Introduction

These guidelines update previous CDC recommendations for treating and preventing active tuberculosis (TB) among adults and children coinfected with human immunodeficiency virus (HIV) (1-3). The most notable changes in these guidelines reflect both the recent advances in the use of antiretroviral therapy and the findings of clinical trials that evaluated new drug regimens for the treatment and prevention of TB among HIV-infected persons. Antiretroviral therapy is discussed in the context of TB treatment only; more detailed information about antiretroviral therapy is published elsewhere (4).

In September 1997, CDC convened a meeting of expert consultants who reviewed and considered background information about HIV-related TB in the United States and the scientific principles of therapy for both diseases (Part I of this report). The consultants then used this review as the basis for updating the recommendations for HIV-infected patients with TB (Part II). During their review of the scientific principles of therapy, the expert consultants focused on epidemiologic and clinical interactions between Mycobacterium tuberculosis infection and HIV infection, considering the frequency of coexisting TB and HIV infection and rates of drug-resistant TB among patients infected with HIV in the United States; the copathogenicity of TB and HIV disease; the potential for a poorer outcome of TB therapy and paradoxical reactions to TB treatment among HIV-infected patients; drug interactions between rifampin used for TB therapy and agents commonly used in antiretroviral therapy; use of TB treatment regimens that do not contain rifampin; and results of clinical trials of therapies to prevent TB among HIV-infected persons. Thus, in addition to CDC's current recommendations, these new guidelines include information about the following topics: directly observed therapy for all patients with HIV-related TB; rifabutin-containing antituberculosis regimens (or a streptomycin-based alternative regimen that does not contain rifamycin) for treating TB among patients taking antiretroviral drugs that have interactions with rifampin; monitoring responses to antituberculosis treatment to decide about the appropriate duration of TB therapy; occurrence and management of paradoxical reactions during TB treatment, when immune function is restored because of antiretroviral therapy; use of 9 months of isoniazid daily or twice weekly for the treatment of M. tuberculosis infection; short-course multidrug therapy for latent M. tuberculosis infection; and special considerations that apply to children and pregnant women with HIV-related TB.

Health-care professionals need to be familiar with these new guidelines to ensure the use of the most effective management strategies for TB patients infected with HIV, while concurrently promoting optimal antiretroviral therapy for these patients. To help clinicians make informed treatment decisions based on the most current research results, the expert consultants have given each recommendation an evidence-based rating similar to the ratings used in previously issued guidelines (4,5). However, these recommendations are not intended to substitute for the judgment of an expert physician. When possible, the treatment of TB in HIV-infected persons should be directed by (or done in consultation with) a physician with extensive experience in the care of patients with TB and HIV disease. The implementation of these recommendations will help prevent cases of drug-resistant TB, reduce TB treatment failures, and diminish the adverse effects that TB has on HIV replication. Moreover, these guidelines will contribute to efforts to control TB and eliminate it from the United States by minimizing the likelihood of M. tuberculosis transmission, which will prevent the occurrence of new cases of TB.

In future years, health-care professionals can expect changes in the recommendations regarding the therapeutic options used to prevent and treat TB among patients infected with HIV. These changes will reflect the availability of new antiretroviral and antituberculosis agents, new information about existing agents, and subsequent changes in CDC's guidelines for the use of antiretroviral therapy for persons infected with HIV. Multiple copies of this report and all updates are available from the Office of Communications, National Center for HIV, STD, and TB Prevention, CDC, 1600 Clifton Road, Mail Stop E-06, Atlanta, GA 30333. The report also is posted on the CDC Division of TB Elimination Internet website at less than http://www.cdc.gov/nchstp/tbgreater than and the MMWR website at . Readers should consult these sources regularly for updates in the guidelines.

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