Concomitant treatment of tuberculosis and HIV co-infection — MSF Tuberculosis

What this guideline says

GMJ summary

This MSF guideline addresses the management of tuberculosis and HIV co-infection, focusing on the optimal timing and selection of antiretroviral therapy (ART) in relation to tuberculosis treatment. For active tuberculosis, TB treatment should be started first, followed by ART initiation within 2 weeks for most patients. The critical exception is TB meningitis, where ART should be delayed until 4 to 8 weeks after starting TB treatment due to increased risk of serious adverse events with early ART initiation.

The guideline provides detailed first-line ART regimens tailored to different patient populations. For neonates, the first-choice regimen is AZT + 3TC + raltegravir, with an alternative of AZT + 3TC + LPV/r. Children should receive ABC + 3TC + dolutegravir as first choice, with alternatives including ABC + 3TC + LPV/r or ABC + 3TC + raltegravir when paediatric dolutegravir is unavailable. For adolescents, adults, and pregnant women, the preferred regimen is TDF + 3TC (or FTC) + dolutegravir, with several alternatives available.

Important drug interactions are highlighted: doses of dolutegravir and raltegravir must be doubled when co-administered with rifampicin. LPV/r should not be used with bedaquiline in children, and LPV/r dosing requires adjustment when given with rifampicin. For patients with latent tuberculosis infection not yet on ART, initiating ART takes priority over starting LTBI treatment.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. For active TB in HIV-infected patients, start TB treatment first, then initiate ART within 2 weeks
2. For TB meningitis with HIV co-infection, delay ART initiation until 4 to 8 weeks after starting TB treatment to reduce risk of serious adverse events
3. First-line ART for neonates with active TB: AZT + 3TC + raltegravir (alternative: AZT + 3TC + LPV/r from 2 weeks of age)
4. First-line ART for children with active TB: ABC + 3TC + dolutegravir (alternatives: ABC + 3TC + LPV/r or ABC + 3TC + raltegravir)
5. First-line ART for adolescents, adults and pregnant women with active TB: TDF + 3TC (or FTC) + dolutegravir
6. Doses of dolutegravir and raltegravir must be doubled in patients taking rifampicin
7. LPV/r should not be used in children taking bedaquiline; LPV/r dose requires adjustment with rifampicin
8. For latent TB infection, initiate ART before starting LTBI treatment

First-line ART for patients with active TB and HIV co-infection

Table extracted from the guideline

Source: Médecins Sans Frontières, Concomitant treatment of tuberculosis and HIV co-infection — MSF Tuberculosis. Reproduced in summary form.

From the guideline

Verbatim

“Antiretroviral therapy (ART) should be initiated within 2 weeks of starting treatment of active TB, except for patients with TB meningitis.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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