Initiation of Anti-retroviral Therapy [ART] in PLHIV with DR-TB

• The use of ART in HIV infected patients with TB improves survival for both drug-resistant and susceptible disease. However, HIV infected DR-TB patients without the benefit of ART may experience mortality rates exceeding 90%.
• As in any other PLHIV, those receiving the shorter oral bedaquiline-containing regimen should also receive prophylactic medication for opportunistic infections (OI), support for TB and ARV medication adherence and close monitoring of biomarkers of immune status.
• Co-trimoxazole can be provided to all patients with HIV as per WHO recommendation.
• Based on NACO Guidelines on ART for HIV infection in adults and adolescents; irrespective of CD4 cell counts, patients co-infected with HIV and TB should be started on ART as soon as possible after initiating TB treatment. The ART should be initiated as soon as possible in all HIV/TB co-infected patients with active TB. Second-line anti-TB drugs should be initiated first, followed by ART as soon as second-line anti-TB drugs are tolerated. Generally, this should be within the first two weeks of initiating DR-TB treatment. On the other hand, undue delay in starting ART could result in significant risk of HIV related death amongst DR-TB patients.
• It is critical that the ART medical officer and physician of N/DDR-TBC collaborate closely to decide on the ART regimen composition to adjust to the shorter oral bedaquiline-containing MDR/RR-TB regimen that is recommended to be used as a package with no scope of any modifications. However, regimen modification may be considered on a case to case basis in longer oral M/XDR-TB regimen based on drug-drug interactions and synergistic side effects between the component drugs of both regimen.
• Occasionally, patients with HIV related TB may experience a temporary exacerbation of symptoms, signs, or radiographic manifestation of TB after beginning TB treatment. This paradoxical reaction occurs in HIV infected patients with active TB and is thought to be a result of immune restitution due to the simultaneous administration of ART and tuberculosis medication (IRIS syndrome). Symptoms and signs may include high fever, lymphadenopathy, expanding intrathoracic lesions and worsening of chest radiographic findings. The diagnosis of a paradoxical reaction should be made only after a thorough evaluation has excluded other etiologies, particularly where TB treatment has failed. For severe paradoxical reactions prednisone (1–2 mg/kg for 1–2 weeks, then gradually decreasing doses) may be used.
• Patients with drug-resistant TB and HIV may suffer from severe wasting, diarrhoeal diseases and malabsorption syndromes. Wherever possible, patients with drug-resistant TB living with HIV should be offered socioeconomic and nutritional support. NTEP also monitors
treatment outcomes separately for HIV-TB patients.
• Considering the risk of developing primary DR-TB among susceptible close contacts, effective TB infection control measures are mandatory. If the patient shows signs of TB treatment failed, further evaluation is warranted. In addition, the ART regimen should be evaluated for possible treatment failed as described in other WHO guidelines.

Anti-retroviral regimen
• Patients of age > 10 years & weight > 30 kgs should be initiated on FDC of tenofovir (300 mg), lamivudine (300 mg) and dolutegravir (50 mg) - single pill daily.
• Patients of age > 10 years & weight < 30 kgs should be initiated on FDC of abacavir, lamivudine as per weight and dolutegravir (50 mg) once daily.