Part II. Recommendations

This section of the report provides clinicians with recommendations for diagnosing, treating, and preventing TB among persons coinfected with HIV while concurrently promoting optimal antiretroviral care for these patients. The recommendations reflect the current state of knowledge regarding the use of antiretroviral agents, but this field of science is rapidly evolving. As new antiretroviral agents and new data regarding existing agents alter therapeutic options and preferences for antiretroviral therapy, these changes might affect future recommendations for the treatment of TB infection and disease among patients coinfected with HIV and the treatment of HIV infection among persons with TB. Expert consultants updated these recommendations after a September 1997 CDC meeting, where they reviewed and considered available information about the scientific principles of therapy for TB and HIV.

To help clinicians make informed treatment decisions based on the most current research results, the expert consultants have given the recommendations evidence-based ratings (general recommendations have no rating). The ratings include a letter and a Roman numeral (Table_10), similar to the ratings used in previously issued guidelines (4,5). The letter indicates the strength of the recommendation, and the Roman numeral indicates the nature of the evidence supporting the recommendation. Thus, clinicians can use the ratings to differentiate between recommendations based on data from clinical trials versus those based on the opinions of experts familiar with the relevant clinical practice and scientific rationale for such practice (when clinical trial data are not available). However, these recommendations are not intended to substitute for the judgment of an expert physician. Management of HIV-related TB disease is complex, and clinical and public health consequences associated with treatment failure are serious. When possible, treatment of TB among HIV-infected persons should be directed by, or conducted in consultation with, a physician with extensive experience in the care of patients with these two diseases.

The objectives of implementing these recommendations are to reduce TB treatment failures, prevent drug-resistant TB, and diminish the adverse effects that TB has on HIV replication. Moreover, these guidelines contribute to efforts to control and eliminate TB from the United States by minimizing the likelihood of M. tuberculosis transmission, which will prevent the occurrence of new cases of TB. 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 and the MMWR website at. Readers should consult these sources regularly for updates in the guidelines.

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