Considerations for Antiretroviral Use in Patients with Coinfections
Mycobacterium Tuberculosis Disease with HIV Coinfection
Last Updated: July 14, 2016; Last Reviewed: July 14, 2016
Panel's Recommendations Regarding Mycobacterium Tuberculosis Disease with HIV Coinfection
- Selection of a tuberculosis (TB)-preventive treatment for individuals living with HIV and coinfected with 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 (AII).
- Only efavirenz (EFV)- or raltegravir (RAL)-based regimens (in combination with either abacavir/lamivudine [ABC/3TC] or tenofovir disoproxil fumarate/emtricitabine [TDF/FTC]) can be used with once-weekly isoniazid plus rifapentine (AIII).
- If rifampin or rifabutin is used to treat LTBI, clinicians should review Tables 21a through 21e to assess the potential for interactions among different antiretroviral (ARV) drugs and the rifamycins (BIII).
- All patients with both HIV and active TB who are not on ART should be started on ART as described below:
- In patients with CD4 counts <50 cells/mm3: Initiate ART as soon as possible, but within 2 weeks of starting TB treatment (AI).
- In patients with CD4 counts ≥50 cells/mm3: Initiate ART within 8 weeks of starting TB treatment (AIII).
- In all pregnant women with HIV: Initiate ART as early as feasible, for treatment of maternal HIV infection and to prevent mother-to-child transmission (MTCT) of HIV (AIII).
- In patients with tuberculous meningitis: Caution should be exercised when initiating ART early, as high rates of adverse events and deaths have been reported in a randomized trial (AI).
- Rifamycins are critical components of TB treatment regimens and should be included for patients with both HIV and active TB, unless precluded because of TB resistance or toxicity. However, rifamycins 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 (BIII).