CS229616_O

August 2016

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

Division of Tuberculosis Elimination

TB Elimination

Special Considerations for Treatment of 

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 largely 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 daily 

regimen consisting of:

• An intensive 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.

Once-weekly INH and rifapentine in the

continuation phase should not be used in any

patient infected with HIV.

Six months is the minimum duration of treatment

for adults with HIV, even for patients with culturenegative TB. In the uncommon situation in which

HIV-infected patients do NOT receive antiretroviral 

therapy during tuberculosis treatment, prolonging 

treatment to 9 months (extend continuation phase 

to 7 months) is recommended. 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 on managing interactions are

likely to be modified.

Anti-retroviral Therapy During 

Tuberculosis Treatment

improve outcomes among tuberculosis patients 

co-infected with HIV. Anti-retroviral therapy 

should ideally be initiated within the first 2 weeks 

of tuberculosis treatment for patients with CD4 

cell counts <50/mm3 and by 8-12 weeks of 

tuberculosis treatment initiation for patients with 

CD4 cell counts ≥50/mm3. An important 

exception is HIV-infected patients with 

tuberculosis meningitis, in whom antiretroviral 

therapy should not be initiated in the first 8 weeks 

of antituberculosis therapy.

Anti-retroviral therapy should be initiated during 

tuberculosis treatment, rather than at the end, to

Case Management

Directly observed therapy (DOT) and other 

adherence promoting strategies should be used in 

all patients with HIV-related TB. The care for HIVrelated 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 adherence to 

both regimens of TB and antiretroviral treatment, 

drug-drug interactions, paradoxical reaction or 

Immune Reconstitution Inflammatory Syndrome 

(IRIS), side effects for all drugs used, and the 

possibility of TB treatment failure or relapse.
CS229616_O

August 2016

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

Division of Tuberculosis Elimination

For More Information

1. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of

America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis.

(2016). Available online at http://cid.oxfordjournals.org/content/63/7/e147

2. Guidance documents for the medical management of HIV. Available online at www.aidsinfo.nih.gov/

guidelines/

3. 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). www.cdc.gov/mmwr/preview/mmwrhtml/mm5302a6.htm

4. Managing Drug Interactions in the Treatement of HIV-Related Tuberculosis. http://www.cdc. gov/tb/

publications/guidelines/TB_HIV_Drugs/default.htm

5. General Considerations for Treatment of TB Disease (Fact Sheet). Available online at http://www.cdc.gov/tb/

publications/factsheets/treatment.htm