This document discusses treatment considerations for patients co-infected with tuberculosis (TB) and HIV. It summarizes evidence on initiating antiretroviral therapy (ART) in patients being treated for TB. Starting ART earlier reduces HIV disease progression and death, but increases the risk of TB-immune reconstitution inflammatory syndrome (IRIS). Later ART initiation reduces IRIS risk, but increases HIV disease progression and death risks. The optimal time to start ART in TB patients may depend on their CD4 count and differs according to the individual's risks.
Hello Guys,
This presentation consists of the updated guidelines under National tuberculosis elimination programme of India (MOHFW). The presentation includes case definitions and diagnostic algorithms for Pulmonary, Extrapulmonary and Drug resistant TB(MDR/ XDR TB) and the tratment protocols in pediatric cases.
Hope you find it useful.
Hello Guys,
This presentation consists of the updated guidelines under National tuberculosis elimination programme of India (MOHFW). The presentation includes case definitions and diagnostic algorithms for Pulmonary, Extrapulmonary and Drug resistant TB(MDR/ XDR TB) and the tratment protocols in pediatric cases.
Hope you find it useful.
Is a condition seen in some cases of AIDS or immunosuppression, in which the immune system begins to recover, but then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse.
Tuberkulosis (TB) pada anak merupakan masalah khusus yang berbeda dengan TB pada orang dewasa. Perkembangan penyakit TB pada anak saat ini sangat pesat. Sekurang-kurangnya 500.000 anak di dunia menderita TB setiap tahun. Di Indonesia proporsi kasus TB Anak di antara semua kasus TB yang ternotifikasi dalam program TB berada dalam batas normal yaitu 8-11 %, tetapi apabila dilihat pada tingkat provinsi sampai fasilitas pelayanan kesehatan menunjukkan variasi proporsi yang cukup lebar yaitu 1,8 – 15,9%.
Case Presentation Co infection Miliary Tuberculosis and HIV/AIIDS Soroy Lardo
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1. TB-HIV co-infection treatment
Gary Maartens
Division of Clinical Pharmacology
UNIVERSITY OF CAPE TOWN
IYUNIVESITHI YASEKAPA
UNIVERSITEIT VAN KAAPSTAD
2. ART in patients with TB co-infection:
current evidence
Gary Maartens
Division of Clinical Pharmacology
UNIVERSITY OF CAPE TOWN
IYUNIVESITHI YASEKAPA
UNIVERSITEIT VAN KAAPSTAD
3. TB in patients starting ART
Khayelitsha, Cape Town
45
40
35
30
% 25
20
15
10
5
0
2001/2
2003
2004
2005
2006
2007
Boulle AIDS 2010;24:563
11. EFV increases during TB Rx:
pharmacogenomics
• PK study in children
– Genetic slow metabolisers in 20%
– EFV concentrations increased 49% during TB
Rx in slow metabolisers
– Likely due to inhibition by INH of CYP2A6
• STRIDE: Cmin trend higher on TB therapy,
significantly higher in blacks
– Pharmacogenomic study underway
Clin Infect Dis. 2013;57(4):586-93
AIDS. 2013 Jul 31;27(12):1933-40.
12. EFV vs NVP in TB patients
• Cohort study in patients with/without TB showed
EFV equal efficacy, but NVP outcomes worse
• CARINEMO study RCT of EFV vs NVP in TB
– CD4 <250
– ART naive
– Non-inferiority
– NVP lead-in dose omitted
Boulle JAMA 2008;300:53
Lancet Infect Dis 2013;13: 303
15. Rifampicin decreases AUC
of all protease inhibitors
PI
Rifampicin
Saquinavir
84%
Atazanavir
95%
Indinavir
89%
Amprenavir
81%
Lopinavir/ritonavir
75%
CDC 2008
16. Adjusted dose PIs & rifampicin:
healthy volunteers
• Very high rates of hepatitis reported in 3 healthy
volunteer studies (Saquinavir, Atazanavir,
Lopinavir); all stopped early due to toxicity
• ?relevant to HIV+ patients
– rif + PZA for LTBI well tolerated in HIV+, but not HIVArch Drug Inf. 2009 Mar;2(1):8-16
AIDS 2008;22:931-5
JAIDS 2009;50:290-3
CID 2004;39:561
17. Double dose LPV/r with rifampicin:
HIV+ adults on 2nd line ART, VL <400
18
Study day 22
16
Double dose
Referent: Study day 1
Lopinavir (mg/L)
14
12
10
8
6
4
2
Recommended trough in ART-naive
0
0
2
4
6
8
10
12
Time (hours)
2/21 asymptomatic grade 3/4 ALT
0/18 grade 3/4 ALT in TB patients
Need to evaluate darunavir-r interaction with rif
Decloedt AAC 2011;55:3195
Decloedt PLoS ONE 7(3): e32173
18. Adjusted dose LPV/r in kids with TB
• “Super boosting”(RTV:LPV = 1:1) resulted
in similar LPV trough concentrations to
controls
• Double dose PLV/r failed: 60% of children
with TB were sub-therapeutic
– Study stopped early by DSMB
• Studies of other dosing strategies needed
McIlleron Anitivir Ther 2011;16:417
JAIDS 2008;47:566
19. Rifabutin dose with PIs
RBT does not induce PI metabolism, but PIs inhibit RBT
Dose-related toxicity (uveitis, neutropenia)
2 PK studies of RBT:
150 mg/d vs 150 mg 3 × a week on LPV-r
Compared with RBT 300 mg daily without PI
150 mg daily
150 mg 3 × week
South Africa
AUC0-48
AUC0-48
Viet Nam
Steady state
32%
52%
45%
Steady state
30%
25-O-desacetyl-RBT metabolite
(active against TB)
ACTG RCT rifampicin vs RBT (3 × a week) with LPV-r in
TB patients underway
Naiker CROI 2012
Huy Dung IAS 2013
24. Bedaquiline ARV interactions
• Extremely long T1/2 (almost 6 months)
• No clear relationship between plasma
concentrations & effect/toxicity
• Healthy volunteer studies data modelled to
estimate steady state show:
– EFV reduces BDQ 48%
– NVP no significant effect
– LPV/r increases BDQ 286%
• Urgent need for data in patients
AAC 2013;57:2780.
Svensson et al. 2013, Int Workshop Clin Pharmacol TB drugs, abstract 28
25. When to start ART in TB?
Earlier
ART
Deferred
ART
Risk of
IRIS
Risk of HIV
disease progression
26. ART timing in TB:
RCT’s primary endpoints
Death
p=0.006
Death/AIDS
p=0.45
Death/AIDS
p=0.73
Median
CD4 25
N Engl J Med 2011;365:1471
N Engl J Med 2011;365:1482
N Engl J Med 2011;365:1492
27. AIDS/death by CD4
CD4 counts
Early ART
Later ART
Comparison (95%CI)
SAPiT
<50
8.5/100 py
26.3/100 py
IRR 0.32 (0.07, 1.13)
≥50
6.6/100 py
4.4/100 py
IRR 1.51 (0.61, 3.95)
STRIDE
<50
15.5%
26.6%
+11.15 (1.5, 20.5)
≥50
11.5%
10.3%
-1.2 (-6.7, 4.3)
28. TB-IRIS by ART timing
Study
Early ART
Later ART
Comparison
SAPiT
19.5/100 py
7.5/100 py
IRR 2.6 (1.5 to 4.8)
CAMELIA
58.2/100 py
20.4/100 py
P<0.0001
STRIDE
11%
5%
P=0.02
STRIDE: “IRIS management required ≥ 1 invasive procedures in 34.4%,
hospitalization in 31.1% and corticosteroids in 54.1%.”
SAPiT: IRIS milder & of shorter duration in later ART group
Ann Intern Med. 2012;157:313
AIDS 2013, 27:2577
N Engl J Med 2011;365:1482
Luetkemeyer JAIDS in press
29. ART & TB: what lies ahead?
• More data needed on PI use with rifampicin
• New TB drug-ARV interactions need to be
established
• If RCTs to prevent TB-IRIS (NSAIDs, low dose
steroids) are successful, this may allow safe
earlier ART use
• New TB drug regimens likely to clear antigens
faster, which should IRIS risk, and earlier ART
initiation may be safer
Editor's Notes
This study was done in HIV+ volunteers (not with TB, subsequent study of 18 in PLOS One was in TB patients) Double dose LPV overcame effects of rif on LPV concentrationsNeed for more clinical data to assess tolerability of double dose LPV with TB therapyPharmaceutical companies won’t do PI-rif interactions following bad experience with HNVs
150 mg daily results in higher concentration – risk of uveitis & neutropenia (both dose related). 150 mg 3 × a week results in lower concentrations – risk of developing rifamycin resistance. Other doses need to be studied.
ART, antiretroviral therapy; BID, twice daily; EFV, efavirenz; RAL, raltegravir; TB, tuberculosis. Ian M. Sanne, MBBCH, FCP (SA): The REFLATE study, supported by the ANRS and conducted predominantly in Brazil, has been much awaited. This phase II trial evaluated alternative antiretroviral treatment options in combination with rifampicin-based tuberculosis treatment in patients with HIV/tuberculosis coinfection. A total of 154 patients were randomly assigned to receive the standard dose of raltegravir (400 mg twice daily), an escalated dose of raltegravir (800 mg twice daily), or standard care with efavirenz, all in combination with tenofovir, lamivudine, and a rifampicin-containing tuberculosis regimen.For more information about this study, go online to: http://www.clinicaloptions.com/HIV/Conference%20Coverage/AIDS%202012/Tracks/Highlights%20From%20AIDS%202012/Capsules/THLBB01.aspx
ART, antiretroviral therapy; D/C = F, discontinuation equals failure; EFV, efavirenz; ITT, intent to treat; M = F, missing equals failure; RAL, raltegravir; VL, viral load. Ian M. Sanne, MBBCH, FCP (SA): Overall, the study results were similar in the 2 raltegravir-containing arms. Although no statistics were provided and the sample size is too small for statistical analysis, there was a numerical benefit in the proportion of patients with virologic suppression at 24 weeks for the raltegravir arms. In addition, the shorter time to HIV-1 RNA suppression with the integrase inhibitor regimens that we discussed earlier was again demonstrated in this study. What was not discussed was whether this influenced tuberculosis outcomes, which the investigators will be analyzing in the future. For example, it would be interesting to see whether an integrase-containing HIV regimen would affect the time to sputum conversion in patients with tuberculosis. The standard dose and the escalated dose of raltegravir provided similar results, which elicits the question of whether the lowest possible dose for therapeutic raltegravir activity has been identified. The pharmacokinetic data for this study were not presented, and we await those results with anticipation.For more information about this study, go online to: http://www.clinicaloptions.com/HIV/Conference%20Coverage/AIDS%202012/Tracks/Highlights%20From%20AIDS%202012/Capsules/THLBB01.aspx
