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Review
. 2010 Jan;5(1):61-9.
doi: 10.1097/COH.0b013e3283339309.

Management of individuals requiring antiretroviral therapy and TB treatment

Karen Cohen  1 , Graeme Meintjes
Affiliations
Review

Management of individuals requiring antiretroviral therapy and TB treatment

Karen Cohen et al. Curr Opin HIV AIDS. 2010 Jan.

Abstract

Purpose of review: Globally, tuberculosis (TB) is the commonest opportunistic infection in people living with HIV. Many co-infected patients first present with advanced immunosuppression and require antiretroviral therapy (ART) initiation during TB treatment. The incidence of TB in patients established on ART remains high. Co-treatment presents several management challenges. Recent data on these management issues are reviewed.

Recent findings: Efavirenz concentrations at standard doses are similar with and without concomitant rifampicin-based TB treatment. Nevirapine concentrations are frequently subtherapeutic during lead-in dosing at 200 mg daily in patients on rifampicin-based TB treatment, which may result in inferior virological outcomes. Hepatotoxicity occurred in three pharmacokinetic studies (conducted in healthy volunteers) of boosted protease inhibitors initiated in participants on rifampicin. Results of a clinical trial comparing efavirenz-based and nevirapine-based ART in patients on TB treatment, with no lead-in dosing of nevirapine, are awaited. Concurrent TB treatment increases the need for stavudine substitutions, mainly related to neuropathy. Consensus case definitions for TB immune reconstitution inflammatory syndrome (TB-IRIS) have been published. It is important to exclude TB drug resistance in patients with suspected TB-IRIS. A clinical trial demonstrated benefit of prednisone for treating TB-IRIS, reducing a combined endpoint of days of hospitalization and outpatient therapeutic procedures. Starting ART during TB treatment improved survival in patients with CD4 cell count less than 500 cells/mul, but the optimal interval between starting TB treatment and starting ART remains to be determined in several ongoing trials.

Summary: ART improves survival in co-infected TB patients, but is complicated by several management challenges that compromise programmatic implementation in resource-limited settings. Recent findings and the findings of ongoing studies will assist clinicians in dealing with these challenges.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig 1
Fig 1. Potential risks associated with early versus delayed ART in patients with HIV-associated TB
Fig 2
Fig 2. Illustrative case of paradoxical TB-IRIS
A 49 year-old man was diagnosed with pulmonary TB (sputum cultured Mycobacterium tuberculosis susceptible to rifampicin and isoniazid). Chest radiograph at TB diagnosis (a) showed a right upper lobe infiltrate. His symptoms improved on TB treatment. His CD4 count was 29 cells/μL and HIV viral load 191 000 copies/mL. He was started on antiretroviral therapy 2 weeks after TB treatment and 2 weeks later developed recurrent cough, night sweats and dyspnoea. Chest radiograph (b) showed worsening of the right upper lobe infiltrate and a new right pleural effusion. His CD4 had risen to 51 cells/μL. Repeat TB cultures from sputum and pleural aspirate were negative. His effusion was therapeutically aspirated and he was treated with prednisone for paradoxical TB-IRIS to which he symptomatically responded. His viral load performed 6 months after ART initiation was < 50 copies/mL.
Fig 2
Fig 2. Illustrative case of paradoxical TB-IRIS
A 49 year-old man was diagnosed with pulmonary TB (sputum cultured Mycobacterium tuberculosis susceptible to rifampicin and isoniazid). Chest radiograph at TB diagnosis (a) showed a right upper lobe infiltrate. His symptoms improved on TB treatment. His CD4 count was 29 cells/μL and HIV viral load 191 000 copies/mL. He was started on antiretroviral therapy 2 weeks after TB treatment and 2 weeks later developed recurrent cough, night sweats and dyspnoea. Chest radiograph (b) showed worsening of the right upper lobe infiltrate and a new right pleural effusion. His CD4 had risen to 51 cells/μL. Repeat TB cultures from sputum and pleural aspirate were negative. His effusion was therapeutically aspirated and he was treated with prednisone for paradoxical TB-IRIS to which he symptomatically responded. His viral load performed 6 months after ART initiation was < 50 copies/mL.
See this image and copyright information in PMC

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