Management of TB/HIV Coinfection - Tuberculosis Treatment

Authors: Jean B. Nachega, MD, PhD, MPH, DTM&H
Editors In Chief: Richard E. Chaisson, MD; Ian M. Sanne, MBBCH, FCP(SA) (More Info)

Last Reviewed: July 8, 2016 (What's New)

Credit Information

inPractice® Africa’s Continuing Education Unit (CEU) provider, the South African Medical Association, offers physicians 3 CPD points on a 70% pass rate for completing this individual module. Nonphysicians who successfully complete the module will receive a participation certificate. To learn more on CPD credits and participation certificates, click here.

Introduction: Tuberculosis Treatment in HIV-Infected Adults

HIV infection has had a dramatic impact on the epidemiology and natural history of tuberculosis (TB) in sub-Saharan Africa. South Africa has the highest absolute number of HIV-infected individuals worldwide, estimated at 6.8 million in 2014.[UNAIDS 2014] Many are coinfected with TB. Out of the approximately 450,000 incident cases of TB in South Africa in 2014, approximately 270,000 were coinfected with HIV.[WHO Global TB 2015] Indeed, HIV infection is one of the greatest risk factors for both reactivation of latent TB as well as progression to active TB disease after primary exposure or reinfection.[Havlir 1999] As an example, in South Africa, the annual risk of TB in an HIV-positive person is 10% compared with a lifetime risk of 10% in a healthy individual (Management Guidelines).[ZA NDOH TB 2014] Furthermore, with advanced immunosuppression (depressed CD4+ cell count) the clinical presentation of TB in HIV-infected patients is altered, with lower incidence of pulmonary cavitation (and sometimes even normal-looking chest x-rays), increased likelihood of negative sputum smears, and increased prevalence of extrapulmonary disease and disseminated TB.[ZA NDOH TB 2014; Picon 2007] Common types of extrapulmonary TB in South Africa include lymphadenitis, pleural TB, pericarditis, and TB meningitis.[ZA NDOH TB 2014] Less common clinical forms include skeletal, liver, spleen, and adrenal TB[ZA NDOH TB 2014] as well as involvement of reproductive organs.[Neonakis 2011; Kulchavenya 2012] Aggressive screening of induced sputum (obtained using nebulised hypertonic saline) found that 64% of confirmed and possible TB cases were acid-fast bacilli sputum smear–negative in a South African HIV cohort.[Wilson 2006] A similar study of automated sputum cultures in newly referred antiretroviral therapy (ART) patients without a TB diagnosis in Cape Town found that > 25% of these had pulmonary TB and > 80% of these had smear-negative disease.[Lawn 2009] The most common cause of mortality in South African HIV-infected patients is TB.[Behroozi 2009] The management of coinfection can also be complex due to shared drug toxicities, drug–drug interactions, and potential for development of immune reconstitution inflammatory syndrome, which, in turn, complicates treatment decisions.[Nachega 2011]

The approaches that are most likely to affect clinical and public outcomes related to TB/HIV coinfection include

  • Early diagnosis of TB (facilitated by intensified case finding)
  • Appropriate management of TB, including comprehensive HIV care and early initiation of ART
  • Use of antiretroviral therapy according to national guidelines
  • Isoniazid preventive therapy[ZA NDOH TB 2014]