Antiretroviral Therapy in AIDS Patients with Tuberculosis

Tuberculosis associated with HIV infection continues to be an important problem throughout theworld. Since the advent of HAART, the medication of HIV-infected patients who have to receive concomitanttreatment for tuberculosis has become a difficult task. The two main problems faced byclinicians include the significant pharmacokinetic interactions between rifamycins, a cornerstone inantituberculosis therapy, and protease inhibitors and nonnucleoside reverse transcriptase inhibitors,which are essential components of antiretroviral combination regimens, as well as the best momentto initiate antiretroviral therapy in patients with tuberculosis. The therapy of choice for patients withno previous antiretroviral experience includes an antituberculous regimen with rifampin and an efavirenz-based antiretroviral regimen. No dose adjustments of these drugs seem to be necessary.Nevirapine can be an alternative to efavirenz in this situation. For patients who cannot take efavirenz,either due to resistance or intolerance, rifabutin and a boosted protease inhibitor can be coadministered,with the necessary dose adjustments. No definite recommendations can be given regardingthe optimal timing of antiretroviral therapy, but a delay of two months after initiation of antituberculosistherapy would be advisable and seems to be safe in most patients.