Care prevention and management of tuberculosis

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.

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.

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.

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

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”.

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.

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.

Learn more: Presentation on drug complications and recommendations for starting patients on ART while they are having their TB treatment

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.

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.

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.

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.

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