Current trends and intricacies in the management of HIV-associated pulmonary tuberculosis

Abstract

Human immunodeficiency virus (HIV) epidemic has undoubtedly increased the incidence of tuberculosis (TB) globally, posing a formidable global health challenge affecting 1.2 million cases. Pulmonary TB assumes utmost significance in the programmatic perspective as it is readily transmissible as well as easily diagnosable. HIV complicates every aspect of pulmonary tuberculosis from diagnosis to treatment, demanding a different approach to effectively tackle both the diseases. In order to control these converging epidemics, it is important to diagnose early, initiate appropriate therapy for both infections, prevent transmission and administer preventive therapy. Liquid culture methods and nucleic acid amplification tests for TB confirmation have replaced conventional solid media, enabling quicker and simultaneous detection of mycobacterium and its drug sensitivity profile Unique problems posed by the syndemic include Acquired rifampicin resistance, drug–drug interactions, malabsorption of drugs and immune reconstitution inflammatory syndrome or paradoxical reaction that complicate dual and concomitant therapy. While the antiretroviral therapy armamentarium is constantly reinforced by discovery of newer and safer drugs every year, only a few drugs for anti tuberculosis treatment have successfully emerged. These include bedaquiline, delamanid and pretomanid which have entered phase III B trials and are also available through conditional access national programmes. The current guidelines by WHO to start Antiretroviral therapy irrespective of CD4+ cell count based on benefits cited by recent trials could go a long way in preventing various complications caused by the deadly duo. This review provides a consolidated gist of the advancements, concepts and updates that have emerged in the management of HIV-associated pulmonary TB for maximizing efficacy, offering latest solutions for tackling drug–drug interactions and remedial measures for immune reconstitution inflammatory syndrome.

Two‐drug vs. three‐drug combinations for HIV‐1: Do we have enough data to make the switch?

“…HIV complicates tuberculosis management, demanding a different approach to effectively tackle both infections . A standard four‐drug followed by two‐drug, rifampicin‐containing regimen given daily for 6 months is still the recommended regimen for pan‐sensitive, pulmonary tuberculosis in PLWH.…”

“…A standard four‐drug followed by two‐drug, rifampicin‐containing regimen given daily for 6 months is still the recommended regimen for pan‐sensitive, pulmonary tuberculosis in PLWH. Tenofovir disoproxil fumarate (TDF), emtricitabine/lamivudine along with efavirenz as a single pill once a day is most ideal . There have been no studies of two‐drug ART combination therapy in HIV patients with pulmonary tuberculosis, so a triple‐drug regimen should always be considered first.…”

Drug susceptibility testing and mortality in patients treated for tuberculosis in high-burden countries

“…In patients co-infected by HIV, the treatment of drug-resistant tuberculosis is challenging for several reasons, including the poorer absorption of drugs [40], the risk of the immune reconstitution inflammatory syndrome (IRIS) [41], or interactions between antiretroviral and second-line tuberculosis drugs [42][43][44]. In contrast to previous studies from South Africa, which reported higher mortality at end of treatment in HIV-positive patients with MDR-TB compared to HIV-negative MDR-TB patients [35,45], we found no association with HIV infection, although confidence intervals were wide.…”

Comparative analysis of the effectiveness of tuberculosis prophylaxis in patients with HIV/AIDS treated with isoniazid

“…Tuberculosis (TB) was diagnosed in approx. 1.4 million patients with HIV infection, this concerns cases diagnosed for the first time in the discussed area (EECA) [1,2,3,4,5].…”