Young adult male, suffering from tuberculosis, of the abdomen involving kidney, pancreas, mesentric nodes, prostate, has a low cd4 of 90. Which of these two diseases need to be treated first, TB or HIV, and how does one predict the onset of IRIS?
Dear Venkata,
Treatment of HIV is almost never an emergency. But treatment of TB can be indeed. In the case you describe what has priority is the treatment of TB.
In case of TB and HIV coinfection, the treatment of TB shouldd be started first and HIV treatment should be started during the TB treatment, not afterwards. That is a kind of basic rule. In case of pulmonary TB, If the patient has less than 50 CD4 cells then the treatment of HIV should start after 2 weeks of efective TB treatment (there is even discussion about starting within 1 week only but general consensus is 2 weeks). If the patient has more than 50 CD4 cells, the HIV treatment can be refered. Because of simplification a general recommendatioin is initiation of HIV treatment 2-4 weeks after the initiation of TB treatment. Nevertheless, these data are for pulmonary TB. There is concern about if we can extrapolate these data to extrapulmonary TB. That is an unknown questioin and it looks like for sever cases (like TB meningitis) HAART should be refered more than 2 weeks.
This is a very interesting and recent review article about the issue:
Naidoo K, Baxter C, Abdool Karim SS. When to start antiretroviral therapy during tuberculosis treatment? Curr Opin Infect Dis. 2013 Feb;26(1):35-42. doi: 10.1097/QCO.0b013e32835ba8f9.
http://www.ncbi.nlm.nih.gov/pubmed/23188213
I agree with Philip answer. Adding some points, although there is no consistent evidence pointing to starting HIV therapy right after TB therapy in all TB cases or other opportunistic infections, there was a shift on this rationale in the last five years or so. Currently most of the researchers are testing if starting HAART as soon as possible leads to better prognosis then late HAART including in ICU setting. Therefore if you start HAART in the first 2 to 3 weeks after RHZE, my guess is that you will suffer very little criticism, if any. Regarding IRIS, as far as I concern, there is no prediction model available to identify IRIS, nevertheless the available data points out that as lower the CD4+ more likely that IRIS will occur. Most of the time, steroids are at the same time diagnostic and therapy for IRIS.
Dear all,
I agree with Philip' s answer. This has been convincingly studied for pulmonary TB, and one issue of the New England Journal reported three studies to that topic . Two concluded that patients with < 50 cd4/µl benefited of starting after 2 weeks vs. after 2-3 months, while patients with >50 cd4 cells did not benefit. One study concluded all patients
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