Coordinated Care Vital in HIV-Tuberculosis Coinfection

New guidelines published in Clinical Infectious Diseases recommends that patients coinfected with HIV and tuberculous (TB) receive prompt, simultaneous treatment for both diseases.

HIV-positive or diabetic patients who take immune-suppressing medications, or who smoke or abuse drugs, have an increased risk of developing TB once infected. Patients are often diagnosed with the 2 conditions at the same time, and TB is the leading cause of death in people with HIV infection.

Back in 2003, when previous TB guidelines were developed, HIV patients would normally not initiate antiretroviral therapy (ART) until after they completed their TB treatment, unless immunosuppression form HIV progressed.

Since then, the recommendations for timing of initiation of ART has changed. The new guidelines were developed by the American Thoracic Society (ATS), Centers for Disease Control and Prevention (CDC), and Infectious Diseases Society of America (IDSA) for the treatment of drug-susceptible TB.

“Data from numerous trials have made it very clear that patients with HIV should begin treatment with antiretroviral therapy during TB treatment, and not wait until after TB therapy is completed,” said lead guidelines author Payam Nahid, MD, MPH. “Research shows that all patients with TB and HIV should receive treatment for both conditions, with HIV treatment beginning within 8 to 12 weeks of the start of TB therapy. Some patients may need HIV treatment even sooner.”

However, study authors noted that ART may need to be delayed, especially in HIV-positive patients with TB meningitis. This is because early initiation of ART — within 2 weeks of the start of TB treatment – has been associated with increased risk of death.

For all other coinfected patients, ART should be initiated as early as possible during TB treatment. If a patient does not receive ART during TB treatment, the new guidelines recommend that TB treatment be extended to 8 months or longer, in order to reduce the risk of relapse.

The new guidelines also recommend comprehensive care (case management) of all TB patients, including the use of directly observed therapy (DOT), which improves the success of treatment.

DOT involves a health care provider overseeing a patient to ensure they swallow each dose of medication during the 6-month course of therapy. The guidelines recommend that all decisions regarding the use of DOT be made with the patient.

Additionally, DOT should only be provided by trained health care professionals in the physician’s office, clinic, or the patient’s home, place of employment, school, or other sites that are convenient for the patient.

The guidelines note that case management is essential for all TB patients to ensure the treatment is effective.

“Case management, including DOT and patient education and counseling, is vital to reducing the risk of non-adherence to treatment, and consequently the risks of TB relapse, drug-resistance and other illnesses,” said Philip LoBue, MD, director of the Division of Tuberculosis Elimination (DTBE) at CDC in Atlanta. “We now have clear evidence to show that the benefits of case management are real.”

Study authors noted that despite the guidelines primary focus on drug—susceptible TB, the recommendations may also help stem the growing issue of acquired drug resistance. This includes recommendations related to avoiding highly intermittent therapies, and using case management strategies, such as DOT.

The guidelines noted that TB treatment should begin as soon as the patient is suspected of having active TB disease, even before test results confirm the diagnosis, because rapid killing of the bacteria reduces the spread of the disease and risk of death.

TB is an infectious disease that primarily affects the lungs. The bacteria are able to spread from one person to another through tiny droplets released in the air through coughs and sneezes, according to the Mayo Clinic. Drug-susceptible TB bacteria is able to be killed by the normally medications used to treat TB.

For 2 decades the amount of TB cases had a steady decline, but provisional data released by the CDC revealed that the number of new TB cases in the United States increased slightly in 2015 to 9563. In 2014, it was considered one of the world’s deadliest diseases and it is estimated that 9.6 million people worldwide became infected with TB, and 1.5 million died.