December 2010

ICAP Webinar Grand Rounds on the HIV/TB Guidelines

ICAP's Clinical Unit will offer a webinar on January 20, 2011 at 10:00 am on the updated TB/HIV Guidelines from WHO. The webinar will be available online here. Past webinars are also available; topics have included Mental Health and HIV (presented by Fran Cournos) and Microbicides and HIV Prevention (presented by Jessica Justman).

Key Recommendations

The key recommendations listed by WHO are:

1. Adults and adolescents living with HIV should be screened for TB with a symptom questionnaire and those who do not report any one of the symptoms of current cough, fever, weight loss or night sweats are unlikely to have TB and should be offered IPT.

2. Adults and adolescents living with HIV and screened with the symptom questionnaire for TB, and who report any one of the symptoms of current cough, fever, weight loss or night sweats may have active TB and should be evaluated for TB and other conditions likely to result in symptom(s).

3. Adults and adolescents living with HIV who have an unknown or positive TST status and are unlikely to have TB should receive at least six months of IPT, irrespective of the degree of immunosuppression, and including those on ART, those previously treated for TB, and pregnant women.

4. Adults and adolescents living with HIV who have an unknown or positive TST status and who are unlikely to have active TB should receive at least 36 months of IPT.*

5. TST is not a requirement for initiating IPT in people living with HIV.

6. People living with HIV who have a positive TST benefit more from IPT; TST can be used where feasible to identify such individuals.

7. Providing IPT to people living with HIV does not increase the risk of developing isoniazid-resistant TB, and therefore concerns regarding the development of isoniazid resistance should not be a barrier to providing IPT.

8. Children living with HIV who do not have poor weight gain, fever or current cough are unlikely to have active TB.

9. Children living with HIV who have any one of the following symptoms—poor weight gain, fever, current cough or contact history with a TB case—may have TB and should be evaluated for TB and other conditions. If the evaluation shows no TB, such children should be offered IPT regardless of their age.

10. Children living with HIV who are more than 12 months of age and who are unlikely to have active TB on symptom-based screening, and have no contact with a TB case should receive six months of IPT (10 mg/kg/day).

11. In children living with HIV who are less than 12 months of age, only those who have contact with a TB case and are evaluated for TB using investigations should receive six months of IPT if the evaluation shows no TB disease.

12. All children living with HIV who have successfully completed treatment for TB disease should receive isoniazid for an additional six months.*

*Conditional recommendation (The Guidelines Panel concluded that the desirable effects of adherence to the recommendation probably outweigh the undesirable effects, and data to support the recommendations are scant).

About ICAP

ICAP was founded in 2004 at Columbia University’s Mailman School of Public Health. Now a global leader in HIV/AIDS services, ICAP supports work at more than 1,200 sites across 15 countries in Africa. More than one million people have received HIV services through ICAP-supported programs.

For more information about ICAP, visit
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For more information about ICAP leadership, visit here.

Supported by Doris Duke Charitable Foundation, Bill and Melinda Gates Foundation, William and Flora Hewlett Foundation, Robert Wood Johnson Foundation, Henry J. Kaiser Family Foundation, Stephen Lewis Foundation, John D. and Catherine T. MacArthur Foundation, National Institutes of Health, David and Lucille Packard Foundation, Rockefeller Foundation, and Starr Foundation.


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SPECIAL EDITION: WHO ISSUES NEW HIV/TB GUIDELINES


On December 1, 2010, the World Health Organization (WHO) released updated Guidelines for Intensified TB Case Finding and Isoniazid Preventive Therapy for People Living with HIV in Resource-Constrained Settings. This represents an update of the WHO/UNAIDS 1998 Policy Statement on Preventive Therapy Against TB for People Living with HIV. This issue of ICAP News summarizes the new WHO recommendations. It also includes examples of ICAP’s work in the expansion of efforts to integrate TB and HIV activities and to contribute to TB case finding efforts and the use of IPT in settings in sub Saharan Africa. For the full version of the guidelines, click here.

Summary

HIV is the strongest risk factor for developing tuberculosis (TB) in persons with latent or new Mycobacterial tuberculosis infection. Worldwide, TB accounts for over a quarter of deaths in people living with HIV (PLWH). To reduce the morbidity and mortality from TB among people living with HIV, WHO has recommended the “Three ‘I’s for HIV/TB,” which include the following elements: Intensified TB case finding, Isoniazid preventive therapy (IPT), and Infection control.

Building on this earlier guidance, WHO now recommends in the new guidelines a simplified screening questionnaire for TB case finding among PLWH using four clinical symptoms. Those who screen negative should be considered potentially eligible for IPT, while those who screen positive require further diagnostic workup for TB. The new guidelines strongly recommend at least six months of IPT for children and adults living with HIV, including pregnant women and those receiving antiretroviral therapy, as well as for those who have successfully completed TB treatment. For adults in settings with high rates of transmission of TB among PLWH, WHO now conditionally recommends IPT for a duration of 36 months. In contrast to the 1998 guidelines, chest radiography is no longer required prior to initiating IPT. The revised guidelines also state that while a tuberculin skin test (TST) can help identify those with latent TB infection who would benefit most from IPT, it is not required for initiating IPT in people living with HIV.

PUTTING TB CASE FINDING AND IPT INTO ACTION: THE ICAP EXPERIENCE

ICAP partners with Ministries of Health to support TB/HIV integration activities. These include the implementation of intensified TB case finding and IPT as part of a comprehensive package of HIV services. The following are a few examples of the current work supported by ICAP.

For a slideshow of ICAP's TB programming, click here.

Improving TB Case Finding at HIV Facilities

High-volume clinics are often limited in terms of both personnel and time. To help find TB cases among HIV patients, a simple screening questionnaire was developed that can be rapidly administered by health care workers.

Initially piloted in Rwanda, this questionnaire is now used to screen patients at more than 600 ICAP-supported sites in nine African countries. The experience at ICAP indicates that integrating this questionnaire into routine HIV care in low-resource settings is feasible and results in a substantial number of HIV patients being diagnosed and treated for TB. Since January 2007, 280,071 HIV-infected patients have been screened for TB using this questionnaire, and 26,699 patients have been diagnosed with TB and begun treatment.

Zambia: Screening for TB in Children with HIV infection

ICAP also developed a pediatric TB screening questionnaire for HIV-infected children presenting for routine clinical care which assesses recent close contact with a pulmonary TB case, cough, failure to thrive/weight loss, fever and night sweats. The questionnaire enables early identification of TB in children, so that further diagnostic tests can be initiated and treatment begun if TB is confirmed or strongly suspected. It also helps identify children who are contacts of TB cases without TB, so IPT can be initiated in this population at particularly high risk. This questionnaire was pilot-tested by the Pediatric Center of Excellence at University Teaching Hospital in Lusaka, Zambia between January and September 2010, during which time nurses in the ART clinic screened 1,024 HIV-infected children, with 139 (13.6%) having a positive screening result. It was modified following field-testing, and lessons from the pilot were shared with ICAP colleagues at the ICAP PMTCT/Pediatrics Meeting in Mombasa, Kenya in November.

Rwanda: Working within Communities to Find TB Cases

To further increase TB case finding in Rwanda, ICAP has partnered with the Rwanda National Network of People Living with HIV (RPR+) to implement a TB screening program at the community level. Through the program, peer educators make regular visits to the homes of patients enrolled in HIV care, and conduct screening of family members for TB using the national TB screening questionnaire. Persons who screen positive are referred to the nearest health care facility for a diagnostic work-up, and TB treatment, if appropriate. Between January 2009 and September 2010, 156,458 persons within these homes were screened for TB through this program, of whom 1,504 (1%) screened positive and were referred to the health care facility for evaluation. Ultimately, 101 persons were diagnosed with TB and began TB treatment through the community-based case finding program. This number represents 6% of all TB cases detected at the 50 ICAP-supported facilities in Rwanda during this time.

Ethiopia: Promoting IPT through Practices and Policy

ICAP pioneered a provider support tool to facilitate IPT initiation at HIV care settings in Ethiopia. The tool combines the TB screening questionnaire mentioned above with an IPT checklist. Clinicians use the checklist to assess patients with a negative TB screen to determine if they are still eligible for IPT. Of 14,189 persons enrolled in HIV care at ICAP-supported sites over the past 12 months, 13,136 (93%) were screened for TB. A total of 5,161 adults and 329 children were initiated on IPT.

More work on IPT

Over the past year, ICAP has also supported planning and scale-up of IPT at the national, provincial, and district levels in Mozambique, South Africa and Nigeria. Between October 2009-September 2010, 1887 persons initiated IPT at 37 ICAP supported sites in Mozambique. In South Africa, 566 persons initiated IPT at 18 ICAP-supported sites. ICAP also recently co-sponsored a workshop on “Revision of the IPT Policy for People Living with HIV in Rwanda,” in collaboration with TRAC Plus