HIV &TB Pediatric.ppt 9224667778886432145

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1. Pediatric HIV Module I:
TB & HIV Coinfection
Annie Buchanan, MD, MPH, DTM&H
Baylor International Pediatric AIDS
Initiative
Kilimanjaro Christian Medical Center

2. Pretest:
1.Which of the following children should
receive INH prophylaxis?
a.A 4-year-old, asymptomatic, HIV neg female, in
close contact with a sputum smear + adult
b.A 6-year-old HIV+ male, asymptomatic, in close
contact with a sputum smear + adult
c.A 2-year-old HIV+ female, with history of cough
and fevers x 1/12, in close contact with a sputum
smear positive adult
d.All of the above
e.A & B only

3. INH Prophylaxis
Figure 1 Suggested approach (World Health Organization, 2006)
to contact management when chest X-ray and tuberculin skin
testing are not readily available.

4. INH Prophylaxis
A recent study in South Africa:
INH prophylaxis given to HIV-exposed children 8
weeks of age or older who did not have TB
Compared with placebo
8% mortality in the INH group and 16% mortality in
the placebo group
Reduction in mortality of 50%
The children receiving INH had a lower incidence
of TB (3.8% compared to 9.9% in placebo arm)
Reduction in TB incidence > 70%
Is INH prophylaxis an effective public health
intervention for HIV+ children in areas with a high
TB prevalence?

5. Pretest:
2.When dealing with HIV+ children, the
diagnosis of TB is made even more difficult
because of which of the following?
a.Tuberculin skin tests are more often non-
reactive in HIV+ children
b.HIV-related lung diseases share many of the
clinical and radiological features associated with
TB
c.The immune system damage caused by HIV
leads to unusual forms of TB
d.A & B only
e.All of the above

6. Pretest:
2.When dealing with HIV+ children, the
diagnosis of TB is made even more difficult
because of which of the following?
a.Tuberculin skin tests are more often non-
reactive in HIV+ children
b.HIV-related lung diseases share many of the
clinical and radiological features associated with
TB
c.The immune system damage caused by HIV
leads to unusual forms of TB
d.A & B only
e.All of the above

7. Pretest:
3.Which of the following statements is false?
a.HIV-infected children are more susceptible to TB
than HIV-uninfected children
b.After being infected with Mycobacterium
tuberculosis, HIV+ children progress more
rapidly to disease than do HIV-negative children
c.The occurrence of miliary TB and TB with pleural
effusions is more common in HIV+ children than
in HIV-negative children
d.The clinical picture of TB in HIV+ children is
markedly different from HIV-negative children
e.TB in HIV-infected children is treated the same
way as in HIV-uninfected children

8. Pretest:
3.Which of the following statements is false?
a.HIV-infected children are more susceptible to TB
than HIV-uninfected children
b.After being infected with Mycobacterium
tuberculosis, HIV+ children progress more
rapidly to disease than do HIV-negative children
c.The occurrence of miliary TB and TB with pleural
effusions is more common in HIV+ children than
in HIV-negative children
d.The clinical picture of TB in HIV+ children is
markedly different from HIV-negative children
e.TB in HIV-infected children is treated the same
way as in HIV-uninfected children

9. Pretest:
4.Among HIV+ children, distinguishing
between LIP and miliary TB on a chest
radiograph can be especially difficult.
Which of the following clinical factors can
help distinguish miliary TB from LIP?
a.Parotid enlargement seldom occurs with miliary
TB, while it sometimes occurs with LIP
b.Most children with miliary TB are acutely ill,
while children with LIP are often not ill at all
c.Miliary TB is seldom associated with clubbing of
the fingers and toes, while clubbing occurs in
most children with LIP
d.A & C only
e.All of the above

10. Pretest:
4.Among HIV+ children, distinguishing
between LIP and miliary TB on a chest
radiograph can be especially difficult.
Which of the following clinical factors can
help distinguish miliary TB from LIP?
a.Parotid enlargement seldom occurs with miliary
TB, while it sometimes occurs with LIP
b.Most children with miliary TB are acutely ill,
while children with LIP are often not ill at all
c.Miliary TB is seldom associated with clubbing of
the fingers and toes, while clubbing occurs in
most children with LIP
d.A & C only
e.All of the above

11. Pretest:
5.You are seeing a 4-year-old male in PIDC, WHO
Stage III for pulmonary TB, currently completing his
second month of TB therapy with R/H/Z/E. His
CD4 count is 650 absolute/24%. What is your next
step in his care and treatment?
a.Plan to start ARVs now, since he is Stage III and has now
completed 2 months of TB therapy
b.Wait on starting ARVs until he has completed his TB
therapy, with a definite plan to start in 4 months
c.Not start ARVs until his CD4 count is below threshold, or
he develops another Stage III or IV illness
d.Start him on ARVs today, though he shouldhave been
started 2 weeks into his TB therapy
e.None of the above are appropriate options

12. Pretest:
5.You are seeing a 4-year-old male in PIDC, WHO
Stage III for pulmonary TB, currently completing his
second month of TB therapy with R/H/Z/E. His
CD4 count is 650 absolute/24%. What is your next
step in his care and treatment?
a.Plan to start ARVs now, since he is Stage III and has now
completed 2 months of TB therapy
b.Wait on starting ARVs until he has completed his TB
therapy, with a definite plan to start in 4 months
c.Not start ARVs until his CD4 count is below threshold, or
he develops another Stage III or IV illness
d.Start him on ARVs today, though he shouldhave been
started 2 weeks into his TB therapy
e.None of the above are appropriate options

13. Pretest:
6.You are seeing a 2-year-old female in PIDC, WHO
Stage IV for TB meningitis. She is currently on
anti-TB therapy, which was started 6 weeks ago.
She is clinically stable at present. As a stage IV it
would be recommended to start ARVs as soon as
possible. Following the WHO Guidelines, what
regimen would be recommended for starting her
ARVs along with her TB therapy?
a.AZT + 3TC + NVP
b.d4T + 3TC + NVP
c.AZT + 3TC + EFV
d.AZT + 3TC + ABC
e.AZT + 3TC + Kaletra (Lopinavir/ritonavir)

14. Pretest:
6.You are seeing a 2-year-old female in PIDC, WHO
Stage IV for TB meningitis. She is currently on
anti-TB therapy, which was started 6 weeks ago.
She is clinically stable at present. As a stage IV it
would be recommended to start ARVs as soon as
possible. Following the WHO Guidelines, what
regimen would be recommended for starting her
ARVs along with her TB therapy?
a.AZT + 3TC + NVP
b.d4T + 3TC + NVP
c.AZT + 3TC + EFV
d.AZT + 3TC + ABC
e.AZT + 3TC + Kaletra (Lopinavir/ritonavir)

15. Pretest:
7.Rifampicin decreases serum
concentrations of all of the following
ARVs except:
a.Nevirapine
b.Efavirenz
c.Abacavir
d.Lopinavir/Ritonavir (Kaletra)
e.Indinavir

16. Pretest:
7.Rifampicin decreases serum
concentrations of all of the following
ARVs except:
a.Nevirapine
b.Efavirenz
c.Abacavir
d.Lopinavir/Ritonavir (Kaletra)
e.Indinavir

17. Rifampicin and ARVs:
Rifampicin is an enzyme inducer –
cytochrome p450 system
It reduces the concentration of most
protease inhibitors by more than 75%
Exception: Ritonavir is decreased by only 35%
NNRTI concentrations are also substantially
reduced:
Nevirapine: 37-58%
Efavirenz: 22%

18. Rifampicin and ARVs:
1
st
line choice for a child < 3 years:
AZT (or d4T) + 3TC + ABC
1
st
line choice for a child > 3 years:
TZ Recommendations:
–AZT (or d4T) + 3TC + EFV
WHO Recommendations:
–AZT (or d4T) + 3TC + ABC
A study of HIV-infected adults showed AZT + 3TC +
ABC had lower virological potency than an EFV-based
regimen (79% vs 89% at 32 weeks of treatment)

19. Timing of ARVs with TB
Therapy:
In HIV-infected children with TB disease, the
initiation of TB treatment is the priority
Optimal timing to start ARVs is not known
Current WHO recommendations:
Children Stage IV: start ARVs within 2-8 weeks after
start of anti-TB therapy
Children Stage III with severe or advanced
immunodeficiency: start ARVs within 2-8 weeks as
above
Children Stage III with mild or insignificant immune
suppression, wait and observe response to ATT (if
good response, start ART when CD4 is below
threshold)

20. LIP or
Miliary
TB?
8.

21. LIP
8.

22. LIP or
Miliary
TB?
9.

23. Miliary
TB
9.

24. Widened
mediastinum
or normal
thymus?
10.

25. Normal
thymus!
10.