Management of HIV-Positive Patient on TLD with Recent Negative TB Screening
Continue the current TLD regimen and ensure annual TB screening is maintained, as this patient has appropriately completed recent TB evaluation with negative results and remains asymptomatic. 1
Current Status Assessment
This patient's management is appropriate based on the following:
- Recent TB screening completed: All TB tests performed 2 months ago were negative, and the patient remains asymptomatic, indicating no active TB disease 1, 2
- Stable HIV management: The patient is on TLD (Tenofovir/Lamivudine/Dolutegravir), which is a highly effective first-line regimen with excellent virologic suppression rates 3, 4
- Appropriate opportunistic infection screening: Testing for N. Gonorrheae, C. Trachomatis, and Toxoplasma was completed and negative 1
Ongoing TB Surveillance Requirements
Annual TB screening is mandatory for HIV-positive patients, even with previous negative results:
- Repeat tuberculin skin testing (TST) at least yearly for HIV-infected persons who remain TST-negative and have ongoing risk of TB exposure 1
- Consider more frequent testing (every 6-12 months) if the patient lives in high-prevalence areas, works in healthcare settings, correctional facilities, or homeless shelters 1
- TST interpretation in HIV patients: Induration ≥5 mm is considered positive 1, 5
Critical Monitoring Points for This Patient
Watch for immune reconstitution effects on TB testing:
- If this patient was severely immunocompromised at HIV diagnosis and has now achieved immune reconstitution on TLD, repeat TST when CD4 count exceeds 200 cells/µL 1, 2
- Previously negative TST results may convert to positive after immune recovery, unmasking latent TB infection 1
Maintain high clinical suspicion for TB symptoms:
- Evaluate immediately if the patient develops cough lasting >3 weeks, hemoptysis, fever, night sweats, or unexplained weight loss 1, 6
- Do not wait for scheduled screening if symptoms develop—perform chest radiography and sputum examination promptly 1, 2
TLD Regimen Considerations
Continue current TLD without modification:
- TLD demonstrates excellent virologic efficacy with 85-95% suppression rates in clinical studies 3, 7, 8
- No drug interactions between TLD and TB preventive therapy if future treatment becomes necessary, though dolutegravir dosing may require adjustment to twice daily (50 mg) if rifamycin-based TB treatment is initiated 9
- TLD is well-tolerated with lower discontinuation rates compared to efavirenz-based regimens 4
Common Pitfalls to Avoid
Do not assume permanent TB-negative status:
- HIV-infected persons remain at lifelong increased risk for TB acquisition and reactivation 1
- Annual screening is not optional—it is a core component of HIV primary care 1
Do not rely solely on symptom screening:
- TB in HIV-infected patients can present atypically with minimal symptoms, normal chest radiographs, or extrapulmonary manifestations 1
- Systematic TST or interferon-gamma release assay (IGRA) testing is required regardless of symptom status 1, 2
Do not delay evaluation if TB exposure occurs:
- If exposed to active TB case, initiate preventive therapy immediately after excluding active disease, regardless of TST results or previous negative tests 1
- Close contacts of infectious TB patients should receive treatment for latent TB infection even with negative testing 1, 2
Next Steps for This Patient
Schedule routine follow-up:
- Repeat TST or IGRA in 10-12 months from last test 1
- Continue monitoring HIV viral load and CD4 count per standard HIV care guidelines 1
- Assess adherence to TLD and screen for medication side effects 1
Document in medical record: