A 30-year-old HIV-positive man (CD4 45 cells/μL, HIV RNA 200,000 copies/mL) is about to start antiretroviral therapy. He also tests positive for latent tuberculosis (positive IGRA). According to current guidelines on timing of ART initiation in TB/HIV coinfection:
- A Start ART immediately with anti-TB treatment regardless of CD4 count
- B Wait until anti-TB treatment is completed (6 months) before starting ART
- C Start anti-TB treatment first; start ART within 2 weeks if CD4 <50, or within 8 weeks if CD4 >50 ✓
- D Start ART first for 4 weeks, then add anti-TB treatment
Correct answer: C. Start anti-TB treatment first; start ART within 2 weeks if CD4 <50, or within 8 weeks if CD4 >50
Explanation
ACTG A5221 (STRIDE) and SAPiT trials established that in HIV/TB coinfection, ART should be started within 2 weeks of anti-TB treatment initiation when CD4 <50 cells/μL (reduced mortality), and within 8 weeks when CD4 ≥50. Earlier ART in severely immunosuppressed patients reduces AIDS-related deaths despite higher risk of immune reconstitution inflammatory syndrome (IRIS). Deferring ART until TB treatment completion increases mortality in advanced immunosuppression.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.