Treatment of Persons Living with HIV

People living with HIV who also have either latent TB infection or TB disease can be effectively treated. The first step is to ensure that people living with HIV are tested for TB infection. If found to have TB infection, further tests are needed to rule out TB disease. The next step is to start treatment for latent TB infection or TB disease based on test results.

Fortunately, there are a number of treatment options for people living with HIV who also have latent TB infection or TB disease. Consult with your state or local health department for treatment options.

Latent TB Infection and HIV

Someone with untreated latent TB infection and HIV infection is much more likely to develop TB disease during his or her lifetime than someone without HIV infection.

The recommended treatment of latent TB infection in adults infected with HIV is a daily dose of isoniazid (INH) for 9 months.

TB Disease and HIV

The recommended treatment of TB disease in adults infected with HIV (when the disease is caused by organisms that are known or presumed to be susceptible to first-line drugs) is a 6-month daily regimen consisting of:

• An intensive phase of isoniazid (INH), a rifamycin (see Drug Interactions below), pyrazinamide (PZA), and ethambutol (EMB) for the first 2 months.
• A continuation phase of INH and a rifamycin for the last 4 months.

Six months should be considered the minimum duration of treatment for adults with HIV, even for patients with culture-negative TB. In the uncommon situation in which HIV-infected patients do NOT receive antiretroviral therapy during tuberculosis treatment, prolonging treatment to 9 months (extend continuation phase to 7 months) is recommended. Prolonging treatment to 9 months (extend continuation phase to 7 months) for HIV-infected patients with delayed response to therapy (e.g., culture positive after 2 months of treatment) should be strongly considered.

Drug-Resistant TB and HIV

Treatment of drug-resistant TB in persons with HIV infection is the same as for patients without HIV; however, management of HIV-related TB requires expertise in the management of both HIV and TB.

Anti-retroviral Therapy During Tuberculosis Treatment

Anti -retroviral therapy should be initiated during tuberculosis treatment, rather than at the end, to improve outcomes among tuberculosis patients co-infected with HIV. Anti-retroviral therapy should ideally be initiated within the first 2 weeks of tuberculosis treatment for patients with CD4 cell counts <50/mm3 and by 8-12 weeks of tuberculosis treatment initiation for patients with CD4 cell counts ≥50/mm3.  An important exception is HIV-infected patients with tuberculosis meningitis, in whom antiretroviral therapy should not be initiated in the first 8 weeks of antituberculosis therapy.

Drug Interactions

One concern is the interaction of rifampin (RIF) with certain antiretroviral agents (some protease inhibitors [PIs] and nonnucleoside reverse transcriptase inhibitors [NRTIs]). Rifabutin, which has fewer problematic drug interactions, may be used as an alternative to RIF for HIV-infected patients.

As new antiretroviral agents and more pharmacokinetic data become available, these recommendations on managing interactions are likely to be modified. Visit Managing Drug Interactions in the Treatment of HIV-Related Tuberculosis for the most recent recommendations.

Case Management

Directly observed therapy (DOT) and other adherence promoting strategies should be used in all patients with HIV-related TB.  The care for HIV-related TB should be provided by, or in consultation with, experts in management of both TB and HIV. The care for persons with HIV-related TB should include close attention to adherence to both regimens of TB and antiretroviral treatment, drug-drug interactions, paradoxical reaction or Immune Reconstitution Inflammatory Syndrome (IRIS), side effects for all drugs used, and the possibility of TB treatment failure or relapse.