HIV coinfection with tuberculosis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Recommendations for treating tuberculosis in adults with HIV infection are, with a few exceptions, the same as those for adult TB patients who are not HIV infected. However, managing HIV-related TB is complex and people with HIV and TB should seek care from a health care provider or providers with expertise in the management of both HIV disease and TB. Because persons with HIV infection are often taking numerous medications, some of which interact with anti-TB medications, experts in the treatment of HIV-related TB should be consulted.
Role of Treatment
- Without treatment, as with any other opportunistic infection, HIV and TB can work together to shorten the life of the person infected.
- Someone with untreated latent TB infection and HIV infection is much more likely to develop active TB disease during his or her lifetime than someone without HIV infection.
- Among people with latent TB infection, HIV infection is the strongest known risk factor for progressing to active TB disease.
- A person who has both HIV infection and active TB disease has an AIDS-defining condition.
- Since viral load is the single greatest risk factor for all modes of HIV transmission, ART use decreases the risk that HIV will be transmitted from one person to another.
Recommended Regimen
The recommended treatment of TB disease in HIV-infected adults (when the disease is caused by organisms that are known or presumed to be susceptible to first-line drugs) is a 6-month regimen consisting of:
- For the first 2 months: An initial phase of isoniazid (INH), a rifamycin, pyrazinamide (PZA), and ethambutol (EMB).
- For the last 4 months: A continuation phase of INH and a rifamycin.
- Patients with advanced HIV (CD4 counts < 100/µl) should be treated with daily or three-times-weekly therapy in both the initial and the continuation phases.
- Twice weekly therapy may be considered in patients with less-advanced immunosuppression (CD4 counts ≥ 100/µl).
- Once-weekly INH/rifapentine in the continuation phase should not be used in any HIV-infected patient.
Duration of Treatment
- Six months: For adults with HIV, even for patients with culture-negative TB.
- Nine months (extend continuation phase to 7 months): For HIV-infected patients with delayed response to therapy (e.g., culture positive after 2 months of treatment).
Drug Interactions
A major concern in treating TB in HIV-infected persons is the interaction of rifampin (RIF) with certain antiretroviral agents (some protease inhibitors [PIs] and nonnucleoside reverse transcriptase inhibitors [NRTIs]).
Rifabutin, which has fewer problematic drug interactions, may be used as an alternative to RIF.
WHO Recommendations
In addition to initiating earlier antiretroviral therapy (ART), WHO recommends the implementation of the Three I's for HIV/TB to reduce the burden of TB among people living with HIV:
- Intensified TB case finding,
- Isoniazid preventive therapy,
- Infection control for TB.
WHO recommends that the Three I's for HIV/TB in addition to ART be part of a TB prevention package and that emphasize that they should be core components of HIV services with AIDS programmes and service providers taking the primary responsibility for the Three I's for HIV/TB.