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Unit 5: IPT Isoniazid TB Preventive Therapy

Unit 5: IPT Isoniazid TB Preventive Therapy . Botswana National Tuberculosis Programme Manual Training for Medical Officers. Objectives. At the end of this unit, participants will be able to: Describe the role of INH Preventive Therapy (IPT) for HIV-infected persons with latent TB infection

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Unit 5: IPT Isoniazid TB Preventive Therapy

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  1. Unit 5: IPTIsoniazid TB Preventive Therapy Botswana National Tuberculosis Programme Manual Training for Medical Officers

  2. Objectives At the end of this unit, participants will be able to: • Describe the role of INH Preventive Therapy (IPT) for HIV-infected persons with latent TB infection • Describe how to appropriately screen eligible patients for IPT

  3. IPT: Isoniazid Preventive Therapy Type of secondary prevention To prevent development of active TB in HIV positive individuals in whom active TB has been excluded 6-month course of INH

  4. Rationale for IPT • 10% lifetime risk of developing active TB if infected with M. tuberculosis alone • 5-10% annual risk of developing active TB if co-infected with HIV • IPT is meant to prevent progression of latent TB to active disease • INH shown to decrease incidence of TB among HIV- infected persons by about 40% • The protection period ranges from <1 year to 3 years* Source: BNTP Manual, 2007.

  5. Rationale for IPT in Botswana HIV prevalence is 17.1% in general population* TB case rate increased ~ 3-fold in 1990s** 1989: 199 /100,000 2002: 623 /100,000 ~80% of adult TB cases are HIV co-infected*** Patients more likely to seek HIV testing if they would receive health benefit such as IPT and ART (1999 KABP study in Botswana) Sources: *HIV Medicine Association, et al., 2007 ** BNTP Manual, 2007. ***BIASII, 2004

  6. IPT Effectiveness South African Miners, 2003 Source: Churchyard GJ, Fielding K, et al., Aurum Health Research, 2003. Overall 55% reduction in TB incidence

  7. IPT Effectiveness Related to ART TB Incidence in 11,026 HIV-infected patients in Brazil Source: Golub JE, et al., Johns Hopkins University2007. 76% reduction with both INH and ART when adjusted for age, previous TB diagnosis and CD4 count at baseline

  8. Assessment for IPT Medical and social history Previous exposure to TB Previous treatment for TB HIV positive TB Screening questions Physical examination Clinical evaluation of TB suspects Sputum smear for microscopy and other investigations as indicated

  9. Screening Questions Cough for 2-3 weeks Weight loss Night sweats Fever Malaise Shortness of breath Chest pain Haemoptysis Consider EPTB: Lymphadenopathy Headache Abdominal pain or distension Swollen joints Backache

  10. TB Screening Tests in Patients with Advanced HIV Disease Mohammed A, et al. Int J Tuberc Lung Dis, 2004.

  11. Signs / symptoms of PTB YES Sputum microscopy x 3 for AFB All negative NO ONE positive CXR & assessment TB likely TB unlikely TREAT FOR TB Poor response Treat for bacterial infection INITIATE IPT Good response Screening Algorithm for IPT

  12. IPT Drugs and Dosages Recommended daily dosage: INH: Adults: 5 mg/kg/day, 300 mg/day max Children: 10-20 mg/kg/day, 300 mg/day max Pyridoxine (B6) co-administered: 25mg orally, daily

  13. Preventing Isoniazid Resistant TB Constant & proper use of the algorithm for the dx of PTB to prevent monotherapy Screening of patients at each visit Thorough investigation of those suspected of having TB Ongoing counselling of patients to maintain adherence

  14. Emergence of Resistance with Single Drug Therapy of Active TB Start INH alone

  15. Reasons to Stop IPT Patient misses 2 consecutive monthly refill/monitoring appointments Develops INH intolerance (serious side effect) Becomes terminally ill Potentially stop if female patient becomes pregnant If less than 3 months of IPT, discontinue If more than 3 months of IPT, continue treatment Develop symptoms of active TB

  16. Patient Education Point Ensure HIV positive patients understand the benefits of IPT (55% reduction in TB disease) Reinforce information at each visit Assess adherence to therapy, as with TB treatment Patients should be taught to recognize signs & symptoms of active TB Discuss side-effects and support patient by problem solving ways to manage minor SEs Encourage questions Unit 5: Infection Control and Prevention of TB

  17. Key Points It is important to appropriately screen for signs & symptoms of TB in HIV positive individuals before initiating IPT HIV positive individuals have a 5-10% chance of developing active TB per year IPT can prevent TB disease in HIV positive individuals

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