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Treatment of Tuberculosis (TB) in Adults with HIV Infection

Table of Contents

This resource is intended to assist clinicians in managing patients with HIV and latent tuberculosis infecion on (LTBI), and drug-susceptible active pulmonary tuberculosis (TB). This guide summarizes the guidelines for the diagnosis and treatment of LTBI and TB and includes clinical signs and symptoms, adult dosing, available dosage forms, drug-drug interactions, side effects, and important patient counseling points.

  • Latent Tuberculosis Infection
      • DIAGNOSIS OF LTBI: Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA)
      • Tuberculin Skin Test
      • Interpretation of TST Results
      • Contraindications to a TST
      • Interferon (IFN)-Gamma Release Assays (IGRAs)
      • Recommendations on the Use of IGRA
      • Repeat for Repeat TST or IGRA
      • Treating LTBI (to prevent TB disease)
      • Monitoring Patients Treated for LTBI
      • COVID-19 Vaccine and TB Testing Iformation
  • TUBERCULOSIS DISEASE
    • Diagnosis of Active Tuberculosis Disease
    • Treatment of Drug-Susceptible TB Disease in Patients with HIV
    • TB Treatment Includes 2 Phases
    • Initiating ART in Patients with HIV with TB Disease
    • Monitoring Treatment for Pulmonary TB
    • Possible Adverse Effects of TB Drugs
    • Immune Reconstitution Inflammatory Syndrome (IRIS)
    • Therapeutic Drug Monitoring (TDM)
  • References
  • Resources
    • HIV/AIDS Resources
    • Tuberculosis Resource
    • SNTC Caliper for Reading a TST
  • Contacts 
    • Regional TB Consultation Services
    • National HIV Clinician Consultation Center
    • AETC National Coordinating Resource Center

Editors

  • Connie Haley, MD, MPH
  • L. Beth Gadkowski, MD, MPH, MS
  • Joanne Urban, PharmD, AAHIVP

Latent Tuberculosis Infection

Latent tuberculosis infection (LTBI) is the presence of Mycobacterium tuberculosis (M.tb) in the body without signs and symptoms, or radiographic or bacteriologic evidence of tuberculosis (TB) disease.

Diagnosis of LTBI: Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA)

  • Pts with HIV have a 3-16% risk per year for developing TB disease if infected with M.tb
  • Test pts with HIV for LTBI, with either a TST or IGRA, at time of entry into care, regardless of risk or CD4 count
  • If the initial test is negative, consider re-testing with a different test when risk for infection, progression to TB disease, and a poor outcome are increased
  • All pts with (+) test for LTBI should be evaluated for TB disease (i.e., chest x- ray [CXR] and clinical evaluation for pulmonary and extrapulmonary symptoms) before starting LTBI therapy
  • Tuberculosis Screening, Testing, and Treatment of U.S. Health Care
  • Personnel can be found online at: https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm?s_cid=mm6819a3_x

Tuberculin Skin Test

Interpretation of TST Results

  • A (+) TST result in pts with HIV is ≥ 5 mm induration
  • Possible reasons for false (+) TST result:
    • Infection with nontuberculous mycobacteria
    • Prior Bacillus Calmette-Guérin (BCG) vaccine or cancer treatment (use of IGRA preferred)
    • Improper administration and/or interpretation of results
  • Possible reasons for false (-):
    • Immuosuppression due to HIV
    • Recent TB infection (within 8-10 wks after exposure)
    • Extremes of age (young children, elderly)
    • Concurrent bacterial, fungal, or viral infections
    • Overwhelming TB disease
    • Immunosuppression due to medications, malignancy, or other conditions
    • Problem with tuberculin used (e.g., improper storage), poor administration technique (e.g., subcutaneous instead of intradermal), improper reading or result interpretation
    • Recent live virus vaccination (administer TST at same time as vaccine or wait 4-6 wks afterwards)
  • Anergy testing is NOT recommended
  • SNTC Caliper for reading a TST. Order online: https://sntc.medicine.ufl.edu/home/index#/products/15 

Contraindications to a TST

Do not re-test persons with a serious reaction to a prior TST. TST is NOT contraindicated in:

  • Adults or children previously vaccinated with BCG
  • Pregnant or breastfeeding women
  • Any person previously tested with TST or IGRA

Interferon (IFN)-Gamma Release Assays (IGRAs)

NOTE: Blood samples must be processed within 8-16 hours after collection so that the white blood cells remain viable

Recommendations on the Use of IGRA

  • IGRA can be used in place of a TST in all situations
  • IGRA is preferred in:
    • Persons who received BCG vaccination or cancer therapy
    • Groups with low rates of return for TST results (e.g., homeless persons, drug-users, and those who previously failed to return for TST reading)
  • Similar to TST, live virus vaccines may affect IGRA results. Perform IGRA either on the same day as live virus vaccines or 4-6 wks after. Current Covid-19 vaccines do NOT contain live virus.

Recommendations for Repeat TST or IGRA

  • If CD4 increases > 200 cells/mm³ in response to antiretroviral therapy (ART) (immunosuppression may cause false (-) TST/IGRA)
  • Pts exposed to a person with pulmonary TB disease; retest again 8-10 wks after TB exposure ended
  • Consider re-testing if pt experiences a new risk factor for TB exposure such as:
    • work or residence in a correctional facility or other high risk congregate setting
    • travel to a country where active TB disease is common (most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe and Russia)
    • uses IV drugs
    • has been homeless or has stayed in a shelter
    • close contact with recent immigrants and other high risk non-US born individuals

Treating LTBI (to prevent TB disease)

Treat pts with HIV for LTBI only after TB disease ruled out:

  • No pulmonary or extra pulmonary symptoms of TB disease
  • No physical findings of TB disease AND patient has either:
    • (+) diagnostic test for LTBI or
    • known contact to pulmonary TB even if TST or IGRA are (-)
  • Collaborate with local health department to provide directly observed therapy (DOT) to ensure completion of LTBI treatment

NOTE: If pt has hx of inadequately treated TB or CXR suggestive of prior TB (e.g, fibrotic changes), rule out TB disease before considering LTBI therapy. Consult an HIV/TB expert.

Table 1. Treating LTBI (to prevent TB disease)
  • Both LTBI treatment and ART decrease the risk of TB disease and are recommended to prevent TB disease.
  • Rule out TB disease before LTBI treatment.
Indications for LTBI Treatment:
  • (+) TST or IGRA and no prior history of completing treatment for active or latent TB;
  • Close contact with infectious TB, regardless of TST or IGRA result.
LTBI Treatment Regimens:

      Preferred:

  •  3HP: 3 mos (12 wks) of once-weekly INH plus rifapentine (RPT) for pts either not receiving ART or receiving a dolutegravir (DTG), efavirenz (EFV), or raltegravir (RAL)-based regimen without tenofovir alafenamide (TAF).
    Doses: INH 15 mg/kg (900 mg max) PO weekly plus RPT: if weight 32.1-49.9 kg, use 750 mg PO weekly; if weight > 50.0 kg, use 900 mg (max) PO weekly plus B6 (pyridoxine): 25-50 mg PO weekly

    Preferably give 3HP by directly observed therapy (DOT). 3HP can be given by SAT in select pts after the first 2-3 doses (contact a TB-HIV expert)

  •  9INH: 9 mos of daily isoniazid (INH) given by self-administered therapy (SAT).
    Doses: INH 300 mg PO daily plus B6 (pyroxidine) 25-50 mg PO daily

     Alternative:

  • 4RIF: 4 mos of daily RIF as drug interactions allow; 4RIF is strongly recommended for adults without HIV, but there is limited evidence available for effectiveness in those with HIV. Ensure no TB by symptom eval, CXR and culture.
  • Some TB HIV experts may substitute 4 mos rifabutin instead of rifampin to avoid drug interactions if INH cannot be used (consult TB HIV expert).

For detailed information about rifamycin (RIF, RFB and RPT) interactions with ARVs see Table 5 and:

COVID-19 vaccine and TB testing information:

https://www.cdc.gov/tb/topic/testing/tbtesttypes.htm 

Tuberculosis Disease

Diagnosis of Active Tuberculosis Disease

  • Symptoms of pulmonary TB disease:
    • Prolonged productive cough (> 3 wks), chest pain, hemoptysis, fever/chills, night sweats, decreased appetite/weight loss, fatigue;
    • Clinical presentation can be atypical or subtle in pts with HIV
  • Pts with HIV have increased risk of extrapulmonary TB; Symptoms and clinical presentation depend on the site of infection. Consult a TB/HIV expert especially if CNS disease.
  • Consult a TB/HIV expert, especially if CNS disease. Aggressively pursue diagnosis when pulmonary and/or extrapulomary TB is suspected to confirm TB vs. other diagnosis and enable TB drug susceptibility testing (DST).
  • If pulmonary or extrapulmonary TB is suspected:
    • Obtain PA and lateral CXR. Abnormalities often seen in upper lobe, but pts with HIV and TB disease may have atypical or normal CXR appearance despite pulmonary disease.
    • Obtain 3 sputum specimens 8-24 hours apart for AFB smear and culture. Consider sputum induction/bronchoscopy to obtain specimen.
    • Obtain nucleic acid amplification testing (NAAT) on >1 respiratory specimen, even if smear (-).
    • If NAAT (+), obtain GeneXpert, HAIN, or other rapid molecular test for rifampin (RIF) resistance; if RIF resistance detected obtain full molecular testing for drug resistance through CDC. Contact your state TB program.
    • If indicated, collect other fluid or tissue specimens and request AFB smear, culture and NAAT (even if smear [-])
    • Obtain culture-based DST on initial TB culture isolate from any source.
  • TST and IGRA indicate that M.tb infection may be present, but do not rule out or confirm TB disease.
  • Aggressively pursue diagnosis when TB is suspected to enable TB susceptibility testing and confirm TB vs. other diagnosis.

NOTE: In extrapulmonary TB, sputum smear, NAAT, and culture should always be done even when (-) CXR to detect subtle TB disease.

Treatment of Drug-Susceptible TB Disease in Patients with HIV

  •  After collection of appropriate specimens, start TB treatment guided by molecular DST.
  • If clinical and radiographic presentation suggest TB disease but NAAT/PCR is (-), consider empirical treatment while cultures pending.
  • For drug-susceptible TB disease, use a 4-drug regimen of isoniazid (INH), (rifampin [RIF] or rifabutin [RFB]), pyrazinamide (PZA), and ethambutol (EMB)
    • RFB is often substituted for RIF in pts with HIV since it is a less potent inducer of drug metabolism and can be used with most ART (See Table 5 for information about drug interactions)
    • Rifapentine (RPT) is a long-acting rifamycin that is dosed once weekly, but should NOT be used to treat TB disease in pts with HIV due to higher rates of relapse and resistance.

Treatment of Drug-Susceptible TB Disease in Patients with HIV

  •  After collection of appropriate specimens, start TB treatment guided by molecular DST.
  • If clinical and radiographic presentation suggest TB disease but NAAT/PCR is (-), consider empirical treatment while cultures pending.
  • For drug-susceptible TB disease, use a 4-drug regimen of isoniazid (INH), (rifampin [RIF] or rifabutin [RFB]), pyrazinamide (PZA), and ethambutol (EMB)
    • RFB is often substituted for RIF in pts with HIV since it is a less potent inducer of drug metabolism and can be used with most ART (See Table 5 for information about drug interactions)
    • Rifapentine (RPT) is a long-acting rifamycin that is dosed once weekly, but should NOT be used to treat TB disease in pts with HIV due to higher rates of relapse and resistance.
Table 2. Adult Dose of Agents for Active TB
Isoniazid Rifampin Rifabutin
Dose (mg/kg) 5 10 5
Usual Daily Dose 300 mg 600 mg 300 mg
Ethambutol (Suggested Doses Using Whole Tablets)
Weight (kg) 40-55 56-75 76-90
Daily Dose 800 1200 1600
Pyrazinamide (Suggested Doses Using Whole Tablets)
Weight (kg) 40-55 56-75 76-90
Daily Dose 1000 1500 2000

Notes:

  1. Dose based on actual body weight if not obese (i.e. > 20% above ideal body weight [IBW]). If obese, use IBW (MD+CALC https://www.mdcalc.com/ideal-body-weight-adjusted-body-weight and consider obtaining serum drug levels and TB/HIV expert consultation). 
  2. Doses are for pts with normal renal and hepatic function. Consult a TB/HIV expert for pts with abnormal renal and/or hepatic function.
  3. Daily therapy is 5-7 days per wk via DOT.
  4. See Table 5 for drug interactions and ART dosing recommendations

TB treatment includes 2 phases:

  • Initial Phase:
    • INH + (RIF or RFB) + PZA + EMB po once daily (5-7 days per wk) for 2 mos
    • Discontinue EMB prior to 2 mos if susceptible to INH, RIF/RFB, PZA
    • Pts should complete 8 wks of PZA
  • Continuation Phase: 
    • INH + (RIF or RFB) 5-7 days per wk for 4 mos;
    • Dosing 3 times per wk may be considered for some pts; consult an expert for use of intermittent TB regimens in pts with HIV to avoid relapse and drug resistance.
    • Extend continuation phase to ≥ 7 mos (e.g. 9 mos total treatment) if:
      • pt is not on ART
      • cavity on chest X-ray, and/or the sputum culture remains (+) at 2 mos.
      • 8 wks of PZA is not completed
    • Completion of TB therapy is based on number of doses received as well as duration in wks.

 

  • Use DOT for all pts treated for TB disease: video DOT (VDOT) may be appropriate (consult public health).
  • Use case management interventions during treatment of pts with TB disease (pt education and counseling, field and home visits, integration and coordination of all providers, pt reminders, and incentives and enablers).

NOTE: If sputum culture remains positive after 2 mos of TB treatment, send repeat sputum for rapid molecular DST (GeneXpert, etc.), assess adherence, consider serum drug levels, and consult a TB/HIV expert.

Initiating ART in Patients with HIV with TB disease

  • All pts with HIV with TB disease should start ART if:
    • CD4 < 50, start ART within 2 wks of starting TB therapy
    • CD4 ≥ 50, start ART within 8 wks of starting TB therapy

NOTE: If TB meningitis is suspected, do not start ART early due to risk of Immune Reconstitution Inflammatory Syndrome (IRIS). Corticosteroids recommended with TB therapy. Consult a TB/HIV expert for management.

Monitoring Treatment for Pulmonary TB

  • See Table 3 for recommended baseline and periodic assessments
  • As part of the baseline and monthly clinical assessment, assess concurrent medications for drug-drug interactions
  • Consult a TB/HIV expert for pts who fail treatment (e.g. (+) sputum culture after 4 mos of treatment) and/or have drug resistance

Possible Adverse Effects of TB Drugs:

Consult a TB/HIV expert for management of significant adverse effects or cases requiring changes in TB regimen.

Immune Reconstitution Inflammatory Syndrome (IRIS)

  • TB IRIS is diagnosis of exclusion. TB treatment failure, drug resistance, and other new diagnoses must be ruled out.
  • IRIS can manifest as worsening symptoms suggesting TB treatment failure, or can unmask undetected TB disease following ART treatment initiation. 
  • Continue both ART and TB therapy while managing IRIS.
    Mild IRIS can be treated with NSAIDs; severe IRIS (e.g., CNS symptoms, compromised airway or swallowing, sterile abscesses, uncomfortable lymph nodes) may require corticosteroids.
    • Steroid dosing option: Prednisone 1.5 mg/kg/day for 2 wks followed by 0.65 mg/kg/day for 2 wks (some pts may require higher doses or slower duration of taper)
  • Consult a TB/HIV expert for assistance.

Therapeutic Drug Monitoring (TDM)

  • Serum drug levels ensure safe and effective drug doses are used:
    • If TB HIV drug interactions exist
    • If pt develops an adverse effect
    • If pt has renal or hepatic disease
    • If pt has risk for malabsorption (e.g. HIV and diabetes)
    • If pt remains culture (+) after 2 mos of appropriate TB therapy or is clinically slow to improve
    • If 2nd-line TB drugs used (e.g., fluoroquinolones, linezolid, etc.)
  • TDM for HIV and TB drugs available through the Infectious Disease Pharmacokinetic Laboratory at U. Florida (https://idpl.cop.ufl.edu/)
    Call TB Hotline 1.800.4TB.INFO (1.800.482.4636) for expert interpretation and consultation regarding TDM.

 

Table 3. Monitoring Treatment for Active TB Disease in Patients with HIV

X=recommended in all pts, O=optional or recommended in certain situations (see footnotes)
Month of Treatment Completed
Activity Baseline 1 2 3 4 5 6 7 8 End of Treatment
Microbiology
Sputum smears and culture1 x x x o o o
Sputum NAAT2 x o
Drug susceptibility testing3 x o
Imaging
CXR or other imaging3 x o o
Clinical Assessment
Weight4 x x x x x x x x x
Symptom and adherence review5 x x x x x x x x x
Vision assessment6 x x x o o o o o o
Laboratory Testing
AST, ALT, bilirubin, alkaline phosphatase7 x x x x x x x x x
Platelet count8 x o o o o o o o o
Creatinine8 x o o o o o o o o
HIV testing9 x
Hepatitis B and C screen10 x
Diabetes Screen11 o
  1. If pulmonary TB, obtain sputa for smear and culture monthly until 2 consecutive (-) culture results. Obtain sputa more frequently early in therapy to assess for treatment response (optional). Test at least one baseline specimen using a rapid molecular test.
  2. Drug susceptibility testing for INH, RIF, EMB, and PZA is recommended. Repeat susceptibility testing if pt remains culture (+) after completing 3 mos of treatment. Molecular resistance testing recommended for pts at risk for drug resistance.
  3. Repeat CXR at 2 mos in pts who were culture (-) at diagnosis. Presumptive diagnosis of TB can be made if CXR is improving on treatment. End of treatment CXR is optional.
  4. Monitor weight monthly and adjust medication dose(s) as indicated.
  5. Assess adherence and monitor improvement in TB symptoms (e.g., cough, fever, fatigue, night sweats). Assess for development of medication adverse effects (e.g., jaundice, dark urine, nausea, vomiting, abdominal pain, fever, rash, anorexia, malaise, neuropathy, arthralgias).
  6. Required for pts on EMB. Baseline testing for visual acuity (Snellen test) and color discrimination. Inquire about visual disturbances and perform color discrimination testing monthly.
  7. Recommended monthly for pts at increased risk for hepatotoxicity, including pts with HIV.
  8. Monitoring beyond baseline only if abnormalities or as clinically indicated.
  9. CD4 and HIV RNA viral load in pts infected with HIV.
  10. Pts with HIV are at increased risk for Hepatitis B or C coinfection.
  11. Fasting glucose or hemoglobin A1c for pts with diabetes risk factors (age > 45, BMI > 25 kg/m², 1st degree relative with diabetes, and race/ethnicity of African American, Asian, Hispanic, American Indian/Alaskan Native, or Hawaiian Native/Pacific Islander.
Table 4. Drugs Used for Treatment of Drug-Susceptible Active TB and LTBI
NOTE: Consult a TB/HIV expert for pts with renal insufficiency (e.g., CrCL < 30 mL/min or on dialysis) and/or hepatic impairment (e.g., AST/ALT > 2 ULN). Although the guidelines provide empiric dosage adjustment recommendations, some experts do not recommend empiric dosage adjustment as TDM is often required to optimize dosing. See the TB Guidelines and call the 24-hour TB Hotline 1.800.4TB.INFO (1.800.482.4636) for assistance in managing pts with renal and/or hepatic impairment.
Drug Dosage Form Food Restrictions Important Points
Isoniazid
(INH)		 100, 300 mg tab;
50 mg/5 mL oral
soln; injection
(100 mg/mL)		 Empty stomach
(30 mins before or
2 hours after a meal)		 Avoid antacids for 2 hours before and after INH
Most common/severe AEs: hepatotoxicity, peripheral neuropathy, optic neuritis, rare hematologic or dermatologic reactions
Co-admin pyridoxine (vitamin B6) 25-50 mg once daily to prevent neuropathy
Rifabutin
(RFB)		 150 mg cap With or without food,
may open cap and mix
in food (applesauce)		 Most common/severe AEs: red-orange discoloration of body fluids (e.g., urine, sweat, tears), rash, flu-like syndrome, arthralgias, hematologic reactions (anemia, neutropenia, thrombocytopenia), uveitis (dose-related), hepatotoxicity
Rifampin
(RIF)		 150, 300 mg cap;
injection
(600 mg vial)		 Empty stomach
(1 hour prior to or 2
hours after meal); may
open cap and mix in
food (applesauce)		 Most common/severe AEs: GI upset, red-orange discoloration of body fluids (e.g., urine, sweat, tears), rash, flu-like syndrome, hematologic reactions (hemolytic anemia, leukopenia, thrombocytopenia), hepatotoxicity, hypersensitivity reaction (dermatologic manifestations including urticaria or rash; renal manifestations including ↑ BUN, ↑ uric acid, acute renal failure)
Rifapentine
(RPT)		 150 mg tab Take with food Most common/severe AEs: red-orange discoloration of body fluids (e.g., urine, sweat, tears), rash, flu-like syndrome, pyuria, hematologic reactions (anemia, neutropenia, thrombocytopenia), hepatotoxicity
Ethambutol
(EMB)		 100, 400 mg tab Take with food to ↓ GI
upset		 Most common/severe AEs: GI upset (nausea, vomiting, anorexia), optic neuritis (pt should report visual changes), peripheral neuropathy, arthralgias, hepatotoxicity, ↑ uric acid, hyperuricemia, rash, hypersensitivity reaction
Pyrazinamide
(PZA)		 500 mg tab With or without food Most common/severe AEs: nausea and vomiting (usually improves after a few wks), hepatotoxicity, arthralgias/myalgias, ↑ uric acid, rare hematologic reactions (thrombocytopenia, porphyria, sideroblastic anemia)

Table 5. Drug-drug Interactions with Rifamycins and ART

For additional details see the drug-drug interactions tables in the Adult/Adolescent ARV guidelines at
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/overview?view=full and www.hiv-druginteractions.org 
Rifampin (RIF)1-based Regimen with ART
NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs)
Do not use RIF with tenofovir alafenamide (TAF) containing regimens unless benefits outweigh the risks. See other sections of table for other ART interactions with TAF.
INTEGRASE STRAND TRANSFER INHIBITORs (INSTIs)
Do not use RIF with bictegravir/emtricitabine/TAF (Biktarvy)
Do not use RIF with cabotegravir (CAB) (Vocabria or Cabenuva)
Increase dolutegravir (DTG) to 50 mg po bid. Use alternative to RIF if INSTI-experienced with certain INSTI-associated resistance substitutions or clinically suspected INSTI resistance.
Do not use RIF with elvitegravir (EVG) containing regimens (Genvoya or Stribild)
Increase raltegravir (RAL) from 400 mg po bid to 800 mg po bid. Do not use once daily RAL with rifampin
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIS)
Efavirenz (EFV) 600 mg po every night (standard). Consider TDM.
Do not use RIF with doravirine (DOR)2, etravirine (ETR), nevirapine (NVP), or rilpivirine (RPV).
PROTEASE INHIBITORS (PIS)
Do not use RIF with any PI (boosted or unboosted) containing regimen.
CCR5 INHIBITOR
Use MVC 600 mg bid with RIF, or 300 mg bid if used with RIF and a strong CYP3A inhibitor
Rifabutin (RFB)-based Regimen with ART
NRTIs
Do not use RFB with TAF containing regimens (i.e. Biktarvy, Descovy, Genvoya, Odefsey)
INSTIs
No dosage adjustments for DTG or RFB3
No dosage adjustments for RAL or RFB3
Do not use RFB with CAB/RPV (Cabenuva).2 No interaction expected between RFB and CAB (Vocabria).3
Do not use RFB with bictegravir/emtricitabine/TAF (Biktarvy)
Do not use CAB with RFB with EVG-containing rregimens (Stribild or Genvoya).
NNRTIs
NNRTI Rifabutin (RFB)
DOR Increase DOR to 100 mg po bid. RFB standard dose.
EFV RFB 450–600 mg po once daily; or RFB 600 mg 3 times/wk with EFV 600 mg po once daily (if EFV is not coadministered with a PI).
ETR Do not combine ETR with RFB if used with a RTV-boosted PI. Standard dose for ETR and RFB if no boosted PI in regimen.
NVP Standard doses for NVP and RFB.
RPV Increase RPV from 25 mg po once daily to 50 mg po once daily. RFB standard dose.

PIs
(all standard dose with modified RFB dose as listed below)
Ritonavir (/r) or Cobicistat (/c)-boosted PIs2
Atazanavir (ATV)/r RFB 150 mg po once daily
Monitor for antimycobacterial efficacy, adverse effects, and consider TDM
Darunavir (DRV)/r
Lopinavir/r
Do not use RFB with cobicistat (/c) boosted PIs (ATV/c or DRV/c)
Unboosted PIs
ATV RFB 150 mg po once daily
CCR5 INHIBITOR
MVC 150 mg po bid (with potent CYP3A inhibitor);
MVC 300 mg po bid (without potent CYP3A inhibitor or inducer);
Dose RFB based on other drugs in regimen (consider TDM)
  1. All are with RIF standard dose.
    2. Cabenuva https://gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Cabenuva/pdf/CABENUVA-PI-PIL-IFU2-IFU3.PDF [package insert]. Research Triangle Park, NC: ViiV Healthcare, Inc.; Revised January 2021.
    3. If boosted PI included in regimen, see dosing recommendations listed above.

References

Unless otherwise noted, the information contained in this card has been adapted from the resources listed below.
For additional up-to-date information on the diagnosis and treatment of LTBI and/or TB disease:

 

Resources

Unless otherwise noted, the information contained in this resource has been adapted from the references listed below. Please consult: www.cdc.gov/tb for additional up-to-date information on the diagnosis and treatment of LTBI and/or TB.

HIV/AIDS Resources

  • ARV Therapy in Adults and Adolescents
  • Pre-Exposure Prophylaxis (PrEP), Non-Occupational Post-Exposure Prophylaxis (nPEP) and Occupational PEP (oPEP)

Visit https://www.seaetc.com

Tuberculosis Resources

  • TB Diagnosis, Radiology, Laboratory, & Management
  • Contact Investigation
  • Program Management
  • TST Train-the Trainer
  • Latent TB Infection
  • Corrections Toolkit
  • Pediatrics
  • Drug Resistant TB (MDR/XDR)

Visit https://sntc.medicine.ufl.edu/

CDC LTBI Resource Page

Visit https://www.cdc.gov/tb/publications/ltbi/ltbiresources.htm

SNP Caliper for Reading a TST

Order online: https://sntc.medicine.ufl.edu/home/index#/products/15

Contacts

Regional TB Consultation Services

TB Hotline – Southeastern National Tuberculosis Center

24-Hour Hotline: 800.4TB.INFO | https://sntc.medicine.ufl.edu/

 

Clinical Consultation Center

National HIV Clinician Consultation Center

Visit nccc.ucsf.edu for additional details including online resources, phone numbers and hours of operation.

Clinical consultation topics:

  • HIV/AIDS Management
  • Perinatal HIV/AIDS
  • Hepatitis C Management
  • Substance Use Management
  • PrEP: Pre-Exposure Prophylaxis
  • PEP: Post-Exposure Prophylaxis

AETC National Coordinating Resource Center

www.aidsetc.org

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