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Treatment of LTBI and TB for Persons with HIV

People with HIV who also have either latent TB infection or TB disease can be treated effectively. The first step is to ensure that people with HIV are tested for TB infection. If found to have TB infection, further tests are needed to rule out TB disease. The next step is to start treatment for latent TB infection or TB disease based on test results.

Fortunately, there are several treatment options for people living with HIV who also have latent TB infection or TB disease. Consult with your health care provider or state or local health department for treatment options.

Latent TB Infection and HIV

Someone with untreated latent TB infection and HIV infection is much more likely to develop TB disease during his or her lifetime than someone without HIV infection. There are several effective latent TB treatment regimens available for people with HIV. Health care providers should prescribe the more convenient shorter regimens, when possible, as patients are more likely to complete shorter treatment regimens.

  • Twelve weeks of once-weekly isonaizid and rifapentine (3HP), given by self-administered therapy or directly observed therapy, is the newest CDC-recommended treatment regimen for persons with latent TB infection and HIV and who are taking antiretroviral medications with acceptable drug-drug interactions with rifapentine.
  • Four months of daily rifampin is another treatment option. This regimen should not be used in people with HIV who are taking some combinations of antiretroviral therapy. In situations where rifampin cannot be used, sometimes another drug, rifabutin, may be substituted.
  • For those taking antiretroviral medications with clinically significant drug interactions with once-weekly rifapentine or daily rifampin, nine months of daily isoniazid is an alternative treatment.

Refer to Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV for more information on the drug interactions.

TB Disease and HIV

The recommended treatment of TB disease in adults infected with HIV is a 6-month daily regimen consisting of:

  • An intensive phase of isoniazid (INH), a rifamycin (see Drug Interactions below), pyrazinamide (PZA), and ethambutol (EMB) for the first 2 months.
  • continuation phase of INH and a rifamycin for the last 4 months.

Once-weekly INH and rifapentine in the continuation phase should not be used in any patient infected with HIV.

Six months should be considered the minimum duration of treatment for adults with HIV, even for patients with culture-negative TB. In the uncommon situation in which HIV-infected patients do NOT receive antiretroviral therapy during TB treatment, prolonging treatment to 9 months (extend continuation phase to 7 months) is recommended. Prolonging treatment to 9 months (extend continuation phase to 7 months) for HIV-infected patients with delayed response to therapy (e.g., culture positive after 2 months of treatment) should be considered.

Drug-Resistant TB and HIV

Treatment of drug-resistant TB in persons with HIV infection is the same as for patients without HIV; however, management of HIV-related TB requires expertise in the management of both HIV and TB.

Antiretroviral Therapy During TB Treatment

For persons with HIV who are not already on ART, treatment for HIV should be initiated during treatment for TB disease, rather than at the end, to improve outcomes among TB patients co-infected with HIV. Anti-retroviral therapy should ideally be initiated within the first 2 weeks of TB treatment for patients with CD4 cell counts <50/mm3 and by 8-12 weeks of TB treatment initiation for patients with CD4 cell counts ≥50/mm3.  An important exception is HIV-infected patients with TB meningitis, in whom antiretroviral therapy should not be initiated in the first 8 weeks of anti-tuberculosis therapy.

Drug Interactions

Rifamycins (a category of drugs for TB disease and latent TB infection treatment) can interact with certain medicines (antiretrovirals) used to treat HIV. One concern is the interaction of rifampin (RIF) with certain antiretroviral agents (some protease inhibitors [PIs] and nonnucleoside reverse transcriptase inhibitors [NRTIs]). Rifabutin, which has fewer problematic drug interactions, may be used as an alternative to RIF for HIV-infected patients.

As new antiretroviral agents and more pharmacokinetic data become available, these recommendations on managing interactions are likely to be modified. Visit Managing Drug Interactions in the Treatment of HIV-Related Tuberculosis and Guidelines for the use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents for the most recent recommendations.

Case Management

Directly observed therapy (DOT) and other adherence promoting strategies should be used in all patients with HIV-related TB.  The care for HIV-related TB should be provided by, or in consultation with, experts in management of both TB and HIV. The care for persons with HIV-related TB should include close attention to adherence to both regimens of TB and antiretroviral treatment, drug-drug interactions, paradoxical reaction or Immune Reconstitution Inflammatory Syndrome (IRIS), side effects for all drugs used, and the possibility of TB treatment failure or relapse.

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