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Isoniazid Preventive Therapy (IPT) administration among People Living with HIV (PLHIV) prevents the incidence and relapse of TB. Concomitant administration of Anti-retroviral Therapy (ART) and IPT, restores TB-specific immunity and prolongs the beneficial effect of IPT.

Combined use of IPT with ART is recommended for all Children Living with HIV (CLHIV)/ PLHIV regardless of: degree of immunosuppression, previous treatment for TB  or pregnancy.

 

If there is any doubt about the TB status of a client, IPT should be delayed.

 

PLHIV/ CLHIV are offered IPT by the treat-only policy, i.e., tests for TB infections, like Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) are not warranted. However, active TB disease must be ruled out before starting IPT.

 

Ruling Out Active TB before initiation of IPT

  • In adults and adolescents living with HIV: Screen for active TB with a clinical algorithm, for the four symptoms (current cough, night sweats, fever, weight loss). When there are no symptoms, there is a very low probability of having TB disease and they can be reliably initiated on IPT. 

  • In CLHIV more than 12 months of age: Screen for current cough, fever, poor weight gain and history of contact with a TB case. When there are no symptoms, they are unlikely to have active TB. A chest X-ray may be useful.

  • Infants aged <12 months living with HIV who are in contact with a person with TB should undergo clinical evaluation. Those who are unlikely to have active TB should receive TB Preventive Treatment (TPT).

 

Contraindications to IPT

 

  • Signs and symptoms of peripheral neuropathy such as persistent tingling, numbness and burning sensation in the limbs
  • Regular and heavy alcohol consumption
  • Active hepatitis
  • Concurrent use of other hepatotoxic medications
  • Contact with a Multidrug-resistant TB (MDR-TB) case
  • PLHIV who have completed DR-TB treatment

 

IPT Work-up: The patient should be examined for signs of liver disease (jaundice, tenderness in the right upper quadrant of the abdomen) and neuropathy. Wherever available, routine Liver Function Tests (LFTs)/ Alanine Aminotransferase (ALT) should be performed, but a lack of LFTs/ALT results should not delay the initiation of IPT in asymptomatic patients. 

Dosage in Adults and Adolescents: Isoniazid 300 mg + Pyridoxine 50 mg (Vitamin B6) per day x 6 months

Table 1: Paediatric Dosages

Weight Range (Kg)

Number of 100 mg tablets of INH to be administered per dose (Total Dose 10 mg/kg/day)

Dose (mg)

<5

1⁄2 tablet

50

5.1–9.9

1 tablet

100

10–13.9

11⁄2 tablets

150

14–19.9

2 tablets

200

20–24.9

21⁄2 tablets

250

>25

3 tablets or one adult tablet

300

Non-availability of pyridoxine should not be a reason to withhold TPT. Alternatively, the multivitamin/ B-complex formulations with the requisite prophylactic dose of pyridoxine may be given.

 

IPT Initiation and Follow-up

  •      All 4S -ve patients should be assessed by the Senior Medical Officer (SMO)/ MO to determine eligibility for IPT. IPT should be considered for both on-ART and pre-ART patients and initiated if not contraindicated. IPT drugs must be provided monthly (30 days) to all eligible patients.
  •      In case a patient becomes 4S +ve during the IPT course, he/she should be investigated for TB and if found positive, IPT should be stopped, and appropriate anti-TB treatment should be initiated.

 

References

 

Assessment 

Question

Answer 1

Answer 2

Answer 3

Answer 4

Correct answer

Explanation

Page ID

Part of pre-test

Part of post-test

Which of the following statements is false?

IPT should be for all infants living with HIV with a history of contact with a PTB case, after ruling out active TB

IPT can be given to a pregnant woman with HIV

If there is any doubt of active TB disease, IPT should be withheld

IGRA  should be done before administering IPT to a PLHIV

4

Tests for TB infection are not indicated in PLHIV. They are offered TPT after ruling out active TB disease by the “Treat only” policy.

3260

Yes

Yes

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