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1.0 Introduction

BHIVA treatment guidelines for TB/HIV infection

Worldwide, HIV infection is the foremost risk factor for development of active tuberculosis (TB). [1–4]

All patients with tuberculosis, regardless of their perceived risk of HIV infection should be offered an HIV test as part of their tuberculosis treatment package. In the United Kingdom, clinicians are caring for increasing numbers of HIV-TB co-infected patients. TB is now the second commonest opportunistic infection in the UK. In 2003 TB contributed to 27% of all AIDS diagnoses. [5–7]

The clinical and radiographic presentation of such individual’s disease may be atypical. Compared to the immune competent general population, HIV infected patients with active pulmonary tuberculosis are more likely to have normal chest radiographs, or be smear negative/culture positive. [8–11]

The clinician caring for HIV infected patients, therefore, needs to have a high index of suspicion for tuberculosis in symptomatic individuals.  As the investigation and treatment of both tuberculosis and HIV require specialist knowledge and expertise, it is mandatory to involve specialist HIV, Respiratory and Infectious Diseases physicians in patient care.

These guidelines have been drawn up in response to a perceived need for a clinical knowledge base covering the treatment of both HIV and tuberculosis in co-infected patients in the United Kingdom. These guidelines do not cover HIV infected children with tuberculosis, nor do they provide advice on HIV testing in adults with newly diagnosed tuberculosis. These treatment guidelines have been written to help physicians manage HIV infected patients with confirmed or suspected tuberculosis. They are based on evidence where it is available but some recommendations have to rely on expert opinion until data from trials are made available. These guidelines are not a manual for treatment of HIV/TB co infection and should be regarded as an adjunct to the BHIVA treatment of HIV guidelines and the BTS guidelines on tuberculosis.

These documents can be downloaded from:

BHIVA is aware of and involved in the creation of NICE guidelines on tuberculosis, which will be available in 2005 but felt that until that time some guidance on TB in HIV should be made widely available.

Recommendations for the treatment of tuberculosis in HIV infected adults are similar to those for HIV uninfected adults. However there are important exceptions.

  1. Some intermittent treatment regimens are contra-indicated in HIV infected patients because of unacceptably high rates of relapse, frequently with organisms that have acquired rifamycin resistance. Consequently, patients with CD4 counts <100/µL should receive daily or a minimum of three times weekly anti-tuberculosis treatment
  2. Adherence strategies including directly observed therapy (DOT) are especially important for patients with HIV related tuberculosis.
  3. HIV infected patients are often taking medication, which might interact with antituberculosis medications for example rifampicin, which interacts with antiretroviral agents and other anti-infectives, for example fluconazole. Drug absorption may also be affected by the stage of HIV infection.
  4. There are overlapping toxicity profiles and drug/drug interactions with some anti-tuberculosis and anti-retroviral drugs that further complicate the concurrent use of HAART and tuberculosis treatment.

There are also concerns about the timing of commencement of HAART in relation to the start of TB treatment in the context of preventing the risk of further HIV progression and the occurrence of paradoxical reactions.