CS229616_O

May 2012

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 

Division of Tuberculosis Elimination

TB Elimination

Treatment of Drug-Susceptible TB Disease 

in Persons Infected with HIV

Introduction

The management of HIV-related tuberculosis (TB) 

disease is complex. Although the treatment of TB 

in people 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 adults 

infected with HIV (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 and 

rifapentine in the continuation phase should not 

be used in any patient infected with HIV.

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 people infected 

with HIV 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

1. Centers for Disease Control and Prevention. 

Treatment of Tuberculosis. MMWR 2003;52(No. 

RR-11). www.cdc.gov/mmwr/PDF/rr/rr5211.pdf

Errata. www.cdc.gov/mmwr/preview/

mmwrhtml/mm5351a5.htm

2. Guidance documents for the medical 

management of HIV. www.aidsinfo.nih.gov/

guidelines/

3. Updated Guidelines for the Use of Rifamycins 

for the Treatment of Tuberculosis Among HIVInfected Patients Taking Protease Inhibitors or 

Nonnucleoside Reverse Transcriptase Inhibitors. 

MMWR 2004: 53 (No. 2). www.cdc.gov/mmwr/

preview/mmwrhtml/mm5302a6.htm

4. Managing Drug Interactions in the Treatment 

of HIV-Related Tuberculosis. http://www.cdc.

gov/tb/publications/guidelines/TB_HIV_Drugs/

default.htm