Management of tuberculosis in HIV patients: British HIV Association Guideline

The British HIV Association has released an updated guideline for the management of tuberculosis (TB) in patients with human immunodeficiency virus (HIV) infection.

The guideline, published in the journal HIV Medicine, contains recommendations on diagnosis of active diagnosis of active pulmonary TB, diagnosis of active extrapulmonary TB, diagnosis of drug‐resistant TB infection, diagnosis of latent TB infection, treatment of LTBI, treatment of active drug‐sensitive TB, management of treatment failure and relapse, management of drug‐resistant TB, choice of antiretroviral treatment in individuals not on ART and drug interactions.

Diagnosis of active pulmonary TB

• Microscopy for acid‐fast bacilli (AFB) in conjunction with culture and drug‐sensitivity testing should be done on respiratory samples (sputum, induced sputum or bronchoalveolar lavage [BAL]); if smear positive, this should be followed by molecular testing (e.g. Xpert^® MTB/RIF; Cepheid, Sunnyvale, CA, USA) for rapid identification of Mycobacterium tuberculosis (MTB).


• All pulmonary smear‐negative samples should be processed for culture and drug‐sensitivity testing. Where there is a high index suspicion for TB, molecular tests should also be considered.


• When individuals present with symptoms suggestive of TB, ask about any known TB contact among family members, colleagues, and friends.

Diagnosis of active extrapulmonary TB

• Cerebrospinal fluid (CSF) samples for TB molecular tests should be sent, conventional microscopy and culture for AFB for the diagnosis of TB meningitis.


• In addition to performing pleural fluid and tissue analysis, microscopy and obtaining cultures for mycobacteria on respiratory samples should be performed (induced sputum/BAL) in individuals with suspected pleural TB, even in the absence of obvious lung parenchymal involvement.


• Obtain material for microscopy and culture for AFB, as well as histology in combination with molecular biological techniques, for diagnosis of extrapulmonary TB.

Diagnosis of drug‐resistant TB infection

• The routine use of molecular techniques should be made, in addition to phenotypic drug susceptibility tests, to achieve rapid detection of at least rifampicin and isoniazid resistance in patients” samples.


• Individuals with positive molecular tests for rifampicin resistance should be assumed to have multidrug‐resistant (MDR)‐TB and be managed in conjunction with a designated center for the management of MDR‐TB.

Diagnosis of latent TB infection

• HIV‐positive individuals from countries should be tested with high and medium TB incidence for latent TB infection (LTBI), including pregnant women, regardless of their CD4+ cell count and receipt of antiretroviral therapy (ART), with particular attention to individuals with newly diagnosed HIV or who have recently been exposed to TB.


• HIV‐positive individuals should be tested from low‐incidence countries for LTBI if they have additional TB risk factors.


• Prior to testing and providing treatment for LTBI, active TB should be excluded, by addressing the presence of TB symptoms and signs and conducting investigations as appropriate.


• In the UK setting, interferon‐gamma release assay (IGRA) should be used rather than tuberculin skin test (TST) when testing HIV‐positive individuals for LTBI.


• The IGRA should be repeated within 4 weeks, where practicable if the first result is indeterminate or borderline.


• The use of IGRA or TST is not recommended in the diagnosis, or exclusion, of active TB.


• Testing for LTBI should not be done in individuals who have been treated for active TB. Determining whether or not to treat for LTBI will require an individual risk assessment.

Treatment of LTBI

• Treatment for LTBI for individuals with a positive IGRA is recommended in whom active TB has been excluded by clinical assessment and chest radiography.


• If first and repeat IGRAs are either indeterminate or borderline, the clinician should use clinical judgment when deciding whether to offer treatment for LTBI.


• We recommend offering to test for, and treatment of, LTBI for all HIV‐positive individuals who are close contacts of people with infectious TB as per the National Institute for Health and Care Excellence (NICE) guidelines.


• Either treatment for LTBI with 6 months of isoniazid plus pyridoxine, or 3 months of isoniazid plus rifampicin plus pyridoxine is recommended.

Treatment of active drug‐sensitive TB

• Daily administration of standard TB therapy is recommended in individuals with drug‐sensitive TB.


• Where effective ART necessitates the use of a ritonavir‐boosted protease inhibitor (PI), rifampicin should be replaced by rifabutin.


• Individuals with TB meningitis should receive corticosteroids.


• Fixed‐dose combination tablets (rifampicin/isoniazid, rifampicin/isoniazid/pyrazinamide and rifampicin/isoniazid/pyrazinamide/ethambutol) should be used wherever possible, in order to enhance treatment adherence.

Management of treatment failure and relapse

• A microbiological diagnosis should be pursued in all individuals with treatment failure and relapse, and that advice is sought from a center with expertise in the management of such cases.


• Individuals who are diagnosed with treatment failure/relapse should be managed in conjunction with centers of expertise where a new regimen may be designed based on results from rapid molecular testing and whole‐genome sequencing. If there is a clinical need for immediate treatment, the individual should receive, as per World Health Organization (WHO) recommendations, at least two to three new drugs from different classes while awaiting the results of drug susceptibility tests.

Management of drug‐resistant TB

• In individuals who are found to be infected with isoniazid mono‐resistant isolates, a regimen of daily rifampicin, ethambutol, levofloxacin, and pyrazinamide for 6 months is recommended.


• All individuals with rifamycin‐resistant (including MDR) TB should be managed in conjunction with centers of expertise in the management of drug‐resistant TB.


• All individuals with rifampicin‐resistant or MDR‐TB who are not already on ART should initiate ART as soon as they are stable and TB treatment is tolerated.

Choice of antiretroviral treatment in individuals not on ART

When to start ART

• All individuals with TB should be offered ART as soon as is practicable and within 8–12 weeks of the TB diagnosis.


• Individuals with a CD4+ cell count <50 cells/mm³ should be offered ART as soon as is practicable and within 2 weeks.


• The early initiation of ART in individuals with the central nervous system (CNS) TB is not recommended.

What ART to start

• Efavirenz (standard dose) should be used in combination with tenofovir disoproxil fumarate and emtricitabine as first‐line ART.


• Raltegravir or dolutegravir can be used for individuals in whom efavirenz is contraindicated.


• Rifabutin should be used instead of rifampicin where effective ART necessitates the use of ritonavir‐boosted PIs.


• Nevirapine should not be used in ART‐naïve individuals with TB treated with rifampicin.


• Cobicistat should not be used with rifampicin or rifabutin.


• Fixed‐dose combinations containing tenofovir alafenamide should not be used when co‐administered with rifampicin/rifabutin and bictegravir.

Drug interactions and toxicities

• A complete medicines reconciliation should be taken prior to starting treatment for either TB or HIV.


• Prescribing resources should be used to screen for drug-drug interactions (DDIs) in all individuals with TB/HIV co‐infection.

For complete recommendations follow the link: https://doi.org/10.1111/hiv.12748