A 30-year-old HIV-positive woman (CD4 550/μL, no prior ART) develops active pulmonary tuberculosis. She is started on RIPE (Rifampicin-INH-Pyrazinamide-Ethambutol). When should antiretroviral therapy (ART) be initiated?
- A Within 2–8 weeks of starting TB treatment, depending on CD4 count ✓
- B After completion of TB treatment (6 months)
- C Within 2 weeks regardless of CD4 count
- D Only if CD4 drops below 200/μL during TB treatment
Correct answer: A. Within 2–8 weeks of starting TB treatment, depending on CD4 count
Explanation
SAPIT and CAMELIA trials established that ART should be started within 2–8 weeks of TB treatment initiation; timing depends on CD4 count. For CD4 <50/μL, ART should be started within 2 weeks (urgent); for CD4 ≥50/μL, within 8 weeks. Starting ART immediately at 2 weeks in patients with CD4 >50/μL increased IRIS without mortality benefit (SAPiT trial). The WHO 2021 guidelines recommend this staged approach. TB meningitis is an exception where ART initiation should be at 4–8 weeks to reduce IRIS risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.