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HIV1/tuberculosis coinfection

also see HIV1, AIDS, & tuberculosis Complications: - combined antiretroviral & antituberculous therapy - immune reconstitution inflammatory syndrome (IRIS) Management: 1) 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] 2) early guidelines a) CD4 count <50 cells/mm3 - start antiretroviral therapy (HART) within 2 weeks after initiation treatment for tuberculosis [1] b) CD4 count >50 cells/mm3 - defer antiretroviral therapy (HART) until the beginning of the continuation phase of treatment for tuberculosis (3 months) 3) recommendations 2014 a) 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] b) 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 c) rifampin should not be coadministered with the 2nd-generation nonnucleoside reverse transcriptase inhibitors (NNRTIs) rilpivirine or etravirine d) high-dose lopinavir/ritonavir regimens should be used together with rifampin-based treatment only if hepatotoxicity is closely monitored e) 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 f) 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 g) increasing maraviroc to 600 mg BID is recommended for adults taking rifampin h) a 150-mg daily dose of rifabutin, monitoring toxicity, can be coadministered with boosted antiretroviral protease inhibitors i) rifabutin can be used in patients on nevirapine-based ART & in those taking standard-dose raltegravir (400 mg BID) j) nevirapine-based HIV treatment can be used in pregnant women receiving rifampin-based TB treatment - more-frequent HIV RNA monitoring is recommended during pregnancy k) 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] 4) 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] 5) patients with latent tuberculosis should receive treatment prior to administration of TNF-alpha inhibitor [3] 6) also see HIV1, AIDS, & tuberculosis

Related

human immunodeficiency virus-1 (HIV-1)

General

coinfection; superinfection tuberculosis complications in patients with HIV1 infection

References

  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: 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: 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: 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: 22010921
  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. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2021.
  4. 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: 30428290 https://www.nejm.org/doi/10.1056/NEJMoa1800762