Andria Amanda P - 1106127784 Bondan Winarno - 1106064700 Ditha AR Pratiwi - 1106127595 Karin Nadia U - 1106127765 Kenneth Johan - 1106064631 Putri Luthfiyah - 1106008864 Tuberculosis • Infection transmitted via airborne; caused by Mycobacterium tuberculosis • TB infection can develop gradually in both immunocompetent and immunocompromised patient • Worldwide, TB is known to be one of the leading mortality rates in people living with HIV • Included as a true AIDS-defining illness in HIV patients – Besides Pneumocyctis carinii pneumonia, cerebral toxoplasmosis or extrapulmonary systemic mycoses • The presence of TB in patients with HIV usually occurs in early stage of HIV infection TB may influence the prognosis of HIV infection Epidemiology • 1997: at least 10.7 million people who were infected by both HIV and TB in the world • 1992, WHO: approximately 4 milllion people were infected by both TB and HIV worldwide and 95% of them were lived in developing countries • 2014, WHO: 1.2 million out of 9.6 million new cases of TB are people living with HIV • Men more prone to get TB infection during HIV infection • People who lived in sub-Saharan countries and southern Asia, in which malnutrition is one of the factors • People living with HIV have a greater risk to develop TB infection up to 30 times greater as compared to those who live without HIV infection • Pedoman Teknis Tatalaksana Ko-infeksi HIV pada TB: 60% of people living with HIV that will be infected as well to TB infection Coordination of TB-HIV • Indonesia high rate of TB infection • The spreading coinfection of TB-HIV is a new challenge in Indonesia – Low integrated service or facility of TB-HIV – Coordination of TB-HIV generally should be strengthen • According to Strategi Nasional Pengendalian TB guideline, there are several things that are still needed to be evaluated: – Many hospitals have not been involved in the national TB control program – TB screening has not been fully managed – Isoniazid preventive therapy has not been included in national collaboration of TB-HIV authorization – TB-HIV program in prison is still limited – Low understading in the community and also the access to TB-HIV materials Coordination of TB-HIV • Integrated TB-HIV service is focused on high risk community in health care facility, including in prisons, which aims: – To improve treatment compliance and patient visits – To activate TB screening for people living with HIV – To expand HIV testing for suspected TB infection – To provide antiretroviral therapy (ART) for patients with co-infection of TB-HIV Pathophysiology of TB in Patients with HIV • Infection by M. Tuberculosis – Penetrates respiratory tract initiation of inflammatory response – Increased number of macrophages and dendritic cells on infected lung tissue – Activation of CD4+ production of IFN-γ – Activation of macrophages inhibits the growth of intracellular bacteria • Tuberculosis: when immune system is weakened, and becomes insufficient to limit the growth of bacteria Pathophysiology of TB in Patients with HIV
• Patients with HIV infection:
– Reduction in number of CD4+ decreased IFN-γ production – Increased risk of reactivation and reinfection of M. tuberculosis Clinical Manifestation of TB Respiratory Systemic • Cough lasting more than 3 • Fever weeks • Malaise • Coughing blood • Sweating at night • Shortness of breath • Anorexia • Chest pain • Weight loss Risk Factors of TB Screening for TB among people living with HIV • Patients who answer at least 1 symptom should undergo a diagnostic evaluation – Smear microscopy and liquid culture of at least 2 sputum specimens – Liquid culture of a lymph node aspirate is there is enlarged lymph nodes Radiological Findings
Gooze L, Daley CL.
Tuberculosis. Dikutip pada 27 November 2014. Diunduh dari: http://www.hiv.va.gov/pro HIV Testing on TB Patients • Rapid test or lab assay -> finger prick or oral specimen
Aaron L, Saadoun D, Calatroni I, Launay O,
Memain N, Vincent V. Tuberculosis in HIV- infected patients: a comprehensive review. Clin Micribiol Infect. 2004;(10):388–98. TB-HIV Treatment Principle • same principle as in other TB patients. • TB patients with HIV increased number of mortality and morbidity given ARV and OAT. • ARV treatment should be initiated immediately within the first 2-8 weeks after the start of TB treatment and well tolerated. • If the patient is in the treatment of ARV , TB treatment should be referred to hospitals for ARV treatment referral. • If found to be HIV-positive at TB patients, refer the patient to the unit with HIV or ARV referral hospitals to prepare for the commencement of HIV treatment. • ARV treatment should be given in the service PDP, which is capable for delivering the treatment of HIV-related complications ARV referral hospitals or satellites. ARV drugs dosage Golongan Obat Dosis Nukleosida RTI (NsRTI) · Abakavir (ABC) 300 mg 2x/hari atau 400 mg 1x/hari · Didanosin (ddl) 250 mg 1x/hari (BB<60 Kg) · Lamivudin (3TC) 150 mg 2x/hari atau 300 mg 1x/hari · Stavudin (d4T) 40 mg 2x/hari (30 mg 2x/hari bila BB<60 Kg) · Zidovudin (ZDV) 300 mg 2x/hari Nukleotida RTI · TDF 300 mg 1x/hari Non nukleosid RTI (NNRTI) · Efavirenz (EFV) 600 mg 1x/hari · Nevirapine (NVP) 200 mg 1x/hari untuk 14 hari kemudian 200 mg 2x/hari Protease inhibitor (PI) · Indinavir/ritonavir (IDV/r) 800 mg/100 mg 2x/hari · Lopinavir/ritonavir (LPV/r) 400 mg/100 mg 2x/hari · Nelfinavir (NFV) 1250 mg 2x/hari · Saquinavir/ritonavir (SQV/r) 1000mg/ 100 mg 2x/hari atau 1600 mg/200 mg 1x/hari · Ritonavir (RTV/r) Kapsul 100 mg, larutan oral 400 mg/5 ml. ARV treatment to HIV-TB The provision of isoniazid (INH) as a prophylaxis. • INH preventive treatment aimed at preventing active tuberculosis in people living with HIV (PLHIV) . • If PLHIV is not proven TB and no contraindications, then INH given at a dose of 300 mg / day and B6 at a dose of 25 mg / day dose of 180 or 7 months. The provision of co-trimoxazole as prophylaxis. • PLHIV decreased immune system that patients are more susceptible to any infection. • co-trimoxazole usually given to PLHIV as a prophylaxis of infectious pneumonia, Pneumocystis pneumonia, toxoplasmosis, isospora belli, salmonella, and others. Drug interactions • Giving rifampicin will reduce levels of NNRTIs and protease inhibitors because it induces the P450 enzymes work on the day. • Efavirenz is a NNRTI’s drug of choice for the treatment of HIV-TB because it interaction with TB drugs is minimal. EFV standard dose is 600mg / day. • NVP (nevapirenz) can also be given, and levels also decreased if given together with rifampicin. TB-HIV drug side effects • Unique to each individual • Can be mild or severe • Target symptomatic relief Management of side effects to patient in TB-HIV therapy • Anorexia, nausea, and stomachache – treat symptomatic complaint, consume drug after meal, and suggests frequent small portion food with soft consistency. • Joint pain – give analgesics such as aspirin or paracetamol • Pins and needle feeling on foot – give B6 vitamin 100mg per day, otherwise consult to specialized hospital. • Orange urine – explain to patient. • Tiredness – tiredness usually occurred for 4 to 6 weeks after ZDV started. If not resolved after 6 weeks, consider to refer. • Changes in fat distribution – educate the patient that this cannot be avoided. • Pruritus – might be allergic reaction or Steven Johnson Syndrome, consider to refer. • Hearing problem – stop streptomycin. • Anemia – check hemoglobin level, in pregnant women, swap ZDV with d4T. • Headache – give analgesics such as aspirin or paracetamol. • Diarrhea- give oralit or substitutional fluids, encourage patient that the diarrhea will resolve. If not resolved within two weeks, then refer References • Aaron L, Saadoun D, Calatroni I, Launay O, Memain N, et al. Tuberculosis in HIV-infected patients: a comprehensive review. Clin Microbiol Infect. 2004; 10: 388-398. • Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan Kementrian Kesehatan Republik Indonesia. Petunjuk Teknis Tatalaksana Klinis Ko-infeksi TB-HIV. 2012. • Narain JP, Raviglione MC, Kochi A. HIV-associated tuberculosis in developing countries: epidemiology and strategies for prevention. Tubercle and Lung Disease. 1992; 73(6): 311-321. • World Health Organization. Tuberculosis and HIV. [Online on the Internet]. 2016. Available on: http://www.who.int/hiv/topics/tb/en/ • Kementerian Kesehatan Republik Indonesia: Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan. Strategi Nasional Pengendalian TB di Indonesia 2010-2014. 2011. • Pawlowski A, Jansson M, Sköld M, Rottenberg ME, Källenius G. Tuberculosis and HIV co-infection. PLoS Pathog 8(2): e1002464. doi:10.1371/journal.ppat.1002464 • Konsensus TB. Pedoman diagnosis dan penatalaksanaan Tuberkulosis di Indonesia. 2012 [cited 2016 Apr 20]. • Centers for disease control and prevention.A new approach for TB disease screening and diagnosis in people with HIV/AIDS. 2012 [Cited 2016 April]. Available from: http://www.cdc.gov/tb/topic/globaltb/screening.htm. • Arunkumar N, Chandrasekhar S, Kumar SR, Menon PA, Narendran G, Padmapriyadarsini C, et al. Impact of HIV infection on radiographic features in patients with pulmonary tuberculosis. Indian J Chest Dis Allied Sci 2007; 49: 133-6 • Gooze L, Daley CL. Tuberculosis. Cited on 27 November 2014. Available from: http://www.hiv.va.gov/provider/image-library/tb.asp?post=1&slide=45. • Perhimpunan dokter paru indonesia. Tuberkulosis: pedoman diagnosis dan penatalaksaaan di Indonesia. Revisi pertama. Jakarta: PHPI, 2011