Tuberculosis
Prevention of Exposure
HIV-infected persons should be advised that certain activities and
occupations may increase the likelihood of exposure to tuberculosis.
These include volunteer work or employment in health-care facilities,
correctional institutions, and shelters for the homeless, as well as in other
settings identified as high risk by local health authorities. Decisions about
whether to continue with activities in these settings should be made in
conjunction with the health-care provider and should be based on factors
such as the patient's specific duties in the workplace, the prevalence of
tuberculosis in the community, and the degree to which precautions are taken
to prevent the transmission of tuberculosis in the workplace. Whether
the patient continues with such activities may affect the frequency with
which screening for tuberculosis needs to be conducted.
Prevention of Disease
When HIV infection is first recognized, the patient should receive a
tuberculin skin test (TST) by administration of intermediate-strength (5-TU)
purified protein derivative (PPD) by the Mantoux method. Routine evaluation
for anergy is not recommended. However, there are selected situations
in which anergy evaluation may assist in guiding individual decisions about
preventive therapy (e.g., for TST-negative persons in populations at high
risk for M. tuberculosis infection).
All HIV-infected persons who have a positive result in the TST (>5 mm of induration) should undergo chest radiography and clinical evaluation for the exclusion of active tuberculosis. HIV-infected persons who have symptoms suggestive of tuberculosis should undergo chest radiography and clinical evaluation regardless of their TST status.
All HIV-infected persons who have a positive TST result yet have no evidence of active tuberculosis and no history of treatment or prophylaxis for tuberculosis should be administered 12 months of preventive chemotherapy with isoniazid (INH). Because HIV-infected persons are at risk for peripheral neuropathy, those receive-ing INH should also receive pyridoxine. The decision to use alternative anti-mycobacterial agents for chemoprophylaxis should be based on the relative risk of exposure to resistant organisms and may require consultation with public health authorities. Rifamycin/protease inhibitor interactions need to be taken into account when non-INH preventive therapy is considered. The need for direct observation as a means of documenting adherence to chemoprophylaxis should be considered on an individual basis.
HIV-infected persons who are close contacts of persons who have infectious tuberculosis should be administered preventive therapyregardless of TST results or prior courses of chemoprophylaxisafter the diagnosis of active tuberculosis has been excluded (AII). In addition to household contacts, such persons might also include contacts in the same drug treatment or health-care facility, coworkers, and other contacts if transmission of TB is demonstrated. Such persons should be tested with 5-TU PPD. If the TST result is initially negative, the person should be evaluated again 3 months after the discontinuation of contact with the infectious source, and the information obtained should be considered in decisions about whether chemoprophylaxis should continue.
TST-negative, HIV-infected persons from risk groups or geographic areas with a high prevalence of M. tuberculosis infection may be at increased risk of primary or reactivation tuberculosis. Some experts recommend preventive therapy for some per-sons in this category. However, the efficacy of preventive therapy in this group has not been demonstrated, and such prophylaxis cannot be routinely recommended. Decisions concerning the use of chemoprophylaxis in these situations must be considered individually.
Although the reliability of the TST may diminish as the CD4+ T-lymphocyte count declines, annual repeat testing should be considered for HIV-infected persons who are TST-negative on initial evaluation and who belong to populations in which there is a substantial risk of exposure to M. tuberculosis. In addition to documenting tuberculous infection, TST conversion in an HIV-infected person should alert health-care providers to the possibility of recent M. tuberculosis transmission and should prompt notification of public health officials for investigation to identify a possible source case.
The administration of BCG vaccine to HIV-infected persons is contraindicated because of its potential to cause disseminated disease.
Prevention of Recurrence
Chronic suppressive therapy for a patient who has successfully completed
a recommended regimen of treatment for tuberculosis is not necessary.
Notes:
Pediatric Note
Infants born to HIV-infected mothers should have a TST (5-TU PPD) at
or before age 912 months and should be retested at least every 23
years. Children living in households with M. tuberculosis-infected
(TST-positive) persons should be evaluated for tuberculosis (17);
children exposed to a person who has active tuberculosis should be administered
preventive therapy after active tuberculosis has been excluded. Decisions
to discontinue prophylaxis for children who remain un-infected after removal
from exposure to a source case can be made as for adults (see Prevention
of Disease [5]).
Note Regarding Pregnancy
Chemoprophylaxis for tuberculosis is recommended during pregnancy for
HIV-infected patients who have either a positive TST or a history of exposure
to active tuberculosis, after active tuberculosis has been excluded.
A chest radiograph should be obtained before treatment and appropriate
abdominal/pelvic lead apron shields should be used to minimize radiation
exposure to the embryo/fetus. In the absence of exposure to drug-resistant
TB, INH is the prophylactic agent of choice. Because of theoretical concerns
regarding possible teratogenicity associated with drug exposures during the
first trimester, providers may choose to initiate prophylaxis after the first
trimester. Preventive therapy with INH should be accompanied by pyridoxine
to reduce the risk of neurotoxicity. Experience with rifampin or rifabutin
during pregnancy is more limited, but anecdotal experience with rifampin
has not been associated with adverse pregnancy outcomes.
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