Clinical Manual for Management of the HIV-Infected ... - myCME.com

Section 6—Disease-Specific Treatment | 6–75
Tuberculosis Treatment in Resource-Limited Settings
Background
Tuberculosis (TB) is the most common severe
opportunistic infection associated with HIV in many
resource-limited areas such as sub-Saharan Africa.
The enormous and increasing number of cases of TB
associated with HIV infection has greatly increased
the demands on TB treatment programs. TB treatment
in HIV-infected patients is different in resourcelimited
settings than in resource-abundant settings,
and treatment details may differ by country. In general,
the emphasis of TB treatment and control in resourcelimited
areas has been on diagnosing sputum smearpositive
patients (ie, those with infectious pulmonary
TB) to minimize the need for expensive technology
and to maximize the public health impact of treatment.
The target for many national TB control programs is
to diagnose 70% of new cases, and for 85% of newly
diagnosed patients to complete a course of therapy. The
following recommendations for diagnosis and treatment
are derived from guidelines by the World Health
Organization (WHO) and the International Union
Against Tuberculosis and Lung Disease.
See the Treatment of Latent Tuberculosis in Resource-
Limited Settings chapter for a discussion of isoniazid
preventive treatment (IPT) for HIV-infected persons.
For more information on tuberculosis, including
diagnosis and treatment, see chapter Mycobacterium
tuberculosis: Treatment in the United States and Other
High-Income Nations.
Diagnosis
HIV counseling and voluntary testing should be
encouraged for every person diagnosed with TB. In
addition, screening for TB symptoms should occur at
every health care interaction with HIV-infected persons.
Patients with both conditions should be referred
between the TB and HIV treatment facilities in order
to access both treatments appropriately. Coordination
between TB and HIV treatment is crucial because of
potential drug interactions, increased risk of toxicity,
risk of immune reconstitution inflammatory syndrome
(IRS), and increased adherence challenges. In many
countries, an effort to coordinate HIV and TB care is
just beginning.
Three sputum smears should be examined for acid-
fast bacilli (AFB) in all patients with chronic cough.
The presence of other respiratory symptoms (eg,
breathlessness, chest pain, hemoptysis) or systemic
symptoms (eg, fever, night sweats, weight loss, loss of
appetite) increase the likelihood of pulmonary TB. For
outpatients, an initial (spot) sputum specimen should
be obtained on the day a patient presents for evaluation.
The patient then is sent home with a sputum cup to
collect a sample immediately after awakening the next
morning. The patient brings the morning specimen
back to the health facility the day it is collected. On
that day, the patient provides a second spot specimen in
the health facility, so that 3 specimens are collected in 2
days. All 3 are stained and examined microscopically for
AFB.
HIV-infected patients with TB, especially those with
advanced immunosuppression, often have either smearnegative
pulmonary disease or extrapulmonary disease.
In such cases, diagnosis relies on clinical judgment and
radiographic imaging, and sometimes on aspirates and
biopsies. In some locations, x-rays may be unavailable,
so TB treatment may be instituted in smear-negative
patients in whom pulmonary TB is suspected (eg,
in patients in whom at least 1 trial of standard
antibiotics has been ineffective and a medical doctor
or an appropriately trained clinician has not made an
alternative diagnosis). In some cases, diagnostic testing
may not be available, and AIDS patients with a wasting
febrile disease may be treated empirically for TB.
TB lymphadenitis often can be diagnosed on an
AFB smear of a needle aspirate of a suspicious
lymph node, or on the gross appearance of caseous
necrosis in a biopsied lymph node. AFB smears are
usually negative in pleural, pericardial, peritoneal,
joint, and cerebrospinal fluids of patients with TB in
those compartments. Diagnosis is based on clinical
presentation and on cell counts and chemistry tests of
the fluids. (Where chemistry tests are not available, the
fluid may be observed for formation of protein clots
over the course of several hours, indicating elevated
fluid protein levels.) Liver and bone marrow biopsy may
be helpful in diagnosing disseminated TB, revealing
granulomas if not acid-fast organisms. If possible,
these fluids and biopsied tissues should be cultured for
Mycobacterium tuberculosis.