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ART Timing in TB Coinfection — SCE Infectious Diseases MCQ

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ModerateHIV MedicineART Timing in TB CoinfectionSCE Infectious Diseases

A 30-year-old man with HIV on DTG/TAF/FTC develops a painless cervical lymph node. FNA shows acid-fast bacilli. GeneXpert confirms MTB without Rifampicin resistance. He is started on RHZE. His DTG is increased to 50 mg BD. When should ART have been started relative to TB treatment in a treatment-naive patient?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Within 2 weeks if CD4 <50; within 8 weeks for CD4 >50 — the CAMELIA, STRIDE, and SAPiT trials guide this; exception: TB meningitis (defer ART to ≥8 weeks to reduce IRIS risk)

Optimal ART timing in TB/HIV co-infection is stratified by CD4: CD4 <50 → start ART within 2 weeks of TB treatment (mortality benefit from early ART outweighs IRIS risk); CD4 >50 → start within 8 weeks (lower urgency, allows TB treatment to stabilise first). The exception: TB meningitis — ART should be deferred to ≥8 weeks due to significantly increased mortality from CNS-IRIS with early ART (Marais et al., NEJM 2014).

Reference: BHIVA 2022 – TB/HIV; WHO 2022; CAMELIA/STRIDE/SAPiT trials