Key points
- People with HIV, especially untreated HIV, are more likely than people without HIV to become sick with TB disease once infected.
- People with HIV who also have either latent TB infection or TB disease can be treated effectively.
- Experts are available to assist U.S. health care providers deliver life-saving HIV and TB treatment and manage complications of HIV and TB coinfection.
Overview
People with HIV who also have either latent TB infection or TB disease can be treated effectively. The first step is to ensure that people with HIV are evaluated for TB infection, especially after exposure to a person with TB disease. If a diagnosis of TB infection is made, further evaluation is needed to rule out TB disease. Treatment for latent TB infection or TB disease may be critical to prevent further disease progression.
State TB programs and the TB Centers of Excellence for Training, Education, and Medical Consultation provide assistance and support for health care providers caring for people with HIV and TB.
Health care providers may also consult TB and HIV coinfection resources available from :
Risk
HIV, especially when a patient's CD4 count is low, is an important risk factor for the development of TB disease in people with TB infection.
When a person has a weakened immune system and is infected with TB bacteria, their body may not be able to control the multiplication and spread of TB bacteria. People with HIV who are infected with TB are much more likely to develop TB disease than people without HIV. For people without HIV or other TB risk factors, the risk of developing TB disease is 10% over a lifetime. For people with HIV and TB infection who are not on antiretroviral therapy, the risk of developing TB disease rises to 7% to 10% each year.
Extrapulmonary TB (TB outside the lungs) disease occurs more often in people with HIV. Some patients who have extrapulmonary TB disease also have pulmonary TB disease.
Evaluation and diagnosis
Health care providers should consider a patient's TB risk factors and use clinical judgment when interpreting TB test results for patients with HIV.
Testing
There are two types of tests that are used to determine if a person has been infected with TB bacteria:
- TB blood tests (Interferon Gamma Release Assay [IGRA]) and
- TB skin test (Mantoux tuberculin skin test)
Interpretation of TB blood test results depend on the test being used. Interpreting a TB skin test reaction depends on the size of the induration and the person's risk factors for TB. For people with HIV, an induration of 5 or more millimeters is considered a positive reaction.
A positive blood or skin test result usually means TB infection. More diagnostic evaluations, such as a physical examination, a chest radiograph, and sometimes sputum or other tests, are needed to rule out TB disease.
A negative TB blood test or TB skin test result means TB infection is unlikely, but cannot be excluded, especially if the patient has signs or symptoms of TB disease or is immunocompromised.
Anergy
Untreated HIV is an important cause of anergy. Anergy is the inability to react to TB blood tests or TB skin test because of a weakened immune system. This may result in a false-negative TB test result. Health care providers may recommend a second TB blood test or TB skin test or make a diagnosis of latent TB infection or TB disease based on other diagnostic evaluations or epidemiologic considerations.
For example, if a person with HIV had prolonged, frequent exposure to someone with TB disease, health care providers may consider prescribing treatment for latent TB infection, regardless of results from TB blood or skin tests.
Chest radiography
In people with HIV and CD4 counts >200 cells/mm3, HIV-related TB disease generally resembles TB disease among people without HIV, and common chest radiographic manifestations are upper lobe infiltrates with or without cavitation.
In people with advanced HIV (CD4 counts <200 cells/mm3), pulmonary TB disease may present with atypical findings, such as lower lobe infiltrates, hilar adenopathy, or with no lesions on the chest radiograph.
Treatment
People with HIV who also have either latent TB infection or TB disease can be effectively. Health care providers should choose the appropriate treatment regimen based on:
- Drug susceptibility results,
- Coexisting medical conditions, and
- Potential for .
State TB programs and the TB Centers of Excellence for Training, Education, and Medical Consultation provide assistance and support for health care providers treating people with HIV and TB disease.
Health care providers may also consult and for more information on TB treatment regimens for people with HIV.
There are several effective latent TB infection treatment regimens available for people with HIV.
Treatment options include:
- Six to nine months of daily isoniazid (H)
- For adults and children of all ages with HIV
- For adults and children of all ages with HIV
- Three months of once-weekly isoniazid (H) plus rifapentine (P) (also called 3HP)
- For adults and children ≥2 years old with HIV, as drug interactions allow
- For adults and children ≥2 years old with HIV, as drug interactions allow
- Three months of daily isoniazid plus rifampin (also called 3HR)
- For adults and children of all ages with HIV, as drug interactions allow
- For adults and children of all ages with HIV, as drug interactions allow
Guidelines
There are several treatment regimen options for TB disease in adults with HIV.
6- or 9-month regimens
The 6- to 9-month TB treatment regimens consist of:
- An intensive phase of isoniazid, a rifamycin, pyrazinamide, and ethambutol for the first 2 months followed by
- A continuation phase of isonaizid and a rifamycin for the last 4 to 7 months.
Six months is the minimum duration of treatment for adults with HIV, even for patients with culture-negative TB disease. In the uncommon situation in which patients do not receive antiretroviral therapy during treatment, prolonging treatment to 9 months (extending the continuation phase to 7 months) is recommended. HIV treatment, however, is a critical predictor of TB treatment success.
Health care providers should consider prolonging to 9 months (by extending the continuation phase to 7 months) for patients with delayed response to therapy (e.g., continued culture positivity after 2 months of treatment).
4-month rifapentine-moxifloxacin regimen
The 4-month rifapentine-moxifloxacin TB treatment regimen consists of:
- An intensive phase of 8 weeks, followed by
- A continuation phase of 9 weeks (total 17 weeks for treatment).
The 4-month rifapentine-moxifloxacin regimen is a treatment option for people with HIV with CD4 counts at or above 100 cells/microliter (μL), in the absence of any other known between antituberculosis and antiretroviral medications.
Guidelines
Treating drug-resistant TB disease in patients with HIV may require similar treatment decisions as treating drug-resistant TB disease for patients without HIV. However, health care providers may wish to consult experts in the management of HIV and TB to address any HIV-related TB complexities.
Guidelines
Additional treatment considerations
Antiretroviral therapy during TB treatment
For persons with HIV who are not already on antiretroviral therapy (ART), HIV treatment is critical for TB treatment success.
ART should ideally be initiated within the first 2 weeks of TB treatment for patients with CD4 cell counts <50/mm3 and by 8-12 weeks of TB treatment initiation for patients with CD4 cell counts ≥50/mm3. An important exception is HIV-infected patients with TB meningitis, in whom antiretroviral therapy should not be initiated in the first 8 weeks of anti-tuberculosis therapy. Health care providers should consult a TB and HIV expert.
Health care providers may refer to the "Special Considerations Regarding ART Initiation" information available in .
Managing drug interactions
Health care providers should be aware of potential drug-drug interactions with antiretroviral therapy (ART) medications.
Directly observed therapy
Directly observed therapy (DOT) and other adherence promoting strategies should be used in all patients with HIV-related TB disease. CDC recommends video DOT (vDOT) as an equivalent alternative to in-person DOT for patients receiving treatment for TB disease.