US DHHS Guidelines with Australian commentary

Last Updated: December 18, 2019; Last Reviewed: December 18, 2019

Panel's Recommendations Regarding Tuberculosis/HIV Coinfection

AU comment: Timing of ART commencement in opportunistic infections

AU comment: Treatment of latent tuberculosis

• Selection of tuberculosis (TB)-preventive treatment for individuals with HIV and latent tuberculosis infection (LTBI) should be based on the individual’s antiretroviral therapy (ART) regimen as noted below:
  • Any ART regimen can be used when isoniazid alone is used for LTBI treatment (AIII).
  • Efavirenz 600 mg once daily- or raltegravir 400 mg twice daily-based regimens (in combination with either abacavir/lamivudine or tenofovir disoproxil fumarate/emtricitabine) can be used without dose adjustment with once-weekly isoniazid plus rifapentine (AII).
  • If rifampin or rifapentine is used to treat LTBI, clinicians should review Tables 21a through 21e to assess the potential for drug-drug interactions among different antiretroviral (ARV) drugs and the rifamycins (AIII).
• All patients with HIV and active TB who are not on ART should be started on ART as described below:
  • CD4 T lymphocyte (CD4) cell counts <50 cells/mm³: Initiate ART as soon as possible, but within 2 weeks of starting TB treatment (AI).
  • CD4 counts ≥50 cells/mm³: Initiate ART within 8 weeks of starting TB treatment (AI).
  • During pregnancy, regardless of CD4 count: Initiate ART as early as feasible, for treatment of the person with HIV and to prevent HIV transmission to the infant (AIII).
  • With tuberculous meningitis: When initiating ART early, patients should be closely monitored as high rates of adverse events and deaths have been reported in a randomized trial (AI).
• For patients with active TB who are receiving ART, the ARV regimen should be assessed with particular attention to potential drug-drug interactions between ARVs and TB drugs. The ARV regimen may need to be modified to permit use of the optimal TB treatment regimen (see Tables 21a through 21e for dosing recommendations).
• Rifamycin antibiotics (rifabutin, rifampin, and rifapentine), are critical components of TB treatment regimens and should be included in regimens for patients with both HIV and active TB, unless precluded because of TB resistance or toxicity. However, rifamycin antibiotics have a considerable potential for drug-drug interactions. Clinicians should review Tables 21a through 21e to assess the potential for interactions among different ARV drugs and the rifamycins (AIII).