A 31-year-old HIV-positive man (CD4 count 35 cells/μL) is diagnosed with pulmonary tuberculosis and starts antitubercular therapy today. When should antiretroviral therapy be initiated according to current guidelines?

• A Only after completing the full course of antitubercular therapy
• B After completing 2 months of intensive phase antitubercular therapy
• C Within 2 weeks of starting antitubercular therapy ✓
• D Antiretroviral therapy should be deferred until the CD4 count exceeds 100 cells/μL

Explanation

For patients with active tuberculosis and CD4 counts below 50 cells/μL, guidelines recommend starting ART within 2 weeks of initiating antitubercular therapy, because mortality benefit outweighs the increased risk of immune reconstitution inflammatory syndrome. Patients with higher CD4 counts can wait until 8 weeks of treatment. Deferring ART until treatment completion leads to unacceptably high mortality in profoundly immunosuppressed patients.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.