The standard of care for tuberculosis (TB) in recent years has been Direct Observed Therapy (DOT), which is defined as a health care worker or designated person directly observing the administration and ingestion of medication. In regards to HIV seropositive patients, the Center for Disease Control (CDC) recommends DOT for TB medications (Center for Disease Control [CDC], 1998; Kaplan, et al., 2009). In addition, the CDC recognizes the importance of providing social and medical support to enhance adherence to a medication regime.
Many obstacles to successful treatment lie in the path of patients with TB. Among those are long course of therapy, side effects of medications, multiple drugs taken multiple times of day, difficulty in making appointments due to issues of transportation and money, cultural insensitivity of clinic workers, stigma, lack of support by community, mental health, drug and ETOH abuse, and previous failed treatment (Lee B Reichman, MD & Alfred A Lardizabal, MD, 2009). It is quite an impressive list. If the patient has a co-infection of HIV, these obstacles are compounded by even more medications, an increasingly complex schedule of treatment, more clinic appointments, providers who may be inexperienced in dealing with co-infections of TB and HIV, added medication side effects and interactions, and the prospect of taking medications for a lifetime. This can be a daunting task, even for people with great organizing and coping skills. For someone who may be homeless, just barely holding onto a job and trying to survive day-to-day, this scenario can be overwhelming. Even health care providers can fall into the non-adherence category (Miller & Snider, 1987).
Fortunately, providing good support in addition to DOT can make a difference in helping patients negotiate difficulties in treatment of a co-infection of HIV and TB. Treat patients with respect during all interactions, whether in the hospital, clinic, or at a home visit. Education of the patient about the basics of why adherence is important, that TB can be cured and they can live a long life even with HIV. They should also be made aware of the side effects of their medications, what to do if they experience the side effects, and that they should contact their provider before discontinuing their medications, if the side effects are severe enough that they don't want to continue taking their medications. Non-judgmental questioning of the patient's medication adherence, while at the same time being able to explain the consequences of non-adherence including being sick longer, the probability of relapse and a more complicated drug regimen. Medical support can include helping the patient find better timing for medications, switching to combination drugs, adjusting dosages, or even reducing weekly frequencies of medication. Under DOT, dosage frequency can be reduced to 3 times weekly for TB medications. Provider appointments, excluding DOT, should be every week to two weeks initially until the patient stabilizes on their medications and they have had a chance to get answers for all their TB and HIV related questions, then the appointments can be every three months. Help patients find ways to remember taking medications including cell phone reminders, calendars, associate with other daily tasks such as tooth brushing. Phone call reminders and incentives such as bus tickets and food vouchers that are offered by the health department may also help encourage adherence to their DOT and clinic appointments.
The future of treatment for co-infection of HIV and TB may rely on the ability to pool the resources for treatment of both diseases, especially in resource poor settings. Providers and researchers are starting to look at ways to alleviate the obstacles patients face in the dual treatment regimens. Combining DOT and support services for HIV and TB during the course of TB treatment has shown promise. Two studies in resource poor settings, one in Peru and another in South Africa, combined resources for both HIV and TB treatment (Jack et al., 2004; Muñoz et al., 2009). Both studies saw a high cure rate of TB, increase of average CD4 count, reduction in average HIV viral load. The Jack study saw only a minimal increase in costs over DOT implementation for TB alone. The Muñoz study was a case-control study that also looked at psychosocial outcomes. It found that the participants indicated a greater quality of life, better communication with their providers, and more motivation to adhere to their medication regimen.
References
Kaplan, J. E., Benson, C., Holmes, K. H., et al. (2009). 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 Recommendations Rep 2009, 58, 1-198.
Center for Disease Control. (1998). Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: Principles of therapy and revised recommendations. Centers for Disease Control and Prevention. MMWR Recommendations Rep 1998, 47, 1-51.
Jack, C., Lalloo, U., Karim, Q. A., Karim, S. A., El-Sadr, W., Cassol, S., et al. (2004). A pilot study of once-daily antiretroviral therapy integrated with tuberculosis directly observed therapy in a resource-limited setting. Journal of Acquired Immune Deficiency Syndromes (1999), 36(4), 929-934.
Lee B Reichman, MD, & Alfred A Lardizabal, MD. (2009, September). Adherence to tuberculosis treatment - UpToDate. Retrieved November 24, 2009, from http://www.uptodate.com.offcampus.lib.washington.edu/online/content/topic.do?topicKey=tubercul/6460&selectedTitle=1%7E150&source=search_result
Miller, B., & Snider, D. E. (1987). Physician noncompliance with tuberculosis preventive measures. The American Review of Respiratory Disease, 135(1), 1-2.
Muñoz, M., Finnegan, K., Zeladita, J., Caldas, A., Sanchez, E., Callacna, M., et al. (2009). Community-based DOT-HAART Accompaniment in an Urban Resource-Poor Setting. AIDS and Behavior. doi: 10.1007/s10461-009-9559-5
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