Combining ART and TB treatment

Clinical description

• Each year, 12,000 (1.2%) of the 986,000 HIV infected Malawians develop active TB and 4,200

die from TB 3.

• The risk of active TB is high for the first 6 months on ART and remains elevated for life.
• Most HIV patients with TB do not have typical TB symptoms (productive cough). Many are

sputum smear negative.

• HIV infected TB patients must start ART and TB treatment as soon as possible. The long-term

outcome is poor if only one treatment is taken.

Selecting ART regimen and adjusting dosage

• See Table 29 on page 134 for a detailed list of potential drug interactions
• ATV/r, LPV/r and DRV have significant interactions with rifampicin. Do not combine if possible.
• DTG-based ART regimens (13, 14, 15) are a good combination with TB 1st line treatment.
• However, the daily DTG dose needs to be doubled while on rifampicin-containing TB treatment:

o Adults take the regular DTG-containing regimen in the morning and one additional tablet of DTG 50mg in the evening (after 12 hours)

o Children on paediatric DTG 10mg formulation take regular DTG dose in the morning and an additional DTG dose in the evening (after 12 hours)

o Continue with double-dose DTG for 7 days after the last dose of rifampicin.

• DTG-based regimens are the best option for patients previously on 6A, 7A, 10A and 11A who need

TB treatment.

• Patients with ART failure (see section 18.10.2on page 91) may develop active TB. In this case, 2nd

line ART needs to be combined with TB treatment.

o Preferred: Use 13A, 14A or 15A (with double dose DTG) while on TB treatment.

o Alternative: Use LPV/r-based 2nd line regimens (9A, 10A, 11A) for patients who cannot use 13A, 14A or 15A.

• Double the daily dose of LPV/r (4 tablets of LPV 200mg / r 50mg every 12 hours) for

the duration of rifampicin treatment.

• For children who can swallow whole tablets (without crushing or chewing), boost

LPV/r with additional LPV/r. Children who cannot swallow tablets whole should not take LPV/r in combination with TB treatment as this will result in development of PI resistance.

3 2021 Global tuberculosis report (WHO)

Continuing ART