HIV-tuberculosis coinfection

Management

Latent Tuberculosis Infection

• When using isoniazid monotherapy, can use any HIV medication
• When using rifampin or rifapentine, need to check for drug-drug interactions

Active Tuberculosis

• Rifampin is a core antimicrobial for tuberculosis and should be given priority in drug-drug interactions
• NRTIs do not require any adjustment, INSTIs and NRTIs often need dose adjustment, and PIs are usually contraindicated
• Regimens that minimize drug-drug interactions:
  • Efavirenz 600 mg PO daily or raltegravir 400 mg PO bid, combined with abacavir/lamivudine or tenofovir disoproxil fumarate/emtricitabine
  • tenofovir disoproxil fumarate/emtricitabine + efavirenz
  • tenofovir disoproxil fumarate/emtricitabine + double raltegravir
  • Abacavir/lamivudine with BID dolutegravir
  • Tenofovir alafenamide may or may not be affected by rifampin
• Timing
  • Start TB treatment immediately
  • If not already on HIV treatment:
    • CD4 count <50 cells/mm³: start HIV treatment as soon as possible, and within 2 weeks of TB treatment
    • CD4 count ≥50 cells/mm³: start HIV treatment within 8 weeks of TB treatment
    • Pregnancy, regardless of CD4: start as soon as feasible, to prevent transmission
  • With tuberculous meningitis, generally defer to 8 weeks, or monitor closely when starting early