Treatment of HIV-related Tuberculosis in the Era of Effective Antiretroviral Therapy

The introduction of combination antiretroviral therapy has revolutionized the treatment of advanced human immunodeficiency virus (HIV) infection, decreasing death and opportunistic infections by 60 to 90%. Most patients with HIV-related tuberculosis in the United States have advanced immunosuppression and high plasma HIV RNA levels at the time of diagnosis. The clinical correlates of these laboratory indices are relatively high rates of other opportunistic infections and death, with most deaths being due to complications of HIV, not tuberculosis. Given the severity of immunodeficiency among patients with HIV-related tuberculosis and the effectiveness of antiretroviral therapy in reversing HIV-induced immunodeficiency, use of antiretroviral therapy in this population has the potential to substantially improve clinical outcomes. However, the use of antiretroviral therapy among persons being treated for tuberculosis is complicated by overlapping toxicity profiles of some antituberculosis and antiretroviral drugs, concerns about drug malabsorption and complex drug-drug interactions, and the occurrence of paradoxical reactions. We review the complexities of using antiretroviral drugs in the context of tuberculosis treatment and suggest management strategies.