HIV and TB: A Fact Sheet for HIV Care Providers in Minnesota

On this page:
Background
Recommendations for TB Testing and Treatment of HIV-Infected Persons
Minnesota Department of Health TB Medications Program
References

Background

• HIV is the most powerful known risk factor for the development of active TB disease. People living with HIV are 20-30 times more likely to develop TB than those without HIV.
• At least one-third of the estimated 37 million people living with HIV worldwide are infected with M. tuberculosis.
• All people living with HIV should be tested for TB at least once.
• Treatment of people living with HIV with latent TB infection (LTBI) is a high priority.
• Ninety-four percent of the TB cases reported in Minnesota from 2011-2015 were tested for HIV; 26 (4%) were co-infected with HIV.

Recommendations for TB Testing and Treatment for People Living with HIV

Clinicians caring for people with HIV should make aggressive efforts to identify and treat those who also are infected with M. tuberculosis.

• All people should be tested for latent TB infection (LTBI) at the time of HIV diagnosis, regardless of their TB risk category.
  
  
• People with negative diagnostic tests for LTBI, advanced HIV infection, and without indications for initiating empiric LTBI treatment should be re-tested for LTBI once they start ART and attain a CD4 count >200 cells/µL.
  
  
• Annual testing for LTBI is recommended for people living with HIV who remain at high risk for ongoing exposure to TB (e.g., people who have been incarcerated, live in congregate settings, are active drug users, or frequently travel to TB-endemic areas).
  
  
• There are two types of diagnostic tests for LTBI: the Mantoux tuberculin skin test (TST) and the Interferon Gamma Release Assay (IGRA). Both tests are acceptable for use in people living with HIV, but the possibility of false negative results should be considered. TSTs are considered positive in people living with HIV if induration of >5 mm is present. IGRAs detect IFN-γ release in response to M. tuberculosis-specific peptides. Use of both tests may be considered for people living with HIV at high risk for infection with M. tuberculosis. Any person living with HIV with reactivity on either LTBI diagnostic test should be considered infected with M. tuberculosis.
  
  
• All people living with HIV with a positive diagnostic test for LTBI should undergo chest radiography and clinical evaluation to rule out active TB disease. TB patients who are living with HIV with low CD4 counts frequently have chest radiographic findings that are not typical of pulmonary TB. Extrapulmonary sites of TB disease are more common in people living with HIV.
  
  
• People living with HIV with LTBI who have not previously received therapy for LTBI should receive treatment, regardless of their age. Prior to initiating treatment for LTBI, a careful medical examination should be done to rule out active TB disease.
  
  
• A medical expert in the treatment of TB should be consulted before starting LTBI therapy in a person living with HIV. Expert medical consultation is available through the MDH TB Prevention and Control Program.
  
  
• People living with HIV should be advised that time spent in congregate settings or other high risk sites for TB transmission (e.g., correctional facilities, homeless shelters, nursing homes) increases the likelihood of contracting M. tuberculosis infection.

MDH TB Medications Program

Any person in Minnesota receiving treatment for LTBI or active TB disease is eligible to receive TB medications at no cost to the patient from the MDH TB Prevention and Control Program. Treatment regimens must follow Centers for Disease Control and Prevention/American Thoracic Society/ Infectious Diseases Society of America treatment guidelines.

• To request medications, the prescribing clinician should contact MDH at 651-201-5414 or 1-877-676-5414 (toll free). You will be asked to provide pertinent demographic and clinical information and a copy of the prescription(s).
• Through a contracted pharmacy, MDH sends a monthly supply of patient-specific TB medications to the designated clinic, local public health agency, or other health care provider licensed to administer medications.
• The health care provider who receives the medications is responsible for monitoring the patient for adherence, adverse reactions, and signs of active TB disease that may develop during treatment. A monitoring flow sheet for LTBI treatment is available at Tuberculosis Medications Program.

References:

Centers for Disease Control and Prevention, Division of TB Elimination www.cdc.gov/tb

Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR 2009; 58.

Guidelines for the Prevention and Treatment of Opportunistic Infections Among HIV-Exposed and HIV-Infected Children: Recommendations from CDC, the National Institutes of health, the HIV Medicine Association of the Infectious diseases Society of America, and the American Academy of Pediatrics. CDC. MMWR 2009; 58(11).

Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection, United States, 2010.  MMWR 2010; 59(5).

Targeted TB Testing and Treatment of Latent TB Infection (LTBI)

Minnesota Department of Health, TB Prevention and Control Program

World Health Organization, Tuberculosis