Page 160 - HIV/AIDS Guidelines

Mycobacterium Tuberculosis Disease with HIV Coinfection (Last updated March 27, 2012;
last reviewed March 27, 2012)

Panel’s Recommendations
• The principles for treatment of active tuberculosis (TB) disease in HIV-infected patients are the same as those for
HIV-uninfected patients (AI).
• All HIV-infected patients with diagnosed active TB should be started on TB treatment immediately (AI).
• All HIV-infected patients with diagnosed active TB should be treated with antiretroviral therapy (ART) (AI).
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• In patients with CD4 counts <50 cells/mm , ART should be initiated within 2 weeks of starting TB treatment (AI).
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• In patients with CD4 counts ≥50 cells/mm who present with clinical disease of major severity as indicated by
clinical evaluation (including low Karnofsky score, low body mass index [BMI], low hemoglobin, low albumin, organ
system dysfunction, or extent of disease), ART should be initiated within 2 to 4 weeks of starting TB treatment. The
strength of this recommendation varies on the basis of CD4 cell count:
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• CD4 count 50 to 200 cells/mm (BI)
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• CD4 count >200 cells/mm (BIII)
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• In patients with CD4 counts ≥50 cells/mm who do not have severe clinical disease, ART can be delayed beyond 2 to
4 weeks of starting TB therapy but should be started within 8 to 12 weeks of TB therapy initiation. The strength of
this recommendation also varies on the basis of CD4 cell count:
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• CD4 count 50 to 500 cells/mm (AI)
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• CD4 count >500 cells/mm (BIII)
• In all HIV-infected pregnant women with active TB, ART should be started as early as feasible, both for maternal
health and for prevention of mother-to-child transmission (PMTCT) of HIV (AIII).

• In HIV-infected patients with documented multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB, ART should
be initiated within 2 to 4 weeks of confirmation of TB drug resistance and initiation of second-line TB therapy (BIII).
• Despite pharmacokinetic drug interactions, a rifamycin (rifampin or rifabutin) should be included in TB regimens for
patients receiving ART, with dosage adjustment if necessary (AII).
• Rifabutin is the preferred rifamycin to use in HIV-infected patients with active TB disease on a protease inhibitor
(PI)-based regimen because the risk of substantial drug interactions with PIs is lower with rifabutin than with
rifampin (AII).
• Coadministration of rifampin and PIs (with or without ritonavir [RTV] boosting) is not recommended (AII).

• Rifapentine (RPT) is NOT recommended in HIV-infected patients receiving ART for treatment of latent TB infection
(LTBI) or active TB, unless in the context of a clinical trial (AIII).
• Immune reconstitution inflammatory syndrome (IRIS) may occur after initiation of ART. Both ART and TB treatment
should be continued while managing IRIS (AIII).
• Treatment support, which can include directly observed therapy (DOT) of TB treatment, is strongly recommended
for HIV-infected patients with active TB disease (AII).

Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = data from randomized controlled trials; II = data from well-designed nonrandomized trials or observational
cohort studies with long-term clinical outcomes; III = expert opinion

Treatment of Active Tuberculosis in HIV-Infected Patients
HIV infection significantly increases the risk of progression from latent to active TB disease. The CD4 cell
count influences both the frequency and severity of active TB disease. 1-2 Active TB also negatively affects

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents J-12

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