Continuing
Education
This
activity
was
planned
by
and
for
the
healthcare
team,
and
learners
will
receive
5.0
Interprofessional
Continuing
Education
(IPCE)
credits
for
learning
and
change.
Physicians
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
designates
this
live
activity
for
a
maximum
of
5.0
AMA
PRA
Category
1
Credits™.
Physicians
should
claim
only the
credit
commensurate
with
the
extent
of
their
participation
in the
activity.
Nurses
Western
Michigan
University
Homer
Stryker
M.D.
School
of
Medicine
designates
this
activity
for
5.0
contact
hours
for
nurses.
Nurses
should
claim
only
credit
commensurate
with
the
extent
of
their
participation
in the
activity.
Activity
Code:
24227
2
HIV and TB: 2 serious infections
•
Rules of the game:
•
1. All HIV patients should be tested for latent
TB infection.
•
2. All active TB patients should be tested for
HIV.
•
3. If pulmonary infiltrates found with HIV+,
keep TB in differential diagnosis.
7/26/2024
3
1. All HIV patients should be tested for latent TB infection.
•
PPD or Quantiferon on baseline
•
Low CD4 may result in false negative test
•
If negative, repeat based on risk… ? Every 2-3
years?
7/26/2024
4
If PPD or IGRA are positive in HIV+
patient
•
Chest X-ray
•
Symptom review for fever, cough, adenopathy
•
Any mass, or any central nervous system
abnormality should be evaluated….
•
If negative, treat for latent TB
•
With
daily isoniazid
, any ARV regimen can be
used.
7/26/2024
5
Latent TB treatment for HIV+ patient
•
www.aidsinfo.nih.gov
•
Newer weekly INH/rifapentine or rifampin
regimen not recommended together with
dolutegravir, bictegravir or protease inhibitors
•
Thanks to LTBI treatment, few HIV patients
develop active TB in Michigan
7/26/2024
6
Active TB in HIV+ patients in Michigan
•
1-2 cases a year (out of 130 cases total)
•
Tend to be foreign born HIV patients
•
Tend to be recent arrivals in USA
7/26/2024
7
New patient in your HIV waiting
room…
•
Tested HIV+ on Immigration screen
•
Came from Sierra Leone 8 months
earlier
•
Dry cough x 2 months
•
Baseline CD4 = 50 cells
•
This is her chest Xray:
Her sputum grew
Mycobacterium
tuberculosis !
•
Due to low CD4 count, inflammatory response
is limited. Xray may show little or no infiltrate.
•
We kept her out of the regular HIV clinic for 2
months, until TB intensive phase of treatment
completed.
7/26/2024
10
G
e
n
E
x
p
e
r
t
A
s
s
a
y
P
r
o
c
e
d
u
r
e
f
o
r
t
h
e
M
T
B
/
R
I
F
T
e
s
t
.
Boehme CC et al. N Engl J Med 2010;363:1005-1015.
TB may not look at all typical in HIV
patients
•
Unusual chest X-ray findings
•
May have a NORMAL chest X-ray !
•
25% of TB will be extra-pulmonary
•
Be especially wary in foreign-borne
patients with HIV
7/26/2024
13
Paradoxical Reaction IRIS
Worsening Radiograph 6
weeks following Initiation of
HIV therapy
IRIS commonly occurs in association with Mycobacterium
tuberculosis, Mycobacterium avium complex (MAC),
cytomegalovirus (CMV), Cryptococcus. May occur with
Pneumocystis, Toxoplasma, hepatitis B and C, human herpes
virus 8 (which causes Kaposi sarcoma), and JC virus (which
causes progressive multifocal leukoencephalopathy, PML).
AIDS + node TB diagnosed January 18
CD4 = 30
Rx HIV and TB January 18:
Feb. 23: diffuse rash, neck
drainage
7/26/2024
14
Best Time to start HIV meds in a HIV-
TB patient?
?
?
?
?
New TB in Untreated HIV patient
CD4 <50
•
INH, Rifampin,
Pyrazinamide, Ethambutol
•
Start HIV therapy within 2
weeks due to high risk of
other AIDS complications
•
Monitor for IRIS
CD4 >50
•
INH, Rifampin,
Pyrazinamide, Ethambutol
•
Start HIV therapy within 2 –
8 weeks
•
Monitor for IRIS
7/26/2024
16
Call for advice
•
MDHHS Consultants
•
Global TB Institute at Rutgers University,
Newark, NJ 1-800-4TBDOCS (800-482-3627)
7/26/2024
17
This content provides an overview of the relationship between TB and HIV, emphasizing the importance of testing HIV patients for latent TB infection and TB patients for HIV. It also outlines the guidelines for managing these co-infections, including diagnostic tests, treatment strategies, and patient care protocols. The information is sourced from a virtual conference organized by the Michigan Department of Health and Human Services and Western Michigan University Homer Stryker M.D. School of Medicine. Key points include the need for regular testing, appropriate treatment options, and the significance of interprofessional education for healthcare teams. The content underscores the critical role of healthcare professionals in addressing TB and HIV co-infections for improved patient outcomes.
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Presentation Transcript
TB and HIV Overview for World TB Day March 2022 James Sunstrum, M.D. Wayne County TB Clinic
2022 MDHHS World TB Day Virtual Conference March 24, 2022 Disclosure Denise Parr Isagenix International (Sales) Western Michigan University Homer Stryker M.D. School of Medicine adheres to the ACCME s Standards for Integrity and Independence in Accredited Continuing Education. Any individuals in a position to control the content of a CE activity, including faculty, planners, reviewers or others are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity. Accreditation In support of improving patient care, this activity has been planned and implemented by Western Michigan University Homer Stryker M.D. School of Medicine and Michigan Department of Health and Human Services. Western Michigan University Homer Stryker M.D. School of Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit amount subject to change. Interprofessional Continuing Education This activity was planned by and for the healthcare team, and learners will receive 5.0 Interprofessional Continuing Education (IPCE) credits for learning and change. Physicians Western Michigan University Homer Stryker M.D. School of Medicine designates this live activity for a maximum of 5.0 AMA PRA Category 1 Credits should claim only the credit commensurate with the extent of their participation in the activity. . Physicians Nurses Western Michigan University Homer Stryker M.D. School of Medicine designates this activity for 5.0 contact hours for nurses. Nurses should claim only credit commensurate with the extent of their participation in the activity. Activity Code: 24227
HIV and TB: 2 serious infections Rules of the game: 1. All HIV patients should be tested for latent TB infection. 2. All active TB patients should be tested for HIV. 3. If pulmonary infiltrates found with HIV+, keep TB in differential diagnosis. 7/26/2024 3
1. All HIV patients should be tested for latent TB infection. PPD or Quantiferon on baseline Low CD4 may result in false negative test If negative, repeat based on risk ? Every 2-3 years? 7/26/2024 4
If PPD or IGRA are positive in HIV+ patient Chest X-ray Symptom review for fever, cough, adenopathy Any mass, or any central nervous system abnormality should be evaluated . If negative, treat for latent TB With daily isoniazid, any ARV regimen can be used. 7/26/2024 5
Latent TB treatment for HIV+ patient www.aidsinfo.nih.gov Newer weekly INH/rifapentine or rifampin regimen not recommended together with dolutegravir, bictegravir or protease inhibitors Thanks to LTBI treatment, few HIV patients develop active TB in Michigan 7/26/2024 6
Active TB in HIV+ patients in Michigan 1-2 cases a year (out of 130 cases total) Tend to be foreign born HIV patients Tend to be recent arrivals in USA 7/26/2024 7
New patient in your HIV waiting room Tested HIV+ on Immigration screen Came from Sierra Leone 8 months earlier Dry cough x 2 months Baseline CD4 = 50 cells This is her chest Xray:
Her sputum grew Mycobacterium tuberculosis ! Due to low CD4 count, inflammatory response is limited. Xray may show little or no infiltrate. We kept her out of the regular HIV clinic for 2 months, until TB intensive phase of treatment completed. 7/26/2024 10
GenExpert Assay Procedure for the MTB/RIF Test. Boehme CC et al. N Engl J Med 2010;363:1005-1015.
TB may not look at all typical in HIV patients Unusual chest X-ray findings May have a NORMAL chest X-ray ! 25% of TB will be extra-pulmonary Be especially wary in foreign-borne patients with HIV
IRIS commonly occurs in association with Mycobacterium tuberculosis, Mycobacterium avium complex (MAC), cytomegalovirus (CMV), Cryptococcus. May occur with Pneumocystis, Toxoplasma, hepatitis B and C, human herpes virus 8 (which causes Kaposi sarcoma), and JC virus (which causes progressive multifocal leukoencephalopathy, PML). Paradoxical Reaction IRIS Worsening Radiograph 6 weeks following Initiation of HIV therapy 7/26/2024 13
AIDS + node TB diagnosed January 18 CD4 = 30 Feb. 23: diffuse rash, neck drainage Rx HIV and TB January 18: 7/26/2024 14
Best Time to start HIV meds in a HIV- TB patient? HRZE INTENSIVE INH, rifampin 4 months CONTINUATION PHASE (RIPE) (Or INITIAL) PHASE 2 months ? ? ? ?
New TB in Untreated HIV patient CD4 <50 INH, Rifampin, Pyrazinamide, Ethambutol Start HIV therapy within 2 weeks due to high risk of other AIDS complications Monitor for IRIS CD4 >50 INH, Rifampin, Pyrazinamide, Ethambutol Start HIV therapy within 2 8 weeks Monitor for IRIS 7/26/2024 16
Call for advice MDHHS Consultants Global TB Institute at Rutgers University, Newark, NJ 1-800-4TBDOCS (800-482-3627) 7/26/2024 17
