From the Guidelines
Military tuberculosis (TB) in HIV-positive individuals requires prompt treatment with a standard four-drug regimen, and it is crucial to start antiretroviral therapy (ART) within 2-8 weeks of TB treatment initiation to improve outcomes. The relationship between military TB and HIV is complex, with HIV infection increasing the risk of TB progression and TB accelerating HIV replication 1. The treatment of TB in HIV-infected patients is essentially the same as for patients without HIV infection, with some important exceptions, such as avoiding once weekly INH-rifapentine in the continuation phase and twice weekly INH-RIF or rifabutin in patients with CD4 lymphocyte counts less than 100/μL 1.
Key considerations in the treatment of military TB in HIV-positive individuals include:
- Prompt initiation of effective antituberculosis treatment to increase the probability of cure and minimize the risk of death 1
- Use of a standard four-drug regimen, consisting of isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA), for 2 months, followed by INH and RIF for an additional 4 months 1
- Extension of treatment to 9-12 months for HIV patients with CD4 counts below 100 cells/mm³ 1
- Careful monitoring for immune reconstitution inflammatory syndrome (IRIS) and drug toxicity, particularly for liver function and vision changes 1
- Consideration of drug interactions between rifampin and certain antiretrovirals, which may require dose adjustments or substitution with rifabutin 1
The dual infection of TB and HIV creates a dangerous synergy, making aggressive treatment of both conditions necessary to improve outcomes 1. Regular monitoring and prompt treatment are essential to prevent the progression of TB and HIV, and to minimize the risk of complications and death.
From the Research
Relationship Between Military Tuberculosis (TB) and Human Immunodeficiency Virus (HIV)
- The relationship between TB and HIV is complex, with HIV increasing the risk of TB infection and disease progression, and TB slowing CD4 recovery and increasing progression to AIDS and death among HIV-infected individuals 2.
- TB is a major cause of morbidity and mortality in HIV-infected patients, and concomitant treatment of both conditions is essential to improve survival 3, 4.
- The principles for treatment of active TB disease in HIV-infected patients are the same as in HIV-uninfected patients, but concomitant treatment is complex due to significant drug-drug interactions between TB and HIV drugs 4.
Treatment of TB in HIV-Infected Patients
- A rifampicin-based antitubercular regimen and an efavirenz-based antiretroviral regimen is the first choice for treatment of TB/HIV co-infected patients 3, 4.
- Rifabutin is the preferred rifamycin to use in HIV-infected patients on a protease inhibitor-based regimen, but the dose of rifabutin needs to be reduced to 150 mg daily 4, 2.
- Daily therapy is required for all coinfected patients, and vitamin B6 supplementation should be given to all coinfected patients receiving isoniazid to reduce peripheral neuropathy 2.
Timing of Antiretroviral Therapy (ART) Initiation
- The timing of ART initiation in patients coinfected with TB is complex, but published evidence demonstrates that TB-HIV integration is essential for improved survival 5.
- Earlier ART initiation is recommended for severely immune-compromised patients, with treatment initiation within 2 weeks preferred for those with CD4 counts of <50 and within 8 to 12 weeks for those with higher CD4 counts 2, 5.
- The survival benefit of earlier ART initiation is accompanied by increased immune reconstitution inflammatory syndrome events 6, 5.