Authors: Faiz Ahmad Khan, MD, MPH—co-author
Madhukar Pai, MD, PhD—Author and Series Editor
Number of pages: 6
Download (2018, pdf, 156kb)
Overview: Tuberculosis (TB) is the leading cause of morbidity and mortality in people living with HIV (PLWH). The epidemiologic link between HIV and TB is strong even in a low HIV prevalence country such as India
– hence all Indian physicians that see patients with suspected or confirmed TB should understand how to approach TB diagnosis and treatment among PLWH, even if they are not working in a community where HIV infection is common. This article provides general practitioners with a concise and practical overview of TB screening, prevention, diagnosis and treatment, in PLWH.
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Management of HIV and Tuberculosis: What Every GP Should Know
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Question 1 of 6
1. Question
Which of the following diagnostic tests is the recommended frontline test for PLWH suspected of having active, pulmonary TB?
Correct
The correct answer is (d). The WHO and STCI recommendation is that GeneXpert (Xpert MTB/RIF) be used as the frontline test for PLWH suspected of having active pulmonary TB) This test is more sensitive than sputum smear microscopy. The interferon-gamma release assay is a test for latent TB infection, it should not be used as a diagnostic test for investigating suspected active pulmonary TB) Sputum culture is highly sensitive and specific for the diagnosis of active pulmonary TB; however, GeneXpert is recommended as the frontline test because it provides results within a few hours, whereas sputum culture can take weeks.
Incorrect
The correct answer is (d). The WHO and STCI recommendation is that GeneXpert (Xpert MTB/RIF) be used as the frontline test for PLWH suspected of having active pulmonary TB) This test is more sensitive than sputum smear microscopy. The interferon-gamma release assay is a test for latent TB infection, it should not be used as a diagnostic test for investigating suspected active pulmonary TB) Sputum culture is highly sensitive and specific for the diagnosis of active pulmonary TB; however, GeneXpert is recommended as the frontline test because it provides results within a few hours, whereas sputum culture can take weeks.
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Question 2 of 6
2. Question
You are seeing a 23 year old engineer who had sputum tested with GeneXpert, and the test result was “MTB detected, Rifampin resistance not detected” Which of the following statements is true:
Correct
The correct answer is (c). The WHO and STCI recommend that all persons diagnosed with active TB should be tested for HIV infection. This is because HIV is more common amongst persons with active TB, and also because the management of active TB will be different among patients that are PLWH.
Incorrect
The correct answer is (c). The WHO and STCI recommend that all persons diagnosed with active TB should be tested for HIV infection. This is because HIV is more common amongst persons with active TB, and also because the management of active TB will be different among patients that are PLWH.
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Question 3 of 6
3. Question
You are seeing a patient in your clinic who was recently diagnosed with HIV. Which of the following is true about TB screening:
Correct
The correct answer is (e). The WHO and the STCI recommend TB screening for PLWH in high TB burden areas. The WHO recommendation is to use symptom-based screening, and if resources are available, a CXR. The symptom-based screen recommended by the WHO consists of asking about the presence of four symptoms: fevers, coughs, night sweats, and weight loss; if any symptom is present, then active TB should be suspected and the patient will require additional diagnostic work up. A CXR should be used as a supplement to symptom-based screening to increase sensitivity. The CXR should be performed even amongst PLWH that do not have any of the four symptoms asked about in symptom-based screening; this will increase the sensitivity. The presence of any abnormality on a CXR means that further diagnostic testing (e.g., GeneXpert) should be pursued in order to diagnose or exclude active TB).
Incorrect
The correct answer is (e). The WHO and the STCI recommend TB screening for PLWH in high TB burden areas. The WHO recommendation is to use symptom-based screening, and if resources are available, a CXR. The symptom-based screen recommended by the WHO consists of asking about the presence of four symptoms: fevers, coughs, night sweats, and weight loss; if any symptom is present, then active TB should be suspected and the patient will require additional diagnostic work up. A CXR should be used as a supplement to symptom-based screening to increase sensitivity. The CXR should be performed even amongst PLWH that do not have any of the four symptoms asked about in symptom-based screening; this will increase the sensitivity. The presence of any abnormality on a CXR means that further diagnostic testing (e.g., GeneXpert) should be pursued in order to diagnose or exclude active TB).
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Question 4 of 6
4. Question
Which of the following interventions will lower the risk of active TB in PLWH?
Correct
The correct answer is (d). Antiretroviral therapy and isoniazid preventive therapy both lower the risk of active TB in PLWH. All PLWH should be regularly assessed to determine if they meet criteria for initiating antiretrovirals.
Incorrect
The correct answer is (d). Antiretroviral therapy and isoniazid preventive therapy both lower the risk of active TB in PLWH. All PLWH should be regularly assessed to determine if they meet criteria for initiating antiretrovirals.
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Question 5 of 6
5. Question
Which of the following will lower the risk of mortality in PLWH who have active TB?
Correct
The correct answer is (d). Antiretroviral therapy and co-trimoxazole lower mortality in PLWH who have active TB) Isoniazid preventive therapy is contraindicated when active TB is suspected (or confirmed, of course)—as this will expose the M. tuberculosis to isoniazid monotherapy which will lead to the development of isoniazid resistance. Antiretroviral therapy should be initiated in all PLWH who have active TB, regardless of their CD4 count, within 8 weeks of starting TB treatment.
Incorrect
The correct answer is (d). Antiretroviral therapy and co-trimoxazole lower mortality in PLWH who have active TB) Isoniazid preventive therapy is contraindicated when active TB is suspected (or confirmed, of course)—as this will expose the M. tuberculosis to isoniazid monotherapy which will lead to the development of isoniazid resistance. Antiretroviral therapy should be initiated in all PLWH who have active TB, regardless of their CD4 count, within 8 weeks of starting TB treatment.
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Question 6 of 6
6. Question
Which of the following is true about TB treatment regimens in PLWH?
Correct
The correct answer is (b). The preferred regimen for the treatment of active TB in PLWH is 2 months of isoniazid, rifampin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampin, with treatment dosed daily throughout. Regimens that used rifampin only in the intensive phase (question 6. choice “a)”, where rifampin is used for only 2 months) have been associated with worse TB outcomes in PLWH (and also in HIV-uninfected TB patients). Intermittent TB therapy has also been associated with worse TB treatment outcomes in PLWH—hence, all efforts should be made to ensure PLWH who have active TB are treated with regimens in which dosing is daily throughout treatment.
Incorrect
The correct answer is (b). The preferred regimen for the treatment of active TB in PLWH is 2 months of isoniazid, rifampin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampin, with treatment dosed daily throughout. Regimens that used rifampin only in the intensive phase (question 6. choice “a)”, where rifampin is used for only 2 months) have been associated with worse TB outcomes in PLWH (and also in HIV-uninfected TB patients). Intermittent TB therapy has also been associated with worse TB treatment outcomes in PLWH—hence, all efforts should be made to ensure PLWH who have active TB are treated with regimens in which dosing is daily throughout treatment.
