Bibliographic Info
Recommendation
Recommended in favor
Strong
Certainty of evidence
Low
(Adults and adolescents) ART should be started as soon as possible within two weeks of initiating TB treatment, regardless of CD4 count, among people living with HIV
Notes and Remarks
- 1.Except when signs and symptoms of meningitis are present. 2.People should be closely followed up to monitor adverse events related to co-treatment, immune reconstitution inflammatory syndrome, including paradoxical TB immune reconstitution inflammatory syndrome, and other incident clinical events requiring prompt assessment and management, especially among children and pregnant or breastfeeding women. HIV programmes and service providers should establish mechanisms for adequate monitoring, including pharmacovigilance and surveillance for drug–drug interactions. HIV programmes must plan to address specific known interactions between rifamycins and ARV drugs, such as the need to forecast and procure single 50-mg DTG tablets for the period of co-treatment. Key considerations include adequate training of health-care personnel and programme managers to deliver integrated TB and HIV services (cross-training) and HIV and maternal, newborn and child health services, including for children, adolescents and pregnant women, co-location of services and establishing an integrated supply chain, laboratory and information systems. Coordination between TB and HIV programmes to deliver these services is critical. Community engagement, patient education, engagement of adherence counsellors and social workers and peer support for early recognition of adverse events and to support retention and adherence to co-treatment are also needed. ART initiation among children with TB also needs parents to support adherence in the context of age-specific HIV disclosure and education regarding TB and HIV diagnosis and treatment (25,26).
- 3.The Guideline Development Group also discussed the PredART study (27), which examined the prophylactic use of prednisone to prevent paradoxical TB immune reconstitution inflammatory syndrome among 240 adults living with HIV with CD4 cell count <100 cells/mm3 with TB initiating ART (within 30 days of TB treatment) in a setting with a high burden of TB and HIV. The study reported high rates of paradoxical TB immune reconstitution inflammatory syndrome (47% in the placebo group and 33% in the prednisone group) and of hospitalization (25%) but very few deaths; and a recently published sub-study of the PredART study found that prophylactic prednisone did not affect pulmonary outcomes (28). The prophylactic use of corticosteroids has not been fully examined with earlier ART start, and the Guideline Development Group agreed that more data are needed to understand the role of corticosteroids in this context. Enhanced monitoring and active surveillance of emerging toxicity and drug–drug interactions are critical for addressing potential safety concerns.
Also Featured In
This recommendation also appears in the following guidelines:
Guidelines: updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring
Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach
WHO consolidated guidelines on tuberculosis: module 4: treatment: drug-susceptible tuberculosis treatment.
Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations
WHO consolidated guidelines on tuberculosis: module 6: tuberculosis and comorbidities.
WHO consolidated guidelines on tuberculosis: module 4: treatment and care
WHO guidelines on the management of advanced HIV disease