8. TB-HIV co-management •
• • • •
• •
Approximately 20-50% of patients with TB are co-infected with HIV, and many patients eligible for antiretroviral therapy will have active TB. Hence, TB diagnosis is an important entry point for a significant percentage of persons eligible for ART. TB is also an important manifestation of Immune Reconstitution Inflammatory Syndrome, and patients already receiving ART may also develop TB. HIV testing and care are important entry points to intensify access to TB-care. Therefore, all HIV-positive persons should be routinely screened for TB, at entry to care and during each subsequent visit ART is recommended for all patients with active PTB (smear positive or negative) with CD4 counts < 350 cells/mm3, and Extrapulmonary or disseminated TB patients irrespective of CD4 count If CD4 count is not possible, all patients with active TB are eligible for ART Suspect tuberculosis if patient presents with one or more of the following signs and symptoms: - Cough > two weeks - Other constitutional symptoms e.g. weight loss, fever, - Chest X-ray suggestive of lung tuberculosis Any patient with suspected TB should be assessed with three sputum smears and chest X-ray, and be offered HIV testing if status is unknown or reasonable time has elapsed since the last negative test result. The major issues in the clinical management of patients co-infected with HIV and active TB are: when to start ART, possibility of high pill burden, risk of drug interactions, drug toxicity, and IRIS. However, in HIV-infected patients who present with TB, priority must be given to initiate DOTS.
63