HomeThe anti-TB regimen choice and duration is the same for people with HIV as for those without HIV, except for the selective use of rifabutin in place of rifampin when necessary to achieve compatibility with the ART regimen (see Table 1).16,18–24
Table 1. Summary of compatible rifamycin-based anti-tuberculous therapy and antiretroviral regimens (last updated September 2021).
| Rifamycin | Anchor drug in antiretroviral regimen | Nucleoside analogue component of anti-retroviral regimen |
|---|---|---|
| Rifampin 600 mg daily | Efavirenz 600 mg daily 38 , 46 Dolutegravir 50 mg twice daily 41 , 43 Raltegravir 800 mg twice daily42 |
No clinically important interactions expected 23 , 38 |
| Rifabutin 150 mg daily | Ritonavir “boosted” protease inhibitor 23 , 48 | No clinically important interactions expected 23 , 38 |
| Rifabutin 300 mg daily | Dolutegravir 50 mg daily 45 Raltegravir 400 mg twice daily 42 , 49 Rilpivirine 50 mg daily23 Doravirine 100 mg twice daily 23 |
No clinically important interactions expected 23 , 38 |
Note: Expert consultation is strongly advised when selecting antiretroviral therapy (ART) regimens in people on tuberculosis treatment.
Daily administration of TB drugs throughout the treatment course is recommended, as intermittent therapy is associated with worse treatment outcomes, including treatment failure, relapse and acquired drug resistance.16,25 Treatment duration is not extended on the basis of HIV co-infection alone. However, in the uncommon scenario where a patient declines to take ART, TB treatment should be extended to 9 months.16,21
Several studies have found that a substantial proportion of people with both HIV and TB infection have low serum concentrations of anti-tuberculous agents.26–31 This is thought to be due to a combination of factors, including drug interactions with ART and decreased absorption related to gastrointestinal dysfunction associated with HIV infection.32 Low serum drug concentrations have been linked to slower response to TB treatment21,29,33,34 and acquired rifamycin resistance.35 Thus, we frequently monitor serum drug concentrations in individuals with HIV co-infection to optimize dosing.
HIV-infected individuals are already at increased risk of neuropathy related to HIV and ART. Therefore, in those taking isoniazid (INH), vitamin B6 supplementation is routinely used prevent additional neurologic toxicity from INH-associated neuropathy.
Recommendations
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We strongly recommend a rifamycin (rifampin or rifabutin)-containing regimen for treatment of TB, despite the potential for drug-interactions with antiretroviral therapy (good evidence).
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We strongly recommend that TB treatment in human immunodeficiency virus co-infected individuals be administered daily throughout (good evidence).
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We conditionally recommend that, if a patient is not taking antiretroviral therapy, TB treatment be extended to 9 months (poor evidence).
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We conditionally recommend that, where available, serum TB drug concentrations be measured in people with human immunodeficiency virus co-infection and used to optimize TB drug dosing (poor evidence).
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