When to Start Antiretroviral Therapy in HIV Patients with Tuberculosis

Tuberculosis (TB) is the most common infectious cause of death in HIV-infected individuals worldwide. Although its incidence and severity increases as immunodeficiency worsens, TB may also appear in HIV-positive subjects with preserved CD4 counts. However, even in the last scenario, there is increased mortality of HIV-infected persons once TB has been diagnosed, regardless of CD4 counts. For this reason, current guidelines recommend initiation of antiretroviral therapy in all HIV/TB patients. However, early initiation of antiretroviral therapy, beginning either simultaneous with or soon after initiating TB drugs, may be associated with a lot of problems, including: (i) drug interactions; (ii) overlapping side effects; (iii) high pill burden and potential compromise in drug adherence; and (iv) immune reconstitution inflammatory syndrome (IRIS). Conversely, a delay in initiating antiretroviral therapy may result in the development of further opportunistic infections and premature death.