A 28-year-old man is newly diagnosed with HIV (CD4 280 cells/μL, viral load 250,000 copies/mL). He has active pulmonary TB. When should antiretroviral therapy (ART) be initiated relative to TB treatment per WHO/ACTG guidelines?
- A After TB treatment is completed (6 months)
- B Simultaneously on day 1 of TB treatment always
- C Within 8 weeks of starting TB treatment regardless of CD4 count, but within 2 weeks if CD4 <50 ✓
- D Only after sputum smear conversion to negative
Explanation
Based on the CAMELIA, STRIDE, and SAPIT trials, ART should be initiated within 2 weeks of TB treatment if CD4 <50 cells/μL (due to risk of AIDS-defining events and death) and within 8 weeks for CD4 >50 cells/μL. Earlier ART in the full group did not show survival benefit and increased immune reconstitution inflammatory syndrome (IRIS) risk. WHO 2021 and BHIVA guidelines endorse this strategy. The preferred ART backbone in TB/HIV coinfection uses efavirenz 600 mg OD (to avoid rifampicin interactions with protease inhibitors and some INSTIs) or dolutegravir with dose adjustment.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.