Comments are being sought by the British HIV Association (BHIVA) on draft guidelines for the treatment of tuberculosis (TB) in HIV-positive individuals.
Key issues covered by the draft guidelines include the duration of anti-TB therapy, the use of directly observed therapy (DOTS), the sequencing of TB and anti-HIV treatments, and the use of prophylaxis.
The BHIVA draft guidelines reflect those of the British Thoracic Society and recommend two months of initial anti-TB therapy with four drugs followed by four months of treatment with two drugs. Patients with TB meningitis are however recommended to receive twelve months of TB treatment, and individuals with a delayed response to TB therapy, those with multi-drug resistant TB, and patients who require non-standard drug therapy are also recommended to receive up to twelve months of treatment.
DOTS is recommended by the US Center for Disease Control for all patients with TB, and the draft BHIVA guidelines mention DOTS as a “gold standard.” But the draft guidelines highlight that in reality few UK patients require DOTS, and that it is very rarely used.
The use of anti-TB regimens with less than once-daily dosing is not recommended by the draft guidelines, and should never be used if a patient has a CD4 cell count below 100 cells/mm3. However, if a patient does require DOTS then intermittent dosing can be considered.
Issues concerning the sequencing of anti-TB and HIV therapy are also considered by BHIVA. The draft guidelines recommend that TB should be treated first if a patient has a CD4 cell count above 200 cells/mm3. The risk of immune restoration syndrome in patients with a CD4 cell count between 100 - 200 cells/mm3 prompts the guideline authors to recommend that there is a gap of two months between the finishing of anti-TB treatment and the commencement of HAART. For patients with a CD4 cell count below 100 cells/mm3 the break between the two therapies may need to be less than two months.
Patients considered to be at high risk of TB, particularly individuals who come from communities with a high prevalence of TB including Africans, are recommended to commence anti-TB prophylaxis consisting of isoniazid until HAART increases CD4 cell count to normal levels reducing the risk of TB disease.
The guidelines are currently in their second draft and will shortly be posted on the BHIVA website for further comment.