HIV/TB Coinfection

Question 1

IRIS

Answer 1

Immune Reconstitution Inflammatory Syndrome – worsening of TB symptoms after starting ART due to recovering immunity

Question 2

Incidence of HIV/TB coinfection

Answer 2

There is a high incidence of TB among HIV-infected persons.
According to the WHO TB REPORT, 2019, around 10 million people fell ill with TB in 2018 with about 10% of these co-infected with HIV.
Consequently, given the high prevalence of co-infection, all HIV-infected individuals should be screened for TB and placed on TB treatment if found with TB.
TB is the most common cause of death among people living with HIV in Zambia

Question 3

Principles of management

Answer 3

All HIV-positive clients must be screened for TB at every contact.
Integrated Services: TB/HIV be provided through one-stop-shop
ART should be started in all TB patients living with HIV regardless of CD4 count
Xpert MTB/RIF is the preferred diagnostic test for HIV associated TB
Isoniazid Preventive Therapy (IPT) for all eligible HIV clients without active TB.
Adherence and Psychosocial Support is Key to success in co-management

Question 4

CF of HIV/TB coinfection

Answer 4

early stage - Similar to Non-HIV
infected with productive
cough
Pulmonary
manifestations dominate
late stage - Atypical presentation:
Extrapulmonary TB is
more common. TB tends
to be disseminated
(involving different
organs like meningitis,
pleura, pericardium,
lymph nodes etc)

Question 5

Investigations of HIV/TB coinfection

Answer 5

GeneXpert MTB/RIF Ultra: First-line test for all presumptive TB cases, including PLHIV.
Chest X-ray: Particularly important for smear-negative or extrapulmonary TB.
First-Line Line Probe Assay
Sputum Microscopy: Supportive role, especially where GeneXpert is unavailable

Question 6

Tx of HIV/TB coinfection

Answer 6

 When TB and HIV are co-existing TB is more life threatening and it should
be treated first and patients should be stabilized.
 The same combination anti-TB drugs are given based on the treatment
category
 Close follow up of patinets on DOTS is required
 Complete cure from TB may be achieved in 6 to 8 months.
 ART can usually be deferred for about 14 days and started as soon as the
patient can tolerate anti-TB medication

First-Line Tx comprises of 4FDCs (RHZE) and 2FDC (RH) for a period of 6-12 months depending on the severity and anatomical location of the disease
Intensive Phase
Designed for the rapid killing of actively growing and semi-dormant bacilli
Achieves a shorter duration of infectiousness
The duration of the phase is two (2) months in new and retreatment cases
Continuation Phase
Eliminates bacilli that are still multiplying and reduces the risk of failure and relapse
The duration is for at least four (4) months in most cases and ten (10) * months if the patient has meningitis, Osteoarticular or spinal TB

Question 7

Challenges in tx of HIV/TB coinfection

Answer 7

 Increased morbidity, mortality and high case fatality rate
 Increased drug toxicity
 Decreased drug absorption
 High pill burden which decreases adherence to treatment
 Drug interaction between anti-TB drugs and ART e.g. TDF/TAF and
Rifampicin (TDF has to be substituted for ABC)

Question 8

INH Preventative therapy

Answer 8

 Advised for HIV infected patients
 Patients should be screened for active TB before they are given preventive
therapy
 INH 300mg/day for 6-9 months
 Alternatively, Rifampicin for 4 months can be used.