Fact Sheets
Treatment of Drug-Susceptible Tuberculosis Disease
in HIV-Infected Persons
Last Updated: March 2003
Introduction
In February 2003, the American Thoracic Society (ATS), the Centers
for Diseases Control and Prevention (CDC), and the Infectious Diseases
Society of America (IDSA) released new guidelines for the treatment
of TB. This fact sheet will provide key points from these guidelines;
however, please refer to the Treatment of Tuberculosis1
for complete recommendations.
The management of HIV-related tuberculosis (TB) disease is complex. Although
the treatment of TB in persons with HIV is essentially the same
as for patients without HIV, there are some important differences.
Recommended Regimen
The recommended treatment of TB disease in HIV-infected adults
(when the disease is caused by organisms that are known or presumed
to be susceptible to first-line drugs) is a 6-month regimen consisting
of
- An initial phase of isoniazid (INH),
a rifamycin (see Drug Interactions below), pyrazinamide (PZA),
and ethambutol (EMB) for the first 2 months.
- A continuation phase of INH and a rifamycin
for the last 4 months.
Patients with advanced HIV (CD4 counts < 100/ml)
should be treated with daily or three-times-weekly therapy in both
the initial and the continuation phases. Twice weekly therapy may
be considered in patients with less-advanced immunosuppression (CD4
counts > 100/ml). Once-weekly
INH/rifapentine in the continuation phase should not be used in
any HIV-infected patient.
Six months should be considered the minimum duration of treatment
for adults with HIV, even for patients with culture-negative TB. 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 strongly considered.
Drug Interactions
A major concern in treating TB in HIV-infected persons 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.
As new antiretroviral agents and more pharmacokinetic data become
available, these recommendations are likely to be modified.
Case Management
Directly observed therapy (DOT) and other adherence promoting strategies
should be used in all patients with HIV-related TB. Whenever possible,
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 the possibility
of TB treatment failure, antiretroviral treatment failure, paradoxical
reactions of TB (e.g., temporary worsening of signs or symptoms
of TB), side effects for all drugs used, and drug toxicities associated
with increased serum concentrations of rifamycins.
For More Information
- American Thoracic Society/Centers for Disease Control and Prevention/Infectious
Diseases Society of America. Treatment of Tuberculosis. Am
J Respir Crit Care Med 2003; 167: 603-662. http://www.thoracic.org/adobe/statements/treattb.pdf
- Guidance documents for the medical management of HIV
http://www.aidsinfo.nih.gov/guidelines/
- Updated Guidelines for the Use of Rifabutin or Rifampin for
the Treatment and Prevention of Tuberculosis Among HIV-Infected
Patients Taking Protease Inhibitors or Nonnucleoside Reverse Transcriptase
Inhibitors. MMWR 2000;49 (No. 9)
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4909a4.htm
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