Index - 6 - 7 - 8/9 - 10/11/12 - 13 - 14 - 15 - 16 - 17 - 18/19 - 20/21 - 22/23
HAART IN TB/HIV CO-INFECTION
CD4 count, cells/μl When to start HAART
<100 As soon as practical
100–350 As soon as practical, but can wait until after completing 2 months TB treatment especially when there are difficulties with drug interactions, adherence and toxicities
>350 At physician discretion
 
CONCOMITANT USE OF ANTI-TB MEDICATIONS AND ANTIRETROVIRALS
  • NRTIs: no significant interaction with rifampicin nor rifabutin
  • NNRTIs:
    • EFV and rifampicin: EFV 800mg qd if weight >60kg, 600 mg qd if <60kg;
      rifampicin at standard dose. Some physicians prefer not to dose adapt efavirenz as data are controversial. In any case TDM is recommended after 2 weeks.
    • EFV and rifabutin: EFV at standard dose; rifabutin 450mg daily
    • NVP: not recommended
    • Etravirine: not recommended
  • PIs
    • and rifampicin: not recommended
    • and rifabutin: rifabutin 150 mg x 3 per week with ATV/r, DRV/r, LPV/r or SQV/r; PI/r at standard dose; monitor liver enzyme tests and, whenever possible, perform TDM for PI
  • Raltegravir
    • and rifampicin: use with caution (only if no alternative), if used: raltegravir 800 mg bid
    • and rifabutin: no data
  • Maraviroc
    • and rifampicin: use with caution at double dose 600mg bd maraviroc
    • and rifabutin: standard doses
  • Enfuvirtide: no significant interaction with rifampicin nor rifabutin

Where combinations are not recommen­ded, specialist HIV treatment advice should be sought. TDM of NNRTI and PI should be performed when drug regimens contain one of these drugs. Drug levels of anti-tuberculosis drugs should be measured when there is clinical concern regarding absorption or response to TB therapy.
 
RECOMMENDED 1ST LINE ARV COMBINATION IN PATIENTS RECEIVING ANTI-TB MEDICATION

Among recommended regimens for antiretroviral-naïve patients, preference should be given to EFV/TDF/FTC with dose adaptation of EFV if needed (cf above).

Alternative =

  • recommended PI/r + TDF/FTC, using rifabutin instead of rifampicin;
  • Use with caution
    1. raltegravir 800 mg bid + TDF/FTC with rifampicin
    2. if plasma viral load < 100,000 c/ml, fixed-dose combination of ZDV/ABC/ 3TC bid +/- tenofovir, could also represent a short term alternative until TB treatment has been completed.

If it is not possible to use these drugs because of resistance/intolerance seek expert help.