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TB / AIDS diagnosis
Nov 22, 2012

Dear experts,

Thailands treatment guideline is focused on low costs and therefore very simple (no drug resistance tests, no individual ART regimen, etc.). At very small private expenses, all drugs and tests as used in developed world are available. Unfortunately, most infected people here do not know about better or additional treatment options. Currently i need your help with the following situation:

30 year female 36kg / 156cm CD4 count at 166 CD4-% 18.0% viral load 862,000 virus has no drug resistance treatment of active TB without side effects since 10 days with isoniazid / rifampicin (rifampin) / pyrazinamide / ethambutol Herpes infect is treated so far successfully with acyclovir. All Hepatitis tested negative

Rifabutin as replacement for rifampin is unavailable in Thailand. National guidelines use Zidovudin / Lamivudin / Nevirapin as standard first-line ART regimen. I guess, that this should not be used during TB treatment with Rifampin (Nevirapine is decreased in blood by Rifampicin by about 50%). European guideline recommends Efavirenz with 2x NRTI.

On next appointment with her health care provider, the following questions need to be answered:

When should ART be started, after 2 weeks, 4 weeks, 2 months of TB treatment ? Which ART regimen is recommended ? What is the best dosing (eg. EFV 20% higher) ? Should an NNRTI-regimen be replaced with an PI-regimen after 9 months of TB-treatment due to NNRTIs lower resistance barrier ? Is Bactrim recommended as PCP prophylaxis until CD4 increased >200 ? Is other prophylaxis recommended in this situation (e.g. broadspectrum antibiotics) ?

I want to avoid outdated local standard treatment for her (until a few weeks, local treatment guideline poisened with Stavudine as part of default first-line regimen). Therefore i kindly ask you to provide me with all recommendations and arguements to be prepared for discussion and optional treatment with her local healthcare provider about final decision over these questions.

Response from Dr. Young

Hello and thanks for posting.

Fortunately, living in Thailand means that there's a high level of HIV and tuberculosis expertise.

In general, it's recommended that HIV treatment be started relatively soon after initiation of TB treatment. Assuming that the TB treatment is tolerated, I'd generally start the HIV treatment within 2-4 weeks.

HIV regimens need to be selected on the basis of available medications, potential for drug-drug interactions and overlapping side effects. The standard Thai first line regimen is generally acceptable, but the possibility of increased risk of liver toxicity from medications is raised with nevirapine and the TB medications. For what it's worth, US and European guidelines no longer place AZT+3TC as a preferred first-line NRTI combo, in favor of either tenofovir+FTC (or 3TC) or abacavir+3TC-- these are generally better tolerated and afford once-daily dosing options. Stavudine (d4T) was long ago abandoned because of increased risk of toxicities.

There is a wealth of experience using NNRTI regimens with efavirenz during TB treatment, and while some experts suggest using a higher dose of efavirenz (800 mg), there's also the competing notion that most Thais are of lower body mass and might also be slower metabolizers of efavirenz. Add to this data on not using increased dose of efavirenz, and I'd empirically believe that standard dose efavirenz would be acceptable.

You're correct in pointing out the differences in potential resistance profiles of NNRTIs and boosted PIs, though I can't say that we plan for switching from one to another for this reason alone.

Trimethoprim/sulfa (Bactrim, Septra, Cotrimoxazole) is recommended for all persons living with HIV who have CD4s less than 200, and we typically continue for several months (3-6) after the count is above 200 and CD4 percentage is above 15. With the patient's CD4 count above 100, no additional antibiotic prophylaxis is recommended.

If it helps, here's the link to the current US DHHS Treatment Guidelines

I hope that helps. Write back any time. BY



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