Chapter 4: Tuberculosis
In this chapter you will learn more about tuberculosis patients, and how it impacts HIV patients in the workplace. This section will help you prepare, and minimize the coinfection capabilities of TB. Additionally, you will learn symptoms, common complications, and updates from the WHO regarding treatment prioritization.
Tuberculosis is currently the number one killer of HIV patients around the world. It is estimated to be in 4.3% of the US population, irrespective to HIV patients. It's primarily passed through moisture droplets, which are contaminated with mycobacterium expelled from the lung; laughing, sneezing, talking, and coughing are common transmission devices. TB can be present in other spaces in the body, such as the spine, but it is primarily found in the lungs.
TB has two stages: latent and active. In the latent phase people infected with TB harbor the bacterium while it grows into an uncontrollable level in the host's lungs. In the active stage patients become violently sick and are able to pass the disease
In the active stage, patients begin to exhibit a range of symptoms, such as:
- Blood from the mouth
- Heavy coughing
- Heavy sweating
- Difficulty breathing
TB has an easier chance to infect immunocompromised patients, such as those with HIV, and the elderly, patients with an underdeveloped immune system (such as a baby), people with chronic stress, fatigue and malnutrition, or those at risk of complications, like cancer and diabetes patients.
Those with HIV often end up dying from conditions such as TB, pneumonia, bacteremia, cerebral toxoplasmosis, and pneumocystis jirovecii pneumonia, as well as fungal infections and meningitis.
HIV and Tuberculosis Stats in the US
Here is a brief overview of why HIV and TB co-infection statistics are encouraging broad changes to diagnosing policy:
- 2016 374,000 people who had both TB and HIV are estimated to have died.
- Deaths from TB alone: 1,300,000
- Deaths from HIV alone: 826,000
- So more people now die from TB than from HIV related infections.
- In 2016 there were an estimated 10.4 million new cases of active TB worldwide. Globally 10% of the incident TB cases in 2016 are estimated to have been among people living with HIV.
Around the World
Over 34 million people are believed to be HIV infected, and a third of that infected with TB. Most cases of TB come from impoverished countries where HIV and TB are common, and treatment for it is scarce. HIV patients are 21-34 times more likely to develop active TB if they are co-infected (WHO, WHO Policy on Collaborative TB/HIV Activities, 2012).
WHO ART Intro
The CDC and the WHO have taken proactive steps in order to curtail the death rates of TB co-infections. For instance, cooperation among different health agencies is being used to develop correlations between risk groups and testing results. Policies are shifting in favor of testing most people with TB for HIV, and vice versa.
In 2012, the WHO released a summary highlighting resource policies they would be using for future TB outbreaks. Examples of this include treating and counseling patients with the earliest signs of symptoms (coughing).
HIV mothers, children, drug users, and prisoners are currently priority targets. A unique strategy that has shown remarkable results is the implementation of the ART system.
Anti-retroviral therapy (ART) is a system that distinguishes the need to test patients, based on the health, and likelihood of TB, and TB co-infections. With preventative antiretroviral medication for example, HIV patients can reduce the odds of getting a TB coinfection as a result of their compromised immune system. Other parts of the system use standard precautions for facilities (proper ventilation for TB, limited contact with other high risk patients), proposed diagnostic criteria, and types of treatment and preventative programs for TB and HIV (HIV awareness, protected sex, identifying symptom signs of TB, and when to seek treatment).
Therapy planning effectiveness is heavily dependent upon HIV and TB factors within a country, the identification of patients, the availability of evidence based TB reduction programs, and the availability of testing and health care resources.
In short, by understanding the population, and the rate of infection, you can decisively plan and adjust resources to reduce the rate of TB and HIV infections. Surveys find that government programs have a higher rate of success when their programs focus on harm reduction services, better prison care management, maternal/child care, and how they introduce routine HIV and TB test screening.
Policy Proposals by the WHO
Three I System
To decrease co-infections you can use the following criteria in your own medical facility:
- Intensified TB case-finding followed by high-quality anti-tuberculosis treatment
- Isoniazid preventative therapy
- Infection control for TB and HIV
Treatment Based on Presence or Absence of Symptoms
Clinical facilities should base their priority treatment criteria on the presence or absence of four major symptoms: cough, fever, weight loss, and night sweats.
One agency should oversee the implementation and results of the TB and HIV co-infection effort, as opposed to individual action (larger scale actions prompt more uniform action to keep results consistent).
Organizations should implement new policies in favor of relocating HIV healthcare workers away from TB patients.
Over 170 countries now use the ART system to decrease the number of TB and HIV cases around the world. Use of the system has become commonplace since 2010. The policy is expected to be reviewed in 2017 in respects to progress and changes.
The WHO implementation of the ART system has achieved remarkable coinfection prevention results:
- 55%-92% success rate at the individual patient level.
- 27%-80% success rate at country wide patient levels.
- Up to a 90% success rate in Brazil and South Africa, while using the ART and isoniazid preventive therapy regime to prevent TB in HIV patients.
Right now it is believed that TB infection in HIV patients can be reduced by 50% when ART and ISP systems are used on patients with CD4 counts greater than 350 cells/mm3. This is currently being debated for the next policy update (Statistics provided by the WHO, WHO Policy on Collaborative TB/HIV Activities, 2012).
Health Care Facilities
- HIV and TB programs should provide a direction for all managers to help them reduce TB infections in health care facilities, and similar settings.
- Every healthcare setting should have a TB infection control plan for the facility to reduce the chance of TB infection being passed environmentally (ventilation for example). TB testing resources, and equipment to avoid transmission between patients and health care workers.
- ART and IPT should be applied to health care workers and care providers as necessary. Employees should not be working in TB rooms and high risk patient areas if co-infection is likely. Immunocompromised health care workers should not work in TB patient rooms.
Provide Testing for Suspected TB Cases
- Routine HIV testing should be offered in assumed and non-assumed TB cases.
- Partners of HIV positive TB patients should be offered mutual HIV testing and counseling.
- TB control programs should be streamlined for the purposes of HIV testing and counseling, including routine services.
- Provide information on HIV and TB through information through pamphlets and other media.
- Encourage confidential counseling and testing services to motivate people to seek help, as well as reduction of workers and TB patient interaction.
- Teach sexual disease prevention, as well as TB transmission methods.
- Provide wider access to diagnosis tools, treatment, as well as care for people who use drugs, preferably using a holistic method (step by step).
- HIV pregnant mothers should be referred to care facilities for anti-retroviral medication, and prophylaxis treatment as needed.
- Follow up care after TB treatment should always be suggested.