Tuberculosis

Prevention of Exposure
(1) HIV-infected persons should be advised that certain activities and occupations may increase the likelihood of exposure to tuberculosis (BIII). These include volunteer work or employment in health-care facilities, correctional institutions, and shelters for the homeless, as well as in other settings identified as high risk by local health authorities. Decisions about whether to continue with activities in these settings should be made in conjunction with the health-care provider and should be based on factors such as the patient's specific duties in the workplace, the prevalence of tuberculosis in the community, and the degree to which precautions are taken to prevent the transmission of tuberculosis in the workplace (BIII). Whether the patient continues with such activities may affect the frequency with which screening for tuberculosis needs to be conducted.

Prevention of Disease
(2) When HIV infection is first recognized, the patient should receive a tuberculin skin test (TST) by administration of intermediate-strength (5-TU) purified protein derivative (PPD) by the Mantoux method (AI). Routine evaluation for anergy is not recommended. However, there are selected situations in which anergy evaluation may assist in guiding individual decisions about preventive therapy (37).

(3) All HIV-infected persons who have a positive TST result (>5 mm of induration) should undergo chest radiography and clinical evaluation for the exclusion of active tuberculosis. HIV-infected persons who have symptoms suggestive of tuberculosis should promptly undergo chest radiography and clinical evaluation regardless of their TST status (AII).

(4) All HIV-infected persons regardless of age who have a positive TST result yet have no evidence of active tuberculosis and no history of treatment or prophylaxis for tuberculosis should be administered 9 months of preventive chemotherapy with isoniazid (INH) daily (AII) or twice weekly (BI) or two months of therapy with rifampin and pyrazinamide (AI) or rifabutin and pyrazinamide (BIII) (37). Because HIV-infected persons are at risk for peripheral neuropathy, those receiving INH should also receive pyridoxine (BIII). A decision to use a regimen containing either rifampin or rifabutin should be made after careful consideration of potential drug interactions, especially those related to protease inhibitors and non-nucleoside reverse transcriptase inhibitors (see Drug Interaction Note). Directly observed therapy should be used with the intermittent dosing regimens (AI) and when otherwise operationally feasible (BIII) (37).

(5) HIV-infected persons who are close contacts of persons who have infectious tuberculosis should be administered preventive therapy-regardless of TST results, age, or prior courses of chemoprophylaxis-after the diagnosis of active tuberculosis has been excluded (AII) (37). In addition to household contacts, such persons might also include contacts in the same drug treatment or health care facility, coworkers, and other contacts if transmission of TB is demonstrated.

(6) For persons exposed to INH- and/or rifampin-resistant TB, the decision to use chemoprophylactic anti-mycobacterial agents other than INH alone, rifampin plus PZA, or rifabutin plus PZA, should be based on the relative risk of exposure to resistant organisms and should be made in consultation with public health authorities (AII).

(7) TST-negative, HIV-infected persons from risk groups or geographic areas with a high prevalence of M. tuberculosis infection may be at increased risk of primary or reactivation tuberculosis. The efficacy of preventive therapy in this group has not been demonstrated. Decisions concerning the use of chemoprophylaxis in these situations must be considered individually.

(8) Although the reliability of the TST may diminish as the CD4+ T-lymphocyte count declines, annual repeat testing should be considered for HIV-infected persons who are TST-negative on initial evaluation and who belong to populations in which there is a substantial risk of exposure to M. tuberculosis (BIII). Repeat TST for those whose immune function has improved because of HAART (i.e. those whose CD4+ T-lymphocyte count has increased to > 200 cells/uL) may also be considered (CIII). In addition to documenting tuberculous infection, TST conversion in an HIV-infected person should alert health-care providers to the possibility of recent M. tuberculosis transmission and should prompt notification of public health officials for investigation to identify a possible source case.

(9) The administration of BCG vaccine to HIV-infected persons is contraindicated because of its potential to cause disseminated disease (EII).

Prevention of Recurrence
(10) Chronic suppressive therapy for a patient who has successfully completed a recommended regimen of treatment for tuberculosis is not necessary (DII).

Notes

Drug Interaction Note
(11) Rifampin should not be administered with protease inhibitors or non-nucleoside reverse transcriptase inhibitors (EI) (37). Rifabutin is an acceptable alternative but should not be used with the protease inhibitors ritonavir or hard-gel saquinavir; caution is also advised if the drug is co-administered with soft-gel saquinavir, but data are lacking. Rifabutin may be administered at one half the usual daily dose (i.e., reduce from 300 mg to 150 mg qd) with indinavir, nelfinavir, or amprenavir. Similarly, rifabutin should not be used with the non-nucleoside reverse transcriptase inhibitor delavirdine but may be administered at an increased dose (450 mg qd) with efavirenz. Information is lacking regarding co-administration of rifabutin with nevirapine.

Pediatric Note
(12) Infants born to HIV-infected mothers should have a TST (5-TU PPD) at or before age 9-12 months and should be retested at least every 2-3 years (CIII). HIV-infected children living in households with TST-positive persons should be evaluated for tuberculosis (AIII); children exposed to a person who has active tuberculosis should be administered preventive therapy after active tuberculosis has been excluded regardless of TST results (AII).

Note Regarding Pregnancy
(13) Chemoprophylaxis for tuberculosis is recommended during pregnancy for HIV-infected patients who have either a positive TST or a history of exposure to active tuberculosis, after active tuberculosis has been excluded (AIII). A chest radiograph should be obtained before treatment and appropriate abdominal/pelvic lead apron shields should be used to minimize radiation exposure to the embryo/fetus. In the absence of exposure to drug-resistant TB, INH daily or twice weekly is the prophylactic agent of choice. Because of concerns regarding possible teratogenicity associated with drug exposures during the first trimester, providers may choose to initiate prophylaxis after the first trimester. Preventive therapy with INH should be accompanied by pyridoxine to reduce the risk of neurotoxicity. Experience with rifampin or rifabutin during pregnancy is more limited, but anecdotal experience with rifampin has not been associated with adverse pregnancy outcomes. Pyrazinamide should generally be avoided, particularly in the first trimester because of lack of information concerning fetal effects.

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