HIV1/tuberculosis coinfection
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Introduction
also see HIV1, AIDS, & tuberculosis
Complications
- combined antiretroviral & antituberculous therapy
Management
- active tuberculosis must be ruled out prior to treatment for latent tuberculosis in patients with positive tuberculin skin test or IFN gamma-release assay[3]
- early guidelines
- CD4 count <50 cells/mm3
- start antiretroviral therapy (HART) within 2 weeks after initiation treatment for tuberculosis[1]
- CD4 count >50 cells/mm3
- defer antiretroviral therapy (HART) until the beginning of the continuation phase of treatment for tuberculosis (3 months)
- CD4 count <50 cells/mm3
- recommendations 2014
- efavirenz (600 mg for adults; standard weight-based dosing for children aged >3 years) plus two NRTIs, along with rifampin-based TB therapy is the preferred strategy[2]
- if efavirenz cannot be used (1st trimester of pregnancy & in children aged <3 years), then a nevirapine or protease inhibitor-based ART regimen can be used in combination with rifampin-based TB therapy
- rifampin should not be coadministered with the 2nd-generation nonnucleoside reverse transcriptase inhibitors (NNRTIs) rilpivirine or etravirine
- high-dose lopinavir/ritonavir regimens should be used together with rifampin-based treatment only if hepatotoxicity is closely monitored
- patients who are unable to take NNRTIs can use rifampin in conjunction with triple- or quadruple-NRTI regimens if their HIV RNA levels are <100,000 copies/mL
- doubling the dose of raltegravir to 800 mg BID is recommended for adults taking rifampin
- do not use raltegravir-rifampin drug combination in patients with high HIV viral loads
- increasing maraviroc to 600 mg BID is recommended for adults taking rifampin
- a 150-mg daily dose of rifabutin, monitoring toxicity, can be coadministered with boosted antiretroviral protease inhibitors
- rifabutin can be used in patients on nevirapine-based ART & in those taking standard-dose raltegravir (400 mg BID)
- nevirapine-based HIV treatment can be used in pregnant women receiving rifampin-based TB treatment
- for children on rifampin-based TB treatment, super-boosted lopinavir plus appropriate NRTIs is recommended
- alternatives include standard-dose efavirenz-based ART for children > 3 years of age & a triple-nucleoside regimen children < 3 years[2]
- 2018 guidelines
- prednisone 40 mg QD for 14 days followed by 20 mg QD for 14 days during the first 4 weeks of antiretroviral therapy in patients with HIV1/tuberculosis coinfection reduces risk of TB-associated immune reconstitution inflammatory syndrome without increasing complications[4]
- patients with latent tuberculosis should receive treatment prior to administration of TNF-alpha inhibitor[3]
- also see HIV1, AIDS, & tuberculosis
More general terms
Additional terms
References
- ↑ 1.0 1.1 Journal Watch, Massachusetts Medical Society October 20, 2011
Abdool Karim SS et al. Integration of antiretroviral therapy with tuberculosis treatment. N Engl J Med 2011 Oct 20; 365:1492. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22010915
Havlir DV et al. Timing of antiretroviral therapy for HIV-1 infection and tuberculosis. N Engl J Med 2011 Oct 20; 365:1482. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22010914
Blanc FX et al. Earlier versus later start of antiretroviral therapy in HIV-infected adults with tuberculosis. N Engl J Med 2011 Oct 20; 365:1471. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22010913
Torok ME and Farrar JJ. When to start antiretroviral therapy in HIV-associated tuberculosis. N Engl J Med 2011 Oct 20; 365:1538. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22010921 - ↑ 2.0 2.1 2.2 Centers for Disease Control and Prevention (CDC) Announcement: Updated guidelines on managing drug interactions in the treatment of HIV-related tuberculosis. Morb Mortal Wkly Rep MMWR 2014 Mar 28; 63:272. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6312a5.htm
Centers for Disease Control and Prevention (CDC). Managing drug interactions in the treatment of HIV-related tuberculosis. June 2013. http://www.cdc.gov/tb/publications/guidelines/TB_HIV_Drugs/pdf/tbhiv.pdf - ↑ 3.0 3.1 3.2 Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2021.
- ↑ 4.0 4.1 Meintjes G, Stek C, Blumenthal L et al. Prednisone for the prevention of paradoxical tuberculosis- associated IRIS. N Engl J Med 2018 Nov 15; 379:1915. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30428290 https://www.nejm.org/doi/10.1056/NEJMoa1800762