Conclusions

Implementing TB prevention and control strategies for persons infected with HIV has always been important and is even more critical now that a larger selection of new, more potent antiretroviral drugs has enabled clinicians to implement therapies that improve the health and prolong the lives of HIV-infected persons. These antiretroviral therapeutic strategies often include the use of drugs such as the protease inhibitors or the nonnucleoside reverse transcriptase inhibitors (NNRTIs), which because of drug interactions cannot be used concurrently with certain other drugs (e.g., rifampin). Thus, to improve the diagnosis and management of TB and HIV coinfection, TB control programs need to be prepared for the following challenges:

• Ensure that all patients with TB receive HIV counseling and testing either on site or elsewhere. Patients with latent M. tuberculosis infection who are at risk for HIV infection also should receive HIV counseling and testing.

• Initiate prompt and effective antituberculosis treatment (ideally with directly observed therapy) for all patients diagnosed with HIV-related TB.

• Promote optimal antiretroviral therapy for patients with M. tuberculosis and HIV infection.

• Become knowledgeable about the indications, potential dosing adjustments, and monitoring requirements of a rifabutin-containing regimen (or an alternative regimen that does not contain rifamycin) for the treatment of TB in patients who are undergoing antiretroviral therapy with protease inhibitors or NNRTIs.

• Identify potential risk factors for TB treatment failure or relapse as well as the potential for paradoxical treatment reactions, and learn how to recognize and manage these outcomes.

• Follow procedures to ensure early recognition and implementation of effective treatment for drug-resistant TB.

• Recognize that previous options that involved stopping protease inhibitor therapy to allow the use of rifampin for TB treatment are no longer recommended for two reasons: a) the most recent guidelines for the use of antiretroviral therapy advise against interrupting HIV therapy, and b) alternatives for TB therapy that do not contain rifampin are available.

• Coordinate efforts and establish TB screening initiatives in settings where a) the prevalence of infection with M. tuberculosis among persons with HIV-infection is expected to be high and b) referral for medical evaluation and therapy for active or latent TB is possible.

• Be aware of changes in options for TB preventive therapy. In addition to recommendations for using 9 months of isoniazid daily or twice a week, new short-course multidrug regimens (e.g., a 2-month course of a rifamycin such as rifabutin or rifampin with pyrazinamide) can be prescribed for HIV-infected patients with latent M. tuberculosis infection.

When faced with treatment choices, TB controllers and clinicians can use these recommendations to make informed decisions based on the most current research results available, keeping in mind that as new antiretroviral and antituberculosis agents become available, these guidelines will likely change. The aim of these recommendations is to help reduce TB treatment failures, prevent cases of drug-resistant TB, diminish the adverse effects that TB has on HIV replication, and support efforts to not only control TB, but to eliminate it from the United States. Future research should include a) the development of methods for early and accurate diagnosis of M. tuberculosis infection in persons coinfected with HIV, b) strategies to help simplify treatment for active and latent TB and increase adherence to and completion of therapy, and c) basic research to define what host factors protect persons from infection with M. tuberculosis and HIV and from the development of TB and HIV disease.

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