In spite of fewer people in this country suffering with TB, it remains a serious threat, especially for HIV-infected persons. In fact, worldwide TB is one of the leading causes of death among people infected with HIV.

People infected with HIV (the virus that causes AIDS) are more likely than uninfected people to get sick with other infections and diseases. TB is one of these diseases.

• Without treatment, as with other opportunistic infections, HIV and TB can work together to shorten the life of the person infected.

• Someone with untreated latent TB infection and HIV infection is much more likely to develop active TB disease during his or her lifetime than someone without HIV infection.

• Among people with latent TB infection, HIV infection is the strongest known risk factor for progressing to active TB disease.

• A person who has both HIV infection and active TB disease has an AIDS-defining condition.

The good news is that HIV-infected persons with either latent TB infection or active TB disease can be effectively treated. The first step is to ensure that HIV-infected persons get a test for TB infection and any other needed tests. The second step is to help the people found to have either latent TB infection or active TB disease get proper treatment. Rapid progression from latent TB infection to active TB disease can easily be prevented.

Treatment

There are a number of treatment options for HIV-infected persons with either latent TB infection or active TB disease. Consult with your state or local health department for treatment options.

Treatment of Drug-Susceptible Tuberculosis Disease in HIV-Infected Persons (Fact sheet) [1].

Fact Sheet

Introduction

In February 2003, the American Thoracic Society (ATS), the Centers for Diseases Control and Prevention (CDC), and the Infectious Diseases Society of America (IDSA) released new guidelines for the treatment of TB. This fact sheet will provide key points from these guidelines; however, please refer to the Treatment of Tuberculosis1 for complete recommendations.

The management of HIV-related tuberculosis (TB) disease is complex. Although the treatment of TB in persons with HIV is essentially the same as for patients without HIV, there are some important differences.

Recommended Regimen

The recommended treatment of TB disease in HIV-infected adults (when the disease is caused by organisms that are known or presumed to be susceptible to first-line drugs) is a 6-month regimen consisting of

• An initial phase of isoniazid (INH), a rifamycin (see Drug Interactions below), pyrazinamide (PZA), and ethambutol (EMB) for the first 2 months.

• A continuation phase of INH and a rifamycin for the last 4 months.

Patients with advanced HIV (CD4 counts < 100/µl) should be treated with daily or three-times-weekly therapy in both the initial and the continuation phases. Twice weekly therapy may be considered in patients with less-advanced immunosuppression (CD4 counts ≥ 100/µl). Once-weekly INH/rifapentine in the continuation phase should not be used in any HIV-infected patient.

Six months should be considered the minimum duration of treatment for adults with HIV, even for patients with culture-negative TB. Prolonging treatment to 9 months (extend continuation phase to 7 months) for HIV-infected patients with delayed response to therapy (e.g., culture positive after 2 months of treatment) should be strongly considered.

Drug Interactions

A major concern in treating TB in HIV-infected persons is the interaction of rifampin (RIF) with certain antiretroviral agents (some protease inhibitors [PIs] and nonnucleoside reverse transcriptase inhibitors [NRTIs]). Rifabutin, which has fewer problematic drug interactions, may be used as an alternative to RIF.

As new antiretroviral agents and more pharmacokinetic data become available, these recommendations are likely to be modified.

Case Management

Directly observed therapy (DOT) and other adherence promoting strategies should be used in all patients with HIV-related TB. Whenever possible, the care for HIV-related TB should be provided by or in consultation with experts in management of both TB and HIV. The care for persons with HIV-related TB should include close attention to the possibility of TB treatment failure, antiretroviral treatment failure, paradoxical reactions of TB (e.g., temporary worsening of signs or symptoms of TB), side effects for all drugs used, and drug toxicities associated with increased serum concentrations of rifamycins.

For More Information

• Centers for Disease Control and Prevention. Treatment of Tuberculosis. MMWR 2003;52(No. RR-11). [2]

Errata [3]

• Guidance documents for the medical management of HIV [4]

• Updated Guidelines for the Use of Rifamycins for the Treatment of Tuberculosis Among HIV-Infected Patients Taking Protease Inhibitors or Nonnucleoside Reverse Transcriptase Inhibitors. MMWR 2004: 53 (No. 2) [5]

Managing Drug Interactions in the Treatment of HIV-Related Tuberculosis [6]

Basic TB Facts

TB" is short for tuberculosis. TB disease is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal.

How TB Spreads

TB is spread through the air from one person to another. The TB bacteria are put into the air when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become

TB is NOT spread by

• Shaking someone’s hand

• Sharing food or drink

• Touching bed linens or toilet seats

• Sharing toothbrushes

• Kissing

Latent TB Infection and TB Disease

Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection and active TB disease.

*Latent TB Infection

TB bacteria can live in your body without making you sick. This is called latent TB infection (LTBI). In most people who breathe in TB bacteria and become infected, the body is able to fight the bacteria to stop them from growing. People with latent TB infection do not feel sick and do not have any symptoms. The only sign of TB infection is a positive reaction to the tuberculin skin test [7] or special TB blood test [8]. People with latent TB infection are not infectious and cannot spread TB bacteria to others. However, if TB bacteria become active in the body and multiply, the person will get sick with TB disease.

TB Disease

TB bacteria become active if the immune system can't stop them from growing. When TB bacteria are active (multiplying in your body), this is called TB disease. TB disease will make you sick. People with TB disease may spread the bacteria to people they spend time with every day. Many people who have latent TB infection never develop TB disease. Some people develop TB disease soon after becoming infected (within weeks) before their immune system can fight the TB bacteria. Other people may get sick years later, when their immune system becomes weak for another reason.

For persons whose immune systems are weak, especially those with HIV infection, the risk of developing TB disease is much higher than for persons with normal immune systems.

The Difference between Latent TB Infection and TB Disease

A Person with Latent TB Infection

• Has no symptoms
• Does not feel sick
• Cannot spread TB bacteria to others
• Usually has a skin test or blood test result indicating TB infection
• Has a normal chest x-ray and a negative sputum smear
• Needs treatment for latent TB infection to prevent active TB disease

A Person with TB Disease

• Has symptoms that may include:

• a bad cough that lasts 3 weeks or longer
• pain in the chest
• coughing up blood or sputum
• weakness or fatigue
• weight loss
• no appetite
• chills
• fever
• sweating at night

• Usually feels sick
• May spread TB bacteria to others
• Usually has a skin test or blood test result indicating TB infection
• May have an abnormal chest x-ray, or positive sputum smear or culture
• Needs treatment to treat active TB disease