tbc hiv presentation

8/13/2019 TBC HIV presentation

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Henie Widowati

Bagian Penyakit Dalam

Fakultas Kedokteran Universitas Trisakti


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Latar Belakang

TB masalah kesehatan masy yg besar sejak lama intervensi pcegahan & pengendalian

Sepertiga populasi dunia terinfeksi TB

Epidemi HIV P meningkat di Asia Tenggara

40% tinfeksi M.Tb ancaman

HIV/AIDS (+) & PPD(+) 60% risiko TB aktif

HIV/AIDS (-) & PPD (+) 10% risiko TB aktif

Sepertiga kasus HIV (+) dunia koinfeksi TB

HIV meningkatkan kekambuhan TB

meningkatkan risiko penularan


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50% kematian HIV/AIDS oleh px paru dan salnapas.

23 - 25% kematian pd HIV/AIDS o.k TB risiko kematian 6x lipat terlambat D/ & th/

5 patogen tsering :

- MTb 37% - criptococcus neoformans 15%

- PCP 24% - streptococcus pneumonia 6%

- nocardia 6% - strongiloides stercoralis 3%

Respons thd th/ umumnya lambat & dipsulitoleh ESO dibandingkan status imunologinya


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TB incidence closely correlated with HIV

prevalence in Africa

0

200

400

600

800

1000

0 10 20 30 40

HIV prevalence, adults 15-49y

E

stimatedTB

incidence

(p

er100,0

00p

opulation)

WHO


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TB meningkatkan progresi HIV

Infeksi ganda TB-HIV viral loads

sangat tinggi

Progresi imunosupresi sangat cepat

survival memendek walaupun th/ TB

telah dilakukan

Koinfeksi TB-HIV periode survivalmenurun dibandingkan HIV tanpa TB


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TB Penyebab kematian utama pd

HIV/AIDS LATE DIAGNOSIS &

TERAPI

Kesulitan D/ :

- sputum sering (-)

- >> EPTB

- atypical radiografi & presentasi klinis- menyerupai infeksi paru oportunistik

yg lain


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CD4 counts >350

Disease usually limited to the lungs Often presents like TB in HIV-uninfected persons

typical chest X-ray findings with upper lobeinfiltrates with or without cavities


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CD4 counts


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Features ofpulmonary TB

Early StageHIV infection

Late StageHIV infection

Clinical picture often resembles

post-primary PTB

often resembles

primary PTB

Sputum smear

result

often positive more likely to

be negative

Chest X-rayappearance

upper lobeinfiltrates with or

without cavitation

infiltrates anylung zone, no

cavitation;

miliary; normal


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1. Skrining 3 kombinasi gejala pada anamnesis :

BATUK, DEMAM, KERINGAT MALAM

lebih dari 3x seminggu2. Bila jawaban TIDAK pd 3 gejala tsb kemungkinan TB kecil

3. Bila jawaban YA minimal 1 pada 3 gejala tsb

evaluasi d/ lanjutan pemeriksaan sputumBTA & kultur, BJH pd kasus pbesaran kelenjar

KGB


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Bila sputum BTA (-)....

Kultur BTA sputum the gold standardunt TB diagnosis

Bila sputum BTA negative:

Lakukan sputum BTA kultur (bilamemungkinkan) Kultur sputum meningkatkan kualitas

perawatan & mbantu konfirmasi diagnosis Foto toraks dpt membantu diagnosis,

mis. Ditemukan gambaran pbesarankelenjar di hilus, milier, infiltrat di lobusatas


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TB Screening

Tempat/lokasi prioritas untintensified TB case-finding (ICF):

Medical and infectious disease wards

VCT and PMTCT centres

Out-patient and emergency roomdepartments

Prisons and jails


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0.00

0.05

0.10

0.15

1985 1990 1995 2000

Annu

alincidencei

nAIDScases

Pulmonary TB

Disseminated TB

Mono Dual Triple therapy

TB among AIDS patients in Brazil

www.aids.gov.br/boletim/bol_htm/boletim.htm

Impact of ART on TBIncidence


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Concomitant HAART markedly improves survival in HIV-infected patients with HIV/TB co-infection. Manosuthi, W et al. JAIDS. 43(1):42-46

Effect of ART on survival


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Abdool Karim SS, et al. NEJM 2010;362:697-706


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Early ART (before 8 wks of

TB treatment)

Delayed ART (after 8

wks o f TB treatment)

Adh erence demand Problematic with use of 4-drug

for TB and multidrug therapy

for HIV

Less problematic because

fewer drugs necessary for

TB treatment

Ab i l i ty to determine

the cause of adverse

events

Complex because of the large

number of medications started

in a short time period and

overlapping side effects

profiles

Simpler because the

number of drugs for TB

treatment is less and there

has been more time to

evaluate response to TB

treatment

Drug-drug

interact ion

Problematic Problematic

Severe imm unereconst i tu t ion

inf lammatory events

Risk may be increased Risk may be decreased

HIV d isease

prog ression (new OI

or d eath

Risk may be decreased Risk may be increased

Burman WJ. Clin Chest Med 2005;26:283-294


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TB regimens terapi SAMA (kec.

Thiacetazon) antara HIV (-) dan (+)

SEGERA!! HIV bhubungan dengan peningkatan

mortaliti pberian ART SEGERA

Pasien dengan sputum BTA (-)

mortalitilebih tinggi dibandingkan pasien dengan

sputum BTA (+)


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CD4 < 50 ART 2 mg setelah th/ OAT

CD4 > 50 dengan klinis berat ART 2 4

mg setelah th/ OAT CD4 > 50 dgn klinis ringan sedang ART

dpt ditunda 2 4 mg tetapi harus dimulai 8-

12 mg setelah th/ OAT

Pd psn HIV-MDR/XDR TBART 2 4 mgsesudah diberikan th/ TB second line.


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PIs and RIF: NotRecommended

Protease Inhibitor Effect of Rifampicin

Saquinavir by 84%Ritonavir by 35%Indinavir by 89%Nelfinavir by 82%

Amprenavir by 81%Lopinavir/ritonavir by 75%

Rifampicin decreases blood levels of all PIs


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In TB/HIV co-infection,ART should be initiated earlier (CD43 years old

Avoid 1st trimester of pregnancy

Efavirenz dose 600mg (or 800mg)

NNRTI d Rif i i


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Rifampicin decreases blood levels of

NVP and EFV

NNRTIs and Rifampicin

NNRTI Effect of Rifampicin

Nevirapine 3758%

Efavirenz 22%


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ART and RIF-based TB Rx

Choice of nucleosides (NRTIs)to combine with efavirenz:

Usual adult first-line therapy (mayalso be used in children >3):

Zidovudine + lamivudine

(AZT/3TC)Alternative in case of anemia:

Stavudine + lamivudine (d4T/3TC)

ART Options: RIF-based TB


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*Tenofovir not recommended in pregnancy

ART Options: RIF based TBRx

More options (consider expertconsultation):

Triple NRTI: abacavir or tenofovir* + 2NRTIs

Not as potent, but no druginteractions

WHO first-line for children >3

Nevirapine + 2 NRTIs Some successful clinical experience

Concern for low blood levels, toxicityoverlap (hepatitis, rash), and

hypersensitivity reactions

ART Options: RIF-based TB


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ART Options: RIF based TBRx

Ritonavir boosting of other PIscan achieve adequate bloodlevels but significant

hepatotoxicity riskCan be used in children (

tbc hiv presentation

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