Case of the Month: HIV and TB Co-Infection Management

Case Summary
A physician called for advice about a 47-year-old male heterosexual patient who’d been newly diagnosed with HIV. The patient had presented with a gastric mass on a CT scan, and was Acid-Fast Bacilli- (AFB) positive on biopsy, indicating possible Tuberculosis (TB) infection. The patient was being treated for both Mycobacterium Avium Complex (MAC) and TB. Two weeks into treatment, the patient was tolerating the following medications well: rifabutin, isoniazid, pyrazinamide, ethambutol, levofloxacin, and clarithromycin. His Glomelular Filtration Rate (GFR) and Liver Function Tests (LFTs) were normal and he had a CD4 count of 120. Given the co-infection with AFB and HIV, with the possibility that the AFB represented TB, the caller wanted to know if it was possible to wait to begin antiretrovirals (ARVs) and what the possible benefits or challenges of waiting might include.

CCC Consultant Advice
The CCC consultant noted that in a case of mild to moderate AFB disease, it may be possible to delay initiation of ARV therapy for eight to 12 weeks after beginning the therapy for AFB infection. There may be a benefit to waiting, because if a definitive diagnosis of TB vs. MAC can be made, the current AFB regimen of seven medications can be reduced. The decreased pill burden and reduction of drug-drug interactions would make choosing an ARV regimen easier and would also likely help with the patient’s ability to adhere to the regimen. Additionally, the consultant noted there may be a benefit to reducing the burden of AFB organism prior to starting ARV as it may reduce the risk of Immune Reconstitution Inflammatory Syndrome (IRIS). In cases of severe AFB disease with organ dysfunction, or if the CD4 count is less than 50, ARV medications should be started within two weeks of beginning the treatment for AFB disease.

Because CCC consultations are based on information provided by the caller or clinician accessing the online consultation center, without the benefit of a direct evaluation or examination of the patient, consultations are intended to be used as a guide. They do not constitute medical advice and are not to serve as a substitute for medical judgment. This Case of the Month includes consultation based on the most up-to-date evidence at the time of its publication. To learn about current recommendations, please call one of our clinical consultation lines.