We have been struggled over the years to find a perfect match, in terms of optimal ARV treatment combination, during TB-HIV co-infection, mainly due to drug-drug interaction between ARVs and Rifampicin. This scenario seems even worse, in developing settings, because of lack of alternatives in HIV armamentarium.

Although, in the light of recent evidences, Raltegravir based-regimen may be an good alternative in this case, extrapolating the phase II data from REFLATE trial presented at last CROI.

Other strategy, probably most feasible in resource-limiting countries, could be the hyper-boosted protease inhibitors like Kaletra. Kaletra is one of the preferred ARV approved during pregnancy. Probably these higher doses might be associated with excess of AEs that may limit adherence and ultimately viral efficacy.

Thank you José for your answer.

i suggest you that you start with TB treatment while 10 weeks and after with ARV treatment to prevent medication interraction

Thank you Cajouste for your answer. How about the risk to develop drugs resistance if I stop ARV therapy for 10 weeks?

Hello! I do not agree with Cajouste.

I will keep the Combivir, but I will replace the NVP by EFV ( 800 mg). Combivir + EFV (800 mg). Rifampicin decreases the effects of NVP ( 37-58%), and EFV of 13-26%. By increasing the dose of EFV, well you handle your treatment.

Thank you Islande for your answer. I prefer Kaletra. Efavirenz is the preferred non-nucleoside reverse transcriptase inhibitor for first-line antiretroviral treatment in many countries. For women of childbearing potential, advantages of efavirenz are balanced by concerns that it is teratogenic. During the first-trimester I think that the foetus could be at risk.

Hello Yanick! It is obvious! A major update of the WHO (June, 2012) on the use of efavirenz (EFV) during pregnancy was made​​.

This document slice very clearly in favor of EFV during pregnancy compared to NVP: no increased risk of the development of the pregnancy and the unborn child, better tolerance and efficacy (more than 5 recent major studies risk ).

WHO now recommends the use of EFV as first choice in women of childbearing age and pregnant women.

Ref. WHO HIV / AIDS Programme

Technical update on treatment optimization. Use of efavirenz falling on pregnancy: a public health perspective.

June 2012 WC 503.2

Thanks a lot for your information. I've read it.WHO has deducted that monitoring of birth defects is difficult and inconsistent. WHO plan to launch a Global Pregnancy Registry to support and encourage countries to register the outcomes of drug use in pregnant women in order to have more available information in the near future. They are not really sure. I don't want to take the risk with my patient. Low evidence for teratogenicity (neural tube defects) during early pregnancy has been noted in the summary of clinical characteristics of efavirenz and nevirapine . WHO has emphasize that additional research and ongoing surveillance through pregnancy registries are needed, both to prospectively collect more data on birth defects and other severe adverse events resulting from exposure to EFV and other ARVs, and to better assess programme, provider and patient perspectives on the true risks and benefits of EFV use, especially in low- and middle-income countries.

Co-administration of Kaletra and rifampicin is not recommended. Rifampicin in combination Kaletra causes large decreases in lopinavir concentrations that

can significantly reduce the effectiveness of lopinavir. Sufficient exposure

lopinavir / ritonavir can be obtained with an increase of Kaletra but the risk of toxicities

gastrointestinal and liver are then increased. Therefore, this co-administration should beavoided unless strictly necessary. there also, you run the risk. All factors must be taken into account with regard to risk.

Thank you Islande for your answer.