Titile:- HIV and TB Infected Patients

Approach
 Fakiya Ahmed-yasin  1204344

1. How can you approach patients with HIV infections ?

Discuss on : History, phiscal examination , staging, investigation ,treatment and prevention

Submitted to:-Dr.Simachew.A
Studies have found that low trust in providers and poor patient-provider relationships have been
associated with lower retention in care and lower satisfaction with the clinic experience.1-3 These
findings underscore the need to build supportive relationships with patients that improve their health
outcomes. Here are some ways health care providers and their practices can achieve this: Download or
order clinician and patient materials from CDC's Let's Stop HIV Together campaign Help patients modify
behaviors that lead to poor retention in HIV care. Communicate with the patient nonjudgmentally to
learn what they know about the importance of retention. Identify skills that the patient might lack to
remain in care, such as problem-solving skills.

Guide the patient to identify possible changes that would eliminate or reduce barriers they face;
congratulate patient when they are able lessen the barriers. Strategize with the patient to identify new
goals and healthy behaviors. Actively refer patients to relevant clinic support services as needed to
provide additional support for retention. Foster patient trust. Be direct, nonjudgmental, and supportive.
Use open-ended questions to involve the patient in decision making regarding their HIV treatment and
overall care. Allow open communication and collaborative decision making. Educate patients about their
options and ask what questions come to mind when considering those options to encourage informed
conversation as part of the decision making process. Encourage discussions on subjects about substance
use, sexual behavior, and mental health. Provide referrals when appropriate, and assess patient
willingness to complete the referral.* Demonstrate interest in addressing barriers to care, including
structural barriers, from the first interaction. When possible, extend office hours or offer more flexible
appointment times one or more days per week (e.g., offer some walk-in or same-day appointments).
Maintain accurate patient contact information and update it at every visit. Use patient-tracking systems
to determine whether a patient has dropped out of care; contact patients promptly to reschedule
missed appointments.

Help patients find resources to address unmet needs and barriers to care. When possible, connect
patients with childcare, transportation, or other services and offer collocation of primary care and social
services.* When warranted, encourage patients to access substance use or mental health services.
Encourage patients to identify friends and family who can help with encouragement, support, and
attend medical appointments with them.

History

The history should be carefully taken to elicit possible exposures to human immunodeficiency virus
(HIV). Risk factors include the following: Unprotected sexual intercourse, especially receptive anal
intercourse (8-fold higher risk of transmission) A large number of sexual partners Prior or current
sexually transmitted diseases (STDs): Gonorrhea and chlamydia infections increase the HIV transmission
risk 3-fold, syphilis raises the transmission risk 7-fold, and herpes genitalis raises the transmission risk up
to 25-fold during an outbreak Sharing of intravenous drug paraphernalia Receipt of blood products
(before 1985 in the United States) Mucosal contact with infected blood or needle-stick injuries Maternal
HIV infection (for newborns, infants, and children): Steps taken to reduce the risk of transmission at
birth include cesarean delivery and prenatal antiretroviral therapy in the mother and antiretroviral
therapy in the newborn immediately after birth.
Physical examination: can give us important information regarding the patient’s general condition and
other factors that may affect tuberculosis management, particularly HIV infection or other illnesses.
Physical examination findings depend on the site of the tuberculosis infection and the most common
physical examination findings are fever, decreased breath sounds, tachypnea and tachycardia. Physical
Examination Pulmonary Tuberculosis Physical examination findings of pulmonary tuberculosis include:
[1] Appearance of the Patient

* Cachexia, Pallor,Vitals, Tachypnea, Tachycardia, Feve, Lungs, Decreased breath sounds, Rales, Rhonchi

Bronchial breath sounds :

Some patients with active tuberculosis may have a normal physical examination, so further testing
should be performed to confirm the diagnosis.

Extra-Pulmonary Tuberculosis:

Extra-pulmonary tuberculosis may also include some of the physical findings of pulmonary tuberculosis
such as fever, cachexia, tachypnea, tachycardia, and may be associated with an active pulmonary
infection

Staging

Without treatment, HIV infection advances in stages, getting worse over time. HIV gradually destroys the
immune system and eventually causes acquired immunodeficiency syndrome (AIDS).

There is no cure for HIV, but treatment with HIV medicines (called antiretroviral therapy or ART) can
slow or prevent HIV from advancing from one stage to the next. HIV medicines help people with HIV live
longer, healthier lives. One of the main goals of ART is to reduce a person's viral load to an undetectable
level. An undetectable viral load means that the level of HIV in the blood is too low to be detected by a
viral load test. People with HIV who maintain an undetectable viral load have effectively no risk of
transmitting HIV to their HIV-negative partner through sex. Series of test tubes containing varying
amounts of HIV particles and CD4 cells to depict the course of HIV infection.

There are three stages of HIV infection:

1.Acute HIV Infection

Acute HIV infection is the earliest stage of HIV infection, and it generally develops within 2 to 4 weeks
after infection with HIV. During this time, some people have flu-like symptoms, such as fever, headache,
and rash. In the acute stage of infection, HIV multiplies rapidly and spreads throughout the body. The
virus attacks and destroys the infection-fighting CD4 cells of the immune system. During the acute HIV
infection stage, the level of HIV in the blood is very high, which greatly increases the risk of HIV
transmission. A person may experience significant health benefits if they start ART during this stage.

2.Chronic HIV Infection

The second stage of HIV infection is chronic HIV infection (also called asymptomatic HIV infection or
clinical latency). During this stage, HIV continues to multiply in the body but at very low levels. People
with chronic HIV infection may not have any HIV-related symptoms. Without ART, chronic HIV infection
usually advances to AIDS in 10 years or longer, though in some people it may advance faster. People
who are taking ART may be in this stage for several decades. While it is still possible to transmit HIV to
others during this stage, people who take ART exactly as prescribed and maintain an undetectable viral
load have effectively no risk of transmitting HIV to an HIV-negative partner through sex.

3.AIDS

AIDS is the final, most severe stage of HIV infection. Because HIV has severely damaged the immune
system, the body can’t fight off opportunistic infections. (Opportunistic infections are infections and
infection-related cancers that occur more frequently or are more severe in people with weakened
immune systems than in people with healthy immune systems.) People with HIV are diagnosed with
AIDS if they have a CD4 count of less than 200 cells/mm3 or if they have certain opportunistic infections.
Once a person is diagnosed with AIDS, they can have a high viral load and are able to transmit HIV to
others very easily. Without treatment, people with AIDS typically survive about 3 years

Investigation

HIV Tests for Screening and Diagnosis

HIV tests are very accurate, but no test can detect the virus immediately after infection. How soon a test
can detect HIV depends upon different factors, including the type of test being used. There are three
types of HIV diagnostic tests: nucleic acid tests (NAT), antigen/antibody tests, and antibody tests. NATs
look for the actual virus in the blood. This test is very expensive and is not routinely used for HIV
screening unless the person recently had a high-risk exposure or a possible exposure with early
symptoms of HIV infection. A NAT can usually detect HIV infection 10 to 33 days after an exposure.
Antigen/antibody tests look for both HIV antibodies and antigens. Antibodies are produced by your
immune system when you’re exposed to viruses like HIV. Antigens are foreign substances that cause
your immune system to activate. If you have HIV, an antigen called p24 is produced even before
antibodies develop. Antigen/antibody tests are recommended for testing done in labs and are now
common in the United States. An antigen/antibody test performed by a laboratory on blood from a vein
can usually detect HIV infection 18 to 45 days after an exposure. There is also a rapid antigen/antibody
test available that is done with a finger prick. Antigen/antibody tests done with blood from a finger prick
can take longer to detect HIV (18 to 90 days after an exposure).

Antibody tests look for antibodies to HIV in your blood or oral fluid. Antibody tests can take 23 to 90
days to detect HIV infection after an exposure. Most rapid tests and the only FDA-approved HIV self-test
are antibody tests. In general, antibody tests that use blood from a vein can detect HIV sooner after
infection than tests done with blood from a finger prick or with oral fluid.

An initial HIV test usually will either be an antigen/antibody test or an antibody test. If the initial HIV test
is a rapid test or a self-test and it is positive, the individual should go to a health care provider to get
follow-up testing. If the initial HIV test is a laboratory test and it is positive, the laboratory will usually
conduct follow-up testing on the same blood sample as the initial test. Although HIV tests are generally
very accurate, follow-up testing allows the health care provider to be sure the diagnosis is right

HIV Treatment

HIV medicine is called antiretroviral therapy (ART).

There is no effective cure for HIV. But with proper medical care, you can control HIV.

Most people can get the virus under control within six months.

Taking HIV medicine does not prevent transmission of other sexually transmitted diseases.

Prevention

* Use condoms. Male latex condoms are the most effective way to prevent HIV and other STIs when you
have sex. ...

* Get tested. Be sure you and your partner are tested for HIV and other STIs. ...

* Be monogamous. ...

* Limit your number of sexual partners. ...

* Get vaccinated. ...

* Don't douche. ...

* Do not abuse alcohol

2. How can you approach patients with TB infections ?

Discuss on : History,physical examination,investigations,treatment and prevention

Approach Considerations

Isolate patients with possible tuberculosis (TB) infection in a private room with negative pressure (air
exhausted to outside or through a high-efficiency particulate air filter). Medical staff must wear high-
efficiency disposable masks sufficient to filter the tubercle bacillus. Continue isolation until sputum
smears are negative for 3 consecutive determinations (usually after approximately 2-4 wk of treatment).
Unfortunately, these measures are neither possible nor practical in countries where TB is a public health
problem.

History of tuberculosis

Throughout history, the disease tuberculosis has been variously known as consumption, phthisis, and
the White Plague. It is generally accepted that the causative agent, Mycobacterium tuberculosis
originated from other, more primitive organisms of the same genus Mycobacterium. In 2014, results of a
new DNA study of a tuberculosis genome reconstructed from remains in southern Peru suggest that
human tuberculosis is less than 6,000 years old. Even if researchers theorise that humans first acquired
it in Africa about 5,000 years ago,[1] there is evidence that the first tuberculosis infection happened
about 9,000 years ago.[2] It spread to other humans along trade routes. It also spread to domesticated
animals in Africa, such as goats and cows. Seals and sea lions that bred on African beaches are believed
to have acquired the disease and carried it across the Atlantic to South America. Hunters would have
been the first humans to contract the disease there

Investegations

There are two kinds of tests that are used to detect TB bacteria in the body: the TB skin test (TST) and TB
blood tests. A positive TB skin test or TB blood test only tells that a person has been infected with TB
bacteria. It does not tell whether the person has latent TB infection (LTBI) or has progressed to TB
disease. Other tests, such as a chest x-ray and a sample of sputum, are needed to see whether the
person has TB disease.

Diagnosis :

If a person is found to be infected with TB bacteria, other tests are needed to see if the person has
latent TB infection or TB disease.

Treatment

The Aims of anti‐TB Treatment

a. To cure the patient of TB

b. To prevent death from active TB or its late effects

c. To prevent TB relapse or recurrent disease

d. To prevent the development of drug resistance

e. To decrease TB transmission to others.

• TB is treatable and curable, even in people living with HIV

• First line TB drugs

 Rifampicin (R)

 Isoniazid (H)

 Ethambutol (E)

 Pyrazinamide (Z)

Gaps in first-line treatment

• High pill burden

• Long duration of treatment

• Side effects

• Drug stock outs

• Interactions with ARVs

• Little to no pediatric data

• What is drug-susceptible (or drug sensitive) TB?

• What is drug-resistant TB?

– Mono-resistant

– Poly-resistant

– Multi-drug resistant

– Extensively-drug resistant

What is drug-susceptible (or drug sensitive)

Caused by:

Poor quality medication Inadequate or erratic treatment

Transmission from one person to another

Multi‐Drug Resistant TB

Difficult to diagnose

‐ Time for culture

‐ Special laboratories Treat with second‐line drugs

MDR TB treatment takes 3‐4 times longer and costs 100 times more

More side effects and drug interaction esp with ART

Extensively drug resistant TB - XDR TB

• MDR‐TB that is also resistant to 2/3 most powerful second line TB drugs

• Difficult to diagnose

– Time for culture

– Special laboratories

• About 10% of MDR TB is XDR

• High fatality rate in people living with HIV

• Present in every region of the world

How could you prevent TB

1. Involve patients & community in advocacy campaigns

2. Infection control plan

3. Safe sputum collection

4. Cough etiquette and cough hygiene

5. Triage TB suspects to fast tract or separation

6. Rapid TB diagnosis and treatment

7. Improve room air ventilation

8. Protect health care workers

9. Capacity building

10. Monitor infection control practices

1. Early diagnosis and prompt effective treatment of infectious cases

2. Good infection control

3. Isoniazid preventive therapy

4. Other factors better housing, nutrition, alcohol reduction….