Summary

This TB-HIV guideline describes the diagnosis, treatment and care of LTBI and active tuberculosis in HIV-infected patients in the Netherlands. The number of TB-HIV coinfected patients is rather low, with 20-30 patients annually, hence all cases need to be discussed with an expert in TB and HIV.

 

All HIV-infected people with an increased risk for LTBI should be screened with a tuberculin skin test (TST) and/or IGRA depending on the CD4 count. Preventive LTBI treatment (different regimen options) is recommended for all HIV-infected people with a positive TST and/or IGRA and all HIV-infected close contacts of contagious pulmonary TB patients regardless TST or IGRA results.

 

All TB patients should be offered an HIV-test, except children younger than 12 years who were born in the Netherlands and diagnosed through contact investigation, as antenatal HIV screening is > 99.5% and vertical transmission has not been notified since 2015.

 

Diagnosis and treatment of tuberculosis in HIV-infected patients is in general similar than in non-HIV- infected patients, although the clinical presentation can be different and extrapulmonary and disseminated tuberculosis are more common, especially in patients with low CD4 counts. Additional diagnostic tests including urine lipoarabinomannan assay (LAM) can be useful, while differential diagnosis with non-tuberculous mycobacteria should also be taken into account and ruled out.

 

Standard duration for TB treatment is 6 months (2HRZ(E)/4HR(E) and 9 months (2HRZ(E)/7HR(E) for TB meningitis. Duration of treatment can also be extended to 9 months in case of extensive cavities, positive sputum culture after 2 months treatment or for patients not receiving antiretroviral treatment. All patients with TB meningitis should be discussed with an expert and possibility for intensified antibiotic treatment should be considered. Therapeutic drug monitoring in HIV patients is advised at least once, with a minimum of 2 weeks after start anti-tuberculous treatment.

 

Despite increased risk for overlapping toxicities and immune reconstitution inflammatory syndrome (IRIS), new HIV patients with CD4 < 50/mm3 should be initiated on ART 2 weeks after start TB treatment to prevent progression of HIV and opportunistic infections; in patients with CD4 > 50/mm3 ART can be initiated 2 – 8 weeks after start TB treatment. The preferred ART regimen when using rifampicin should comprise dolutegravir (or raltegravir as alternative) combined with 2 nucleoside/nucleotide analogues. The dosage of dolutegravir and raltegravir should be adjusted to 50 mg twice a day and 800 mg twice a day respectively. TB-IRIS is diagnosed by excluding other causes of disease worsening and treated with corticosteroids, in cases with high risk for IRIS preventive treatment with prednisone can be considered.

 

Immuno-incompetent contacts are more common amongst (close) contacts of HIV-infected TB patients and once infected at increased risk of progression to active TB. Hence contact investigation should start within 2 weeks of notification of the index patient and primary prophylaxis should be considered.

 

TB-HIV coinfected patients should be treated and supported by a multidisciplinary team providing patiënt-centred-care, with a TB public health nurse as case manager ensuring effective collaboration and communication between the HIV treatment centre and TB department at GGD.

 

HIV-infected children should not be vaccinated with BCG. Only foreign-born children of mothers with unknown HIV status, should be screened for HIV before BCG vaccination, all other children can be vaccinated without HIV testing.