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TB Nurse Case ManagementSan Antonio, Texas

December 8 10 2009December 8-10, 2009

Case Management of the TB/HIV Infected PatientSarah Hoffman MPH MSN ACRNSarah Hoffman, MPH, MSN, ACRN

December 9, 2009

TB/HIV: Considerations in the Care of the Coinfected Patient

Sarah Hoffman MPH MSN ACRNSarah Hoffman, MPH, MSN, ACRNNetwork Nursing Education Coordinator, Acute Care

Seton Family of Hospitals

December 9, 2009

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Global Perspective

• Classified in 1993 as AIDS-defining illness by the CDC

• Increasing global burden of TB strongly connected to global HIV epidemic

• Primary cause of death in HIV infected individuals

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• Congruent epidemics raise the potential threat of a global epidemic of drug resistant TB

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Global Statistics

• Tuberculosis– Approximately 1/3 of the global population infected with TB at a

i tigiven time

– 9 million new cases per year

– 2 million annual deaths from TB

• HIV/TB– In 2007, 1.4 million cases of HIV positive TB globally.

– 15% of total incident TB cases are found among PLWHIV

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g• Double previous estimates

– 42 million individuals globally infected with HIV• More than 25% also infected with MTB

Epidemiology of TB/HIV in the US

• 12,904 TB cases (4.2/100,000) reported in the US in 2008

• Overall rate declining but the• Overall rate declining, but the decrease has slowed over time

• In 2005, HIV status of 31% of TB patients was unknown

• 9% of TB patients were HIV positive in 2005

• Areas of ongoing concern:– # of cases of TB declining

nationally, however still reported in almost all states with increases

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in almost all states with increases in areas

– National data on coinfection incomplete

– Given these interactions, missed opportunities to intervene in both disease processes

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Implications of Coinfection

• Risk of developing active TB from LTBI increased 100-fold with HIV infection

• Risk of developing TB disease 7-10% each year with coinfection,– 10% over a life time for non-HIV infected individuals with LTBI

• HIV increases risk of contracting TB regardless of CD4

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c eases s o co t act g ega d ess o Ccount

• TB accelerates progression of HIV disease process

Case Management

A collaborative process in which a case manager assesses plans implements coordinates monitors andassesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health (treatment) needs through communication and available resources to promote quality cost-effective

outcomes. ~Case Management Society of America;1995

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Considerations in the NCM of the Coinfected Patient

• Screening and Diagnosis• Drug-Drug interactionsDrug Drug interactions• Monitoring• Adherence challenges with polypharmacy &

DOT• Overlapping side effect profiles• IRIS

D i t t TB

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• Drug resistant TB• Health Literacy• Nutrition

Basics of HIV

• Terms:– CD4

• Function• Normal range: 500-1400• AIDS defining criteria

– Viral Load (copies/mL)– HAART– Opportunistic Infection

• Testing:– ELISA with confirmatory Western Blot

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y(antibody)

– Antigen testing• Natural History

– In absence of treatment

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Screening• Understand and act on screening guidelines

for TB and HIV.• (2006) CDC recommendation for universal

testing of HIVtesting of HIV.• TB screening guidelines in HIV positive

individuals– CDC recommends testing in HIV-infected pts

w/out previously positive TST.– TST should be repeated annually if initial test

negative and patient at high risk for TB.– TST should be repeated upon immune

reconstitution or when CD4 count reaches 200.

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• Risk for TB greatest with CD4 count in the range of 200-500

• 65% false negative in AIDS patients with active TB

Interferon Gamma Release Assay• Selects for protein specific to Mycobacterium tuberculosis• Positives:

– Eliminates false positives from BCG vaccine or non-ptuberculous mycobacteria

– Less likely than TST to be inaccurate– Requires only one visit for blood draw

• Limitations:– Limited accuracy data in HIV positive populations

• Three versions of test

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– Quantiferon-TB Gold (QFT-G)– Quantiferon-TB Gold In-Tube (QFT-GIT)– T-Spot TB

• Can be used in all situations in which TST is used

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12%

800

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700

Percentage of Notified TB Cases Tested for HIV

Number of TB cases tested (thousands)

Percentage of notified TB cases tested

8.5%

3.2%4.0%

400

500

200

300

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12

4

6

8

600

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0.5%

0

100

0

2

2002(9, 37%)

2004(84, 61%)

2003(92, 53%)

Year

2005(118, 83%)

2006(112, 90%)

Note: Numbers under bars represent the number of countries reporting data followed by the percentage of total estimatedHIV-positive tuberculosis cases accounted for by reporting countriesSource: WHO, 2008

Special Populations & Risk Factors

• Foreign born persons

– 59% national case total (increase)(increase)

– 48.1% of cases in TX

• Low income

– 48.3% of cases in TX

• Overlapping risk factors with HIV infection

ETOH and substance abuse

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– ETOH and substance abuse

– Inmates

– Migrant populations

– Homeless

• Disenfranchised individuals

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TB Diagnosis• Presumptive diagnosis:

– Based on clinical symptoms– Abnormal CXR– Sputum smear positive for AFB– Nucleic acid amplification (NAA) positive – more sensitive than

AFB smear (80% vs 50%)

• Definitive confirmation of diagnosis depends on a positive MTB culture

• 50% of patients (HIV positive or negative) with culture positive MTB have negative smears

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positive MTB have negative smears

• Clinical features varying with CD4 count– Greater than 350– Less than 50

Overview of HIV Treatment• Drugs developed to

interfere with viral replication at major pointsreplication at major points in HIV lifecycle

• HIV treated with at least 3 drugs from at least 2 classes

• Rationale similar to treatment of TB– Avoid propagation of

resistant virus

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Treatment Considerations in Coinfection

• Initiation of HAART and TB treatment– Initiation should not be simultaneousInitiation should not be simultaneous

• Ideally treat TB first with initiation of HAART introduced at 4-8 weeks.

• Possible exception, pts with CD4 < 50

• Management of TB RegimenSimilar to patients without HIV

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– Similar to patients without HIV• 2 month initial phase

• 4 month continuation phase

• Pts with CD4 < 100, dosing daily or tri-weekly

Drug-Drug Interactions: Rifamycins & ARVs

**Goal is to manage complications, not avoid them

• Preferred regimen: Rifampin and the NNRTIs– Rifampin → ↓Efavirenz concentrations– Can dose adjust Efavirenz: 600 → 800 mg q day

• Not all patients can tolerate NNRTIsAlt ti h i PI

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– Alternative choice: PIs

• Rifampin contraindicated with all boosted PIs– Alternative choice: Rifabutin

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Drug-Drug Interaction: Rifabutin and PI Based HIV Therapy

• Preferred therapy for patients unable to tolerate NNRTI-based regimensg

• PI’s ↑ concentrations of Rifabutin– Dose adjusted Rifabutin– Concern with discontinuation of med or nonadherence

• No published studies of potential drug-drug interactions between 2nd line TB drugs and ARVs

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between 2nd line TB drugs and ARVs

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Treatment Options

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Monitoring: Baseline

• LFT’s

R l f ti• Renal function

• CBC

• CMP

• Uric Acid with PZA

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• Visual acuity with EMB

• CD4

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Ongoing Monitoring

• Clinical assessment monthly• Laboratory

– LFT’s at 1 and 3 months routine and with symptomsLFT s at 1 and 3 months routine, and with symptoms hepatotoxicity

– Sputum smear and culture at least monthly until 2 consecutive smears are negative

– CXR at 2 months and termination of therapy– VL at 1-4 weeks and 3-4 months if starting HAART– CD4 at 3-4 months if starting HAART

• Improvement (Similar to HIVΘ):

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Improvement (Similar to HIVΘ):– Afebrile within 7-14 days– Sputum culture becomes negative within 2 months in 85%

coinfected pts– Important to distinguish IRIS from treatment failure

Managing Pill Burden & Adherence

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Overlapping Side Effects

HEPATOTOXICITY NEUROLOGICAL DERMATOLOGIC RENAL OPTHALMOLOGIC HEMATOLOGIC METABOLIC

INH Periph Neuropathy Rash Streptomycin Vision Changes Rifampin Lactic Acidosis

Rifampin INH INH Amikacin Ethambutol Rifabutin AZT

PZA Ethionamide ABC Capreomycin Rifabutin Ethambutol D4T

Ethionamide Linezolid Lipo-Dyst/Atrophy Rifampin Linezolid INH ddI

PAS CNS d4T Rifabutin Uveitis PZA Hyperlipidemia

NVP INH AZT TDF Rifabutin Linezolid d4T

EFV Ethionamide PI’s IDV Orange Tears AZT PI’s except ATV

PI’s Fluoroquinolones Rifampin d4T EFV > NVP

d4T Cycloserine Insulin Resistance

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AZT Amikacin PI’s except ATV

ddI Linezolid

EFV

*HIV *TB

TB IRIS

→Emergence of new manifestations of TB or the worsening of existing symptoms of TB in the presence of appropriate anti-TB therapyy

• Frequency of reaction varies from 11% to 45% • Occurs more often in patients with:

– lower CD4+ counts– extra-pulmonary disease– disseminated disease– shorter interval from TB diagnosis to antiretroviral initiation

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• Reported most frequently within 6 weeks of TB treatment initiation in the presence of HAART

• Cues to place IRIS on differential

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Drug Resistant TB

• HIV considered risk factor for drug resistant tuberculosis

• Drug resistant TB is a significant cause of death in HIV/TB coinfected patients

• Sudden epidemic of XDR-TB in KwaZulu, Natal in South Africa in 2006.

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2008: Countries Reporting at Least One Case of XDR-TB

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Health Literacy

• WHO defines as: “The cognitive and social skills which determine the motivation and ability of individuals tomotivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health.”

• People with limited health literacy skills:– Report poorer overall health– Less likely to make use of screening– Present in later stages of disease

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– More likely to be hospitalized– Have poorer understanding of treatment– Have lower adherence to medication

regimens

Nutrition: Major Impact on Health Outcomes

• WHO recommendations for energy intake in the HIV infected patient

A t ti HIV i f t d d lt• Asymptomatic HIV-infected adults• Symptomatic HIV-infected adults• Symptomatic children

• Nutrition & TB• Risk factor in the development of

active disease• Increase rates of relapse

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p• Likelihood of treatment failure

• Research– 50% rate of relapse– Weight gain during initial phase of

therapy

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Questions?

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Thank you.

ReferencesInfectious Diseases Society of America (2009, March 27). Alarming New Data Shows TB-HIV Co-infection A Bigger

Threat. ScienceDaily. Retrieved June 9, 2009, from http://www.sciencedaily.com-/releases/2009/03/090324131600.htm

http://www.afro.who.int/press/20070829.htmlhttp://www.qamapserver.who.int/mapLibrarary/app/searchResults.aspxp q p p y pp phttp://www.euro.who.int/document/TUB/pr3s1TB-HIVLDitiuENG.pdfMorbidity and Mortality Weekly Report. Reported HIV Status of Tuberculosis Patients -- United States, 1993—2005.

Published: 11/12/2007.TB and HIV Coinfection: Current Trends, Diagnosis and Treatment Update Liza King, MPH and Shama Ahuja, MPH

Based on a Presentation at PRN by: Sonal S. Munsiff, MDhttp://www.prn.org/index.php/coinfection/article/tbhivcoinfectioutreatment80

http://www.uhavax.hartford.edu/bugl/hiv.htmhttp://www.who.int/tb/publications/global_report/2009/en/index.htmlhttp://data.unaids.org/pub/GlobalReport/2008/2008_globalreport_figure5_10_en.ppt#418,1,Slide 1

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