What are the key considerations for managing a patient with TB who is also living with HIV?

Key considerations for management and investigations of a patient with tuberculosis (TB) living with HIV include:

• Prompt specialist referral and assessment: Patients with suspected active TB and HIV should be urgently referred to a multidisciplinary TB team for diagnosis and management without waiting for culture results, due to the increased risk and complexity associated with HIV infection ¹,².
• Use of rapid diagnostic tests: Rapid nucleic acid amplification tests (NAATs) for Mycobacterium tuberculosis complex should be performed on primary specimens in patients with HIV to enable quick diagnosis and appropriate treatment initiation ².
• Comprehensive diagnostic sampling: Multiple respiratory samples (preferably three deep cough sputum samples including an early morning sample) should be collected for microscopy, culture, and NAATs. Alternative sampling methods such as sputum induction, bronchoscopy, or organ-specific biopsy may be necessary depending on disease site and patient condition ².
• Imaging investigations: Chest X-ray is essential, and CT or MRI scans should be considered especially if extrapulmonary or central nervous system TB is suspected, which is more common in HIV-positive patients ².
• Standard TB treatment with modifications: Standard combination antibiotic therapy (usually 6 months of isoniazid, rifampicin, pyrazinamide, and ethambutol) should be initiated promptly. Treatment regimens may need adjustment for drug interactions with antiretroviral therapy (ART) and for renal impairment ¹,².
• Management of drug-resistant TB: Multidrug-resistant TB requires prolonged and complex treatment regimens, often involving multiple drugs for 18–24 months, with specialist input ¹.
• Enhanced adherence support: Due to increased risk of poor treatment outcomes and adverse effects in HIV co-infection, enhanced case management including directly observed therapy (DOT) or video observed therapy (VOT) is recommended to improve adherence ¹.
• Infection control and public health measures: Patients with pulmonary or laryngeal TB should follow respiratory hygiene measures and wear masks until at least two weeks of treatment have been completed. Contact tracing and notification to public health authorities are mandatory ¹,².
• Multidisciplinary care coordination: Care should be coordinated between TB specialists, HIV clinicians, pharmacists, social workers, and other relevant professionals to address clinical, social, and psychological needs ¹,².
• Monitoring and managing drug interactions: Careful monitoring for interactions between TB drugs and ART is essential to avoid toxicity and ensure efficacy ¹.