12. Key messages, additional reading and references

IDevice Icon

1. HIV positive TB patients should start antiretroviral treatment regardless of the CD4 count,as soon as possible and no later than 8 weeks after the start of anti-tuberculosis treatment..

2. An EFV-containing regimen is the preferred treatment option, associated with two NRTIs.

3. Incident active TB while on ART does not always mean antiretroviral treatment failure.

4. Limited treatment options are available for patients requiring second-line ART in combination with a rifampicin-based TB-regimen.

5. IPT has proven its efficacy in reducing TB incidence. However, several issues including exclusion of active TB, INH-resistance, adverse effects, adherence to and distribution of IPT in resource-limited settings may prevent broad-scale implementation of this measure.

6. DR-TB is an increasing problem in the world and use of Xpert MTB/RIF is recommended for initial diagnosis of TB and rifampicin resistance in HIV positive patients. 

7. Early initiation of DR-TB treatments, particularly those with HIV co-infection is highly recommended. Treatment outcomes are still poor, and newer treatment regimens are intensively under investigation.


We hope you enjoyed this module!
Do not forget to complete the assignment!

Not tired yet? OK, this is a bonus activity.

Not only TB causes problems.

Patients in an advanced HIV stage may have other opportunistic infections when they start ART. This complicates the clinical management because of drug interactions, because the possibility of immune reconstitution inflammatory syndrome (IRIS) and because of cumulative toxicity of OI drugs and ART. We would like to share with you an interesting but complex case that we received from Dr Rabin Shrestha from Dharan, Nepal.

References

 

WHO. Global Tuberculosis Report, 2013.
WHO. Improving the diagnosis and treatment of smear-negative pulmonary and extra pulmonary tuberculosis among adults and adolescents, 2007
WHO. Consolidated guidelines on the use of ARV drugs for treating and preventing HIV infection, 2013.
WHO. Three I’s Meeting Report, 2008.
WHO. Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource-constrained settings, 2011.
WHO. Guidelines for the programmatic management of drug-resistant tuberculosis. Emergency update, 2008.
WHO. Guidelines for the programmatic management of drug-resistant tuberculosis – 2011 update.

 

Additional readings

Helen McIlleron et al. Double-dose Lopinavir/Ritonavir Provides Insufficient Lopinavir Exposure in Children Receiving Rifampicin-based Anti-TB Treatment. Presented at CROI 2009. Available at http://retroconference.org/2009/Abstracts/34615.htm

WHO. Global Tuberculosis Control. 2013.

Aït-Khaled N et al. Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues. Int J Tuberc Lung Dis. 2009 Aug;13(8):927-35

Boule A et al. Outcomes of Nevirapine and Efavirenz Based Antiretroviral Therapy When Coadministered With Rifampicin-Based Antitubercular Therapy. JAMA 2008 Aug, 300 (5): 530-539

C. J. L. la Porte et al. Pharmacokinetics of Adjusted-Dose Lopinavir-Ritonavir Combined with Rifampin in Healthy Volunteers. Antimicrobial Agents and Chemotherapy. 2004; 48: p. 1553-1560.

Graeme Meintjes, et al. Randomized Placebo-controlled Trial of Prednisone for the TB Immune Reconstitution Inflammatory Syndrome. Abstract 34. Presented at CROI 2009, Montreal. Available at http://retroconference.org/2009/Abstracts/34429.htm

WHO. Rapid implementation of the Xpert MTB/RIF diagnostic test. May 2011.

Török et al. Timing of initiation of antiretroviral therapy in human immunodeficiency virus-associated tuberculous meningitis. Clin Infect Dis 2011; 52:1374-1383

Getahun et al. Development of a standardized screening rule for tuberculosis in people living with HIV in resource-constrained settings: individual participant data meta-analysis of observational studies. PLoS Med 2011; 8 (1): e1000391