Care prevention and management of tuberculosis

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TB and HIV > Patient care
  • Standard statement
  • Rationale
  • Resources
  • Professional practice
  • Outcome
  • References

The patient receives prophylactic treatment against common opportunistic infections, support and information with regard to staying healthy with HIV, including treatment with antiretroviral drugs, if appropriate, while on TB treatment before being transferred for ongoing care.

tb teams

Treatment for TB (click to view)

Treatment of TB with an appropriate standardised regimen should be seen as the priority, as left untreated TB can rapidly become fatal for people with HIV infection.

patient
Prevention of other infections (click to view)

People infected with HIV are vulnerable to a variety of respiratory, gastrointestinal, skin and mouth, neurological and sexually transmitted infections. The risk of a number of common bacterial infections as well as those more usually associated with HIV infection can be reduced by certain preventive treatments, such as cotrimoxazole prophylaxis, which should be considered for all HIV-infected TB patients. It is recommended that preventive treatment be started 2 weeks after the beginning of TB treatment, as both can cause similar adverse drug effects, such as a skin rash and hepatitis. It should also be started before antiretroviral therapy (ART) is started, if that is being considered. Infections can also be prevented through practical measures, such as good general hygiene, especially hand washing, the boiling of drinking water and the practice of safer sex.

prevention poster
Antiretroviral treatment (click to view)

Treatment with antiretroviral (ARV) drugs is not an emergency, and other aspects of HIV care can be implemented before the patient starts ART. ART aims to maintain or restore the patient’s immune function by suppressing the replication of the virus, which, in turn, prevents the patient’s susceptibility to HIV-related conditions.

learn more Read more: TBCTA (2006) Standard 14 in Standards for Treatment

young patient
The decision to start ART (click to view)

If it is available, patients with HIV infection can be prepared to start ART according to the severity of their condition. The WHO has devised a staging system using indicators, such as the level of immunosuppression based on the CD4 count (if available) or the presence of other HIV-related conditions to assist those making decisions about when to start ART.
“Because extremely high levels of adherence are required to prevent drug resistance and treatment failure, it is critical that patients start treatment only after having been counselled in detail about possible adverse drug effects, dosing instructions, and the importance of strict adherence”.

 

pills
The importance of adherence to ART (click to view)

Every effort must be made to offer as much support as possible to enable the patient to adhere to the treatment regimen. High levels of adherence are required if ART is to be effective. One study by Paterson et al. Concludes that taking more than 95% of the ARV drugs prescribed gives patients an 80% chance of stopping viral replication. This drops to only 20% if less than 80% of doses are taken.

 

child patient
Potential complications (click to view)

Taking antiretroviral drugs (ARVs) at the same time as TB treatment can lead to drug-drug interactions that the patient may not be able to tolerate, impose a high pill burden that may be a barrier to compliance, and provoke an exacerbation of the TB as the immune system is reconstituted. There may also be a problem with the efficacy of some of the ARV drugs and rifampicin due to drug-drug interactions. Ideally, ART should not be started until the TB treatment has been completed successfully. However, if the patient is very sick, concurrent ART may be necessary. In these cases, a healthcare worker with expertise in treating both HIV and TB should be involved so that any complications can be identified and managed appropriately.

video presentation Learn more: Presentation on drug complications and recommendations for starting patients on ART while they are having their TB treatment
patient
Prevention of transmission of HIV (click to view)

Anyone tested positive for HIV should be counselled as to how to prevent transmission to others. The patient needs to be advised with regard to practising safer sex and avoiding high-risk behaviour, such as sharing needles, if he or she is an injection drug user. The transmission of HIV between patients in health care facilities can be avoided if recommended sterilisation procedures are followed regarding medical, surgical and dental equipment, and if the use of injections in general is reduced. Rarely, staff may be infected through needle-stick injuries or injury involving other contaminated “sharps”. These risks are significantly reduced if standard infection control procedures are followed and “sharps” are disposed of safely according to local policies.

 

street
Ongoing support and counselling (click to view)

The patient can be very distressed on finding out that he or she is infected with HIV in addition to having TB. It is essential to assess the patient’s reactions and respond appropriately so that he or she develops confidence in the care offered. Disclosure of the patient’s HIV status needs to be discussed, but again this may need to be addressed over time to give the patient the opportunity to come to terms with the diagnosis and develop an understanding of the condition.

 

candy
Assessing the patient’s information needs (click to view)

It is essential that the patient receives the necessary information to assist him or her to stay healthy. Many issues will need to be covered, but it is important that information is offered over time, as the patient may find it difficult to absorb large amounts of information when he or she is distressed. Patients’ needs regarding HIV should be assessed in the same way as TB (see earlier standards). It cannot be assumed that the patient will absorb everything he or she is told, so it is important to check what the patient has understood and encourage him or her to ask questions.

 

nurse
Liaison with other services (click to view)

The patient is likely to have complex needs that may benefit from a variety of services offered by local organisations outside the management unit. The patient should be made aware of other organisations in the local community where he or she can access help. Referrals should only be made with the patient’s explicit permission, as confidentiality must be maintained if he or she is to develop trust in the service.

 

weavers
Documentation (click to view)

Clear, prompt and accurate record keeping is necessary to monitor the progress of each patient and his or her treatment. National policies and procedures must be followed in terms of how information regarding co-infected patients is recorded

visiting patient

Do you have the resources required for best practice?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

Joint plans, guidelines and policies for the treatment and care of co-infected patients have been developed in partnership between the National AIDS Programme and the National TB Programme. These plans include guidance about documentation

Staff have an understanding of both TB and HIV treatment and care

Nursing and medical follow-up with the appropriate expertise in both conditions

Space for privacy to be maintained

Relieble supply and storage of drugs and laboratory materials for the treatment and monitoring of TB and common HIV related infections as well as cotrimoxazole prophylaxis

Group education covering variaty of themes associated with treatment, safer sex and prevention of further infection

Access to variaty of local support services, which can offer additional care to patients according to their needs

Trained staff with access to information - WHO, IMAI, UNAIDS guidelines

TB and HIV infection control procedures in place in line with WHO guidelines

A referral system for ongoing patient care following the completion of his or her TB treatment

 

How is your practice?

Best Practice Requirement

Your Current Practice

Identify Gaps in your Practice

The patient’s understanding of TB and HIV, how it is transmitted and how it is treated

The presence of HIV-related conditions that may or may not require treatment

The patient’s readiness to start ART and his or her ability to adhere to
4. the regimen

Psychosocial issues which may affect the patient’s care or treatment

The patient’s feelings about disclosing his or her HIV and TB status to others

Any adverse drug effects the patient is experiencing and what medication this is likely to be associated with

Following such assessments:

The appropriate support information can be provided at a time when the patient is most likely to need and absorb it

Referrals are made with the agreement of the patient according to the patient’s needs and the services available locally

Adverse drug effects are managed appropriately whether they are related to treatment in association with TB† or HIV

If the patient is on ART, regular assessment is carried out with regard to:

Any changes in the patient’s condition, e.g., weight gain and the resolution of opportunistic infections can indicate a good response to treatment; CD4 counts can also be used but are not always available

The health-care worker are aware of immune reconstitution syndrome (IRIS), which can make TB worsen even while the immune system is improving

Ensuring that the regimen and dosages prescribed are based on national guidelines

Laboratory monitoring according to local policies

The patient’s adherence to the regimen prescribed

All health-care workers follow local procedures for clear, accurate and prompt record keeping

 

 

Your Action Plan for improvement

Use the following box to develop an action plan on how you will improve
your practice with regards to care for a patient co-infected with HIV and TB

Things you will change in the patient treatment cards and notes to ensure you keep a record
of patients progress and record any side effects of ARTs and other related medication.

Things you will change the support and information you give the patients,
who are co-infected with HIV and TB, during their Tb treatment.

Things you will change about how liaise with HIV services to ensure the HIV
treatment for the patient is continued during and after their TB treatment is complete.

LisList yours and others training needs and identify how you will address
them to enable best practice when caring for patients co-infected with HIV and TB.

 

 

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