HIV-positive individuals with tuberculosis (TB) are generally receiving the standard of treatment recommended by current guidelines, according to a clinical audit presented to the Eleventh Annual Conference of the British HIV Association (BHIVA) in Dublin on April 21st. However, a lack of negative pressure facilities, the lack of routine HIV testing for patients with tuberculosis, and delays in the reporting of sputum smear results were highlighted as areas of concern.
Every year, BHIVA conducts an audit to determine the level of adherence to its treatment guidelines, and to assess current clinical practices. Confidential feedback is provided to centres contributing data to enable them to assess their practices and performance against other clinics.
Guidelines for the treatment of TB in HIV-positive patients were recently developed by BHIVA. Between October 2004 and January 2005 a total of 132 treatment centres provided information about their management of patients with both HIV and TB.
Experience
The total number of patients with HIV and TB coinfection was 543. Most of the centres (n = 80) treated between zero and five patients with the two infections, and at the other end of the spectrum, seven HIV clinics reported providing treatment to between 31 – 100 individuals with HIV and TB.
Between zero and 10% of TB cases seen at 120 HIV centres involved multi-drug resistant TB, and four centres said that between 10% - 20% of individuals with HIV had TB which was multi-drug resistant. One centre said that 50% of the TB it treated was multi-drug resistant, however this clinic only reported treating two patients with HIV and TB coinfection.
Facilities
A third of centres (41 of 132) said that they were “not happy” with the negative pressure facilities available in their unit. In addition, 20 centres reported having no isolation units for patients with multi-drug resistant TB, and 18 said that were unable to conduct TB PCR tests.
Most centres, however, said that they were happy with the general infection control procedures, although 41 treatment centres indicated dissatisfaction.
Notification
All cases of TB were notified to the Health Protection Agency by 114 centres. In most instances (74), the TB physicians reported the case, the HIV doctor having responsibility at eleven centres, and shared responsibility reported by 33 clinics. However, it was suggested that these reporting practices could result in the significant under-notification of TB cases in HIV-positive patients.
HIV testing
Only 60 of the 132 centres said that they routinely offered HIV tests to all adults under 65 with TB. Twelve centres said that they only offered HIV tests to individuals who came from areas with a high HIV risk, 24 centres said that they offered HIV tests only if they thought an individual had risk factors for HIV and four centres said that they did not recommend routine HIV testing for TB patients.
Prophylaxis
Only half of the centres provided an answer to a question on the use of chemoprophylaxis for TB. Of the centres replying, 36 said that they did not use, it, 15 said that they would use 15 months isoniazid, 13 reported that they would use three – four months of rifampicin and isoniazid, and five clinics indicated that they would use an alternative regimen.
Sputum results
Less than a quarter (23%) of clinics said that sputum smear results would be available the same day, and 28% of clinics said that results took two or more working days.
TB treatment
The overwhelming majority of clinics (103) said that, for patients with fully sensitive TB, they would provide the standard four drug treatment regimen recommended by the BHIVA TB guidelines. For the first two months, treatment with pyrazinamide, ethambutol, rifampicin and isoniazid is recommended by the guidelines, with the next four months of therapy consisting of just rifampicin and isoniazid.
Anti-HIV therapy and TB treatment
If an individual had a CD4 cell count below 100 cells/mm3 and TB, 64 centres said that they would try and minimise the risk of interaction between HIV and TB treatment by delaying the initiation of HAART until an individual had taken TB therapy for a month, and 46 centres said that they would start TB and HIV treatments together immediately.
When a patient had a CD4 cell count between 100 – 200 cells/mm3, 16 centres said they would start both treatments immediately, 38 reported that they would wait until TB treatment had been taken for a month before initiating HAART, and 78 clinics indicated that they would delay the initiation of HAART until the first two months of TB treatment had been completed.
For individuals with CD4 cell counts above 200 cells/mm3, nine centres said that they would not initiate HAART until a month of TB treatment had been completed, 29 centres said HAART would be started after two months of TB therapy, and 78 clinics reported that they would wait until the complete six months of TB treatment was completed before HAART was started.
Immune reconstitution inflammatory syndrome (IRIS)
Just over half of the clinics had seen patients with IRIS, 55 said that they would use steroids to treat it, and 17 reported that they had treated the condition by stopping HAART.
Multidisciplinary teams
Almost all the centres said that HIV-positive patients with TB received treatment and care from a multidisciplinary team. However, nine centres said that this team did not include an infectious diseases or respiratory diseases physicians, and 28 centres said that their team did not include a specialist TB nurse.
Directly observed therapy
Only twelve centres routinely used directly observed therapy, but a further 40 said that they had used it for patients with multi-drug resistant TB or with other complicating factors.
Intermittent therapy
One centre said it routinely used thrice-weekly dosing of TB therapy, rather than daily dosing. A further 14 clinics said that they used it when directly observed therapy was being used, but the vast majority of treatment centres said they never used it.
Although a general level of satisfaction was expressed about the level of adherence with the BHIVA recommended guidelines for the treatment of HIV-positive patients with TB, there were some concerns, particularly relating to the lack of negative pressure facilities, the lack of routine HIV testing, and the length of time it took some centres to obtain sputum smear test results.
BHIVA's TB treatment guidelines can be read here here.
Freeman A. BHIVA national clinical audit presentation survey of the management of TB and HIV coinfection. Eleventh Annual Conference of the British HIV Association, Dublin, April 21st, 2005.