Download 2008-9 TB and HIV co-infection

TB and HIV co-infection
BHIVA Clinical Audit Sub-Committee:
M Backx, C Ball, G Brook, P Bunting, C Carne, A
DeRuiter, K Foster, A Freedman, P Gupta, V Harindra,
M Johnson, G McCourt, C O’Mahony, E Monteiro, E
Ong, K Orton, R Pebody, A Rodger, C Sabin, R
Weston, E Wilkins, D Wilson, M Yeomans
Aim of audit
To assess adherence to guidelines for management
of TB/HIV co-infected patients including:
 BHIVA treatment guidelines for TB/HIV infection, 2005.
(BHIVA)
 National Collaborating Centre for Chronic Conditions:
Tuberculosis: Clinical diagnosis and management of
tuberculosis, and measures for its prevention and
control, 2006. (NCCCC)
 Stopping tuberculosis in England: an action plan from
the Chief Medical Officer, 2004. (CMO)
 HPA Standards Unit. BSOP 40 Investigation of samples
for mycobacterium species, 2006. (HPA).
Methods and participation
Casenote review of 236 HIV positive adults who
started treatment for active TB during October 2007
– April 2008:
 Data were collected October-December 2008 so
most cases had time to complete treatment.
 Chemoprophylaxis for latent TB was excluded.
 Suspected/unconfirmed cases were included
unless TB therapy was stopped on medical
grounds due to confirmed alternative diagnosis.
Accompanying surveys completed by 124 HIV
treatment sites and 18 TB clinics/units.
Arrangements for care of HIV/TB co-infected patients
 19 (15.3%) HIV sites were integrated
departments managing both HIV and TB monoand co-infected patients.
 69 (56%) HIV sites, 16 (89%) TB sites: HIV and
TB clinicians liaise, each managing respective
aspects of care.
 12 (10%) HIV sites, 3 (17%) TB sites: hold joint
clinics for co-infected patients.
 12 (10%) HIV sites, 0 TB sites: HIV clinicians
manage uncomplicated TB, refer more complex
cases.
NB percentages do not add up because respondents could select
more than one option.
Responsibility for notification of TB in HIV patients
No answer
Unclear
Laboratory
HIV clinician
Joint
TB clinician
0%
20%
40%
60%
Base is all responding sites, whether HIV, TB or integrated services.
Communication of HIV status
Of those who notify TB cases outside their main or
host commissioning area:
 68 (71%) routinely include information that a
patient is also HIV positive, unless the patient
refuses consent
 12 (12%) sometimes do so
 16 (17%) do not.
Of the 19 integrated and 18 TB services, 3 (8%) use
different tests when screening close household
contacts of an HIV positive as compared with HIV
negative TB index case.
Policies on HIV testing of TB patients
Guidelines: All patients with TB should
have risk assessments for HIV (NCCCC).
All patients with TB should be offered an
HIV test, regardless of risk (BHIVA). 2008
national HIV testing guidelines: Testing
should be routinely offered and
recommended.
No answer
Unclear
Other
Refer for risk
assessment/testing
Offered according to
individual risk
Offered if under 65
Routine if under 65
Routine for all adults
0
10
TB and integrated services
20
30
40
50
HIV services not integrated with TB services
NB: TB and integrated services gave their own policy. Other HIV services answered according to what they
believed their local TB service’s policy to be.
Policies on latent TB screening for HIV patients
Consistent with guidelines, 95 (77%) of
HIV/integrated services do not routinely screen
newly diagnosed HIV patients for latent TB.
 14 (11%) screen those from high TB prevalence
countries
 6 (5%) screen other selective groups
 6 (5%) screen all
 3 (2%) did not answer.
Rapid resistance testing
Guidelines: If a risk assessment suggests
MDR TB, rapid testing should be done for
rifampicin resistance. HIV patients are at
increased risk (NCCCC, BHIVA).
The 47 sites which treat TB* were asked about rapid
molecular testing for rifampicin resistance . Of the
37 which responded:
 17 (46%) did rapid testing routinely for HIV
patients
 18 (49%) took HIV status into account when
considering rapid testing
 2 (5%) did not use rapid testing.
*ie 18 TB services, 19 integrated services, and 10 HIV services which
manage uncomplicated TB cases themselves.
TB key-workers
Guidelines: All people with TB should have
a key worker to help educate and promote
treatment adherence (NCCCC). Best
practice includes named case manager
assigned to every TB patient (CMO).
All sites were asked who would normally act as key
worker for an HIV/TB patient:
 89 (63%): TB nurse specialist
 11 (8%): HIV nurse specialist
 9 (6%): HIV/TB nurse specialist
 11 (8%): other clinician(s)
 22 (15%): unsure or no answer.
Patient data from casenote review
Demographic data
Patients (N=236) were:
 52.5% female, 47.0% male, 0.4% not stated
 74.6% black-African, 9.7% white, 6.8% Asian,
3.8% black-other, 3.0% other, 2.1% not
known/not stated
 13.6% under 30, 73.7% 30-50, 9.8% over 50,
3.0% not stated
 84.7% born in high TB prevalence country
(overwhelmingly in Africa), 4.7% in non-UK low
TB prevalence country, 9.3% in UK, 1.3% not
known/not stated.
TB notification
Guidelines: Notification is required by law.
The doctor making or suspecting the
diagnosis is legally responsible.
Had TB been notified?
 85 (36.0%) recorded in notes
 113 (47.9%) believed to have been done
 6 (2.5%) not done
 28 (11.9%) not known
 4 (1.7%) no answer.
Among 132 patients for whom information was
given, HIV status had been passed on with the TB
notification for 87 (65.9%) and had not for 45
(34.1%).
NB: “Not known” on this and subsequent slides may reflect audit completion on basis of HIV notes without
access to TB clinic notes.
TB key worker
Guidelines: All people with TB (except
inpatients) should have a key worker to
help educate and promote treatment
adherence (NCCCC). Best practice
includes named case manager assigned to
every TB patient (CMO).
Was the identity of the patient’s TB key worker
recorded in HIV notes?
 150 (63.6%) yes, name and contact details
documented
 59 (25.0%) believed to have a key worker but
details not documented
 10 (4.2%) no key worker*
 17 (7.2%) not known/not answered.
*including one long-stay inpatient.
TB contact tracing
Guidelines: Once a person has been
diagnosed with active TB, the need for
contact tracing should be assessed without
delay. Screening should be offered to the
household contacts of any person with
active TB (NCCCC).
.
Had TB contact tracing been done?
 152 (64.4%) yes
 20 (8.5%) no
 64 (27.1%) not known/not answered.
HIV clinic attendance since TB diagnosis
Number of
patients
Percent of
patients
Attends regularly
185
78.4
Attends, some missed appointments
21
8.9
Stopped: died*
6
2.5
Stopped: left UK
9
3.8
Stopped: transferred care within UK
5
2.1
Stopped: not known to have died, left
UK or transferred
9
3.8
1
0.4
236
100.0
Not answered
Total
*1 death was attributed to TB, 1 to drug hepatotoxicity, 1 other cause, 3 unknown.
Timing of HIV diagnosis
 131 (55.5%) before seeking care for TB
 80 (33.9%) during investigation of TB
 19 (8.1%) via routine screening as a result of TB
diagnosis
 4 (1.7%) after TB diagnosis but not via routine
screening
 2 (0.9%) unclear/not known/not answered.
Of the 4 HIV diagnoses not made before or as a
result of the TB, 2 had declined screening and 1 had
not been offered it (TB diagnosis was not
confirmed). Information was missing for the other.
HIV disease stage at TB diagnosis
CD4 count in cells/mm3 nearest in time to diagnosis
of active TB was:
 163 (69.1%) under 200, including 73 whose HIV
had been diagnosed before seeking care for TB
 36 (15.3%) 201-350
 20 (8.5%) 351-500
 13 (5.5%) over 500
 4 (1.7%) not known/not answered.
Site of TB
Number of patients
Percent of patients
Pulmonary
137
58.1
Any extrapulmonary, comprising:
140
59.3
Peripheral lymph node
61
25.8
Meningeal
20
8.5
Disseminated, including miliary
44
18.6
Other
35
14.8
Totals do not add because there could be more than one site.
TB diagnosis
Number of
patients
Percent of
patients
Culture (any site)
136
57.6
AFB microscopy (any site), without culture
32
13.6
NAAT, without culture or AFB
1
0.4
Cytology/histology without culture, AFB or NAAT
12
5.1
None of the above reported
55
23.3
Method or basis of diagnosis
Culture confirmation of pulmonary cases
Guidelines: At least 65% of pulmonary
cases to be culture-confirmed (CMO).
Of 137 patients with pulmonary TB:
 60 (43.8%) were sputum smear positive
 69 (50.4%) had a positive sputum culture
 A further 21 (15.3%) had a positive culture other
than sputum.
 This gives a total of 65.7% culture-confirmed
cases.
Time to receive sputum smear results
Guidelines: Positive results within 24
hours, 6 day/week service. Written reports
in 16-72 hours (HPA).
Interval between taking sample and
receiving result for patients with positive
sputum smear
Number of
patients
Percent of
patients
Same day
12
20.0
Next day
15
25.0
2 days
8
13.3
3 days
2
3.3
4+ days
15
25.0
Not answered
8
13.3
Total
60
100.0
TB drug resistance
 11 patients had known TB drug resistance at the
time of initial prescribing (8 isoniazid, 2
streptomycin, 1 ethambutol).
 3 were later found to have drug resistance (1
MDR, 2 isoniazid).
 2 showed evolving resistance to drugs to which
they were initially susceptible (1 initially
streptomycin resistant became partially rifamycin
resistant, 1 initially fully susceptible became
isoniazid/streptomycin resistant).
Assessment of likely adherence
Guidelines: All patients should have a risk
assessment for adherence to TB treatment.
(NCCCC)
158 (66.9%) of patients were assessed for likely
adherence before starting TB treatment:
 139 were expected to adhere well (5 received
DOT)
 18 were expected to adhere poorly (13 received
DOT)
 For 1 the outcome of the assessment was not
known.
28 (11.9%) were not assessed (5 received DOT)
50 (21.2%): not known/not answered (8 received
DOT).
TB regimens
Guidelines: 6IR 2PE is standard
recommended regimen. Use 12 month
regimen for meningeal TB. (NCCCC)
A wide range of initial TB regimens was reported:
 173 (73.3%) contained isoniazid + rifampicin
+pyrazinamide + ethambutol and 17 (7.2%)
contained these except rifabutin instead of
rifampicin.
 113 (47.9%) patients were prescribed the
standard 6 months IR + 2 months PE regimen.
 46 (49.5%) of patients with pulmonary TB and
no known drug resistance were prescribed the
standard regimen.
The initial TB regimen was later extended or
modified for 59 (25.0%) of all patients.
Outcomes of TB treatment
Guidelines: All outcomes recorded, 85%
successful completion. (CMO)
Number of
patients
Percent of
patients
Completed full course without interruption
144
61.0
Treatment ongoing at audit
51
21.6
Interrupted
12
5.1
Transferred care within UK
6
2.5
Died before completion
6
2.5
Left UK while on treatment
11
4.7
Stopped attending while on treatment, not
known to have transferred care or left UK
6
2.5
236
100.0
Total
Outcomes of TB treatment, continued
Guidelines: All outcomes recorded, 85%
successful completion. (CMO)
Based on data on previous slide, 80.8% of patients
completed treatment successfully:
 This includes 3 patients who re-started after
interruption and then completed
 It excludes 54 patients whose treatment was
ongoing at audit.
Timing of HAART relative to start of TB treatment
Number of
patients
Percent of
patients
HAART started more than 2 months before
TB treatment
61
25.8
2 weeks-2 months before
14
5.9
Within 2 weeks before or after
18
7.6
More than 2 weeks after starting TB
treatment, but during intensive phase
51
21.6
During TB treatment, after the intensive
phase
38
16.1
After completion of TB treatment
12
5.1
HAART not started
36
15.3
Not known/not answered
6
2.5
236
100.0
Total
HAART during TB treatment
Guidelines: Substitute rifabutin for
rifampicin if using boosted PI. Adjust EFV
dose when using with rifampicin. Avoid
daily rifampicin with NVP. (BHIVA)
HAART regimens used for patients
treated during TB treatment
Number of
patients
Percent of
patients
NNRTI-based
139
79.0
PI-based
31
17.6
NRTI only
6
3.4
176
100.0
Total
Immune reconstitution inflammatory syndrome
 14 (5.9%) patients were diagnosed with IRIS, of
whom 11 were treated with steroids and 1 was
already on steroids.
 14 (5.9%) further patients experienced some
worsening of symptoms after starting HAART,
but it was unclear if this was due to IRIS. 2 of
these patients were already on steroids.
Limitations
 Few TB clinics/units took part in the survey.
This probably reflects the recruitment method.
Better uptake might have been achieved by
writing directly to trust TB leads, instead of
asking HIV services to invite their corresponding
TB services to participate.
 Some patient data was incomplete because this
was provided via HIV services, not all of whom
had access to TB clinic records.
Conclusions
In general the findings of this audit were positive, but
with some areas of concern:
 Some services not offering HIV testing routinely
regardless of risk, although this may have
changed following 2008 guidelines.
 Poor documentation of TB notification, and
some cases not notified.
 Unacceptable delays in sputum smear results.
 80.8% TB treatment completion rate did not
meet 85% target.
Conclusions, continued
 Many patients had very low CD4 counts. This
partly reflected stage at diagnosis of HIV, even
though nearly all patients were screened at the
time of TB diagnosis.
 Non-attendance/treatment refusal/nonadherence are of concern in relation to both HIV
and TB.
 Some patients apparently received rifampicin
with PI-based HAART.
 Some patients received NRTI-only ART
regimens during TB treatment.
Conclusions, continued
Other points of note are:
 As expected in HIV co-infection, extrapulmonary
TB was common, making diagnosis more
complex.
 Many patients received non-standard TB
regimens. The reasons are unclear.
 Practices vary as regards reporting the patient’s
HIV status when notifying TB.
Future TB surveillance and reporting
Health Protection Agency is introducing web-based
Enhanced Tuberculosis Surveillance:
 “..collects demographic, clinical and
microbiological data on all cases of TB
 “Case reports can be passed between clinics, if
the patient’s care becomes transferred
 “Laboratory results .. will be linked to case
reports at the local level .. data from reference
laboratories will be loaded into the system at
frequent intervals.”
BHIVA Audit & Standards Committee
Other current/planned activity:
 Briefing on the role of primary care in HIV
Data collection autumn 2009:
 Casenote review and survey of management of
HIV and hepatitis B/C co-infection
 Survey of management of paediatric aspects of
adult HIV care: ensuring testing of children of
adult patients; transition for young people.