TUBERCULOSIS AND HIV CO-INFECTION

Active TB may be present when ART needs to be initiated or it may develop during treatment.

TB and HIV care for co-infected patients should be provided in an integrated manner under one roof by one care team (one-stop-shop).

Co-management of TB and HIV is complicated by:

  • Drug interactions between rifampicin and both the NNRTI and PI classes
  • Immune reconstitution inflammatory syndrome (IRIS)
  • Pill burden, overlapping toxicities and adherence issues.

Management

ART should be initiated in all TB/HIV co-infected people irrespective of their clinical stage or CD4 count. However, the timing of initiation of treatment may differ based on whether the patient is diagnosed with TB before or after
initiating ART.

SITUATION RECOMMENDATIONS
TB patients diagnosed
with HIV
Start anti-TB medicines
immediately, THEN start
ARVs 2 weeks later (see table
below)
Patient already on ART,
diagnosed with TB
Start anti-TB medicines
immediately, adjust regimen as
per guidelines below
ADULT TB patients
diagnosed with TB but
with CD4 <50
Start anti-TB medicines
immediately, start ARVs before
completing 2 weeks

ARV regimen in ART-naive patients on TB treatment

AGE GROUP RECOMMENDED REGIMEN
Adults, Pregnant and
Breastfeeding Women, and
Adolescents
TDF+3TC+EFV
Children aged 3 – < 12 years ABC+3TC+EFV
Children 0 – < 3 years ABC+3TC+AZT

ARV regimen substitution for patients initiating TB treatment while on ART

AGE GROUP REGIMEN WHEN
DIAGNOSED
WITH TB
RECOMMENDED
ACTION/ SUBSTITUTION
Adults,
Pregnant and
Breastfeeding
Women and
Adolescents
If on EFVbased
regimen
Continue with the
same regimen
If on DTG
based regimen
Continue the same
regimen but double the
dose of DTG (give DTG
twice daily)
If on NVP
based regimen
Substitute NVP
with EFV. If EFV is
contraindicated, give
DTG as above. If DTG
not available, give a
triple NRTI regimen
(ABC+3TC+AZT).
If on LPV/r
based regimen
Continue the same
regimen and give
Rifabutin for TB
treatment
If on ATV/r
based regimen
Children aged
3 – <12 years
If on EFVbased
regimen
Continue the same
regimen
If on NVP or
based regimen
Substitute NVP with
EFV.If EFV is
contraindicated, give
a triple NRTI regimen
(ABC+3TC+AZT)
LPV/r Continue the same
regimen and give
Rifabutin for TB
treatment
Children 0 –
<3 years
If on LPV/r
or NVP based
regimen
Give triple
NRTI regimen
ABC+3TC+AZT

Second line ART for patients with TB

  • There are significant drug interactions with PIs and rifampicin.
  • If rifabutin is available, it may be used in place of rifampicin with ATV/r or LPV/r, but it is contraindicated in patients with WBC counts below 1000/mm3.
  • Maintaining PI in second line regimens while switching from Rifampicin to Rifabutin (if available) is ideal

TB prevention

  • BCG immunisation: it protects children against severe forms of TB. It can be given at birth. If delayed, avoid in symptomatic HIV
  • IPT (Isoniazid Preventive Treatment).