Treatment of Drug-Susceptible Tuberculosis Disease
in HIV-Infected Persons
Last Updated: March 2003
In February 2003, the American Thoracic Society (ATS), the Centers
for Diseases Control and Prevention (CDC), and the Infectious Diseases
Society of America (IDSA) released new guidelines for the treatment
of TB. This fact sheet will provide key points from these guidelines;
however, please refer to the Treatment of Tuberculosis1 for complete
The management of HIV-related tuberculosis (TB) disease is complex.
Although the treatment of TB in persons with HIV is essentially
the same as for patients without HIV, there are some important differences.
The recommended treatment of TB disease in HIV-infected adults
(when the disease is caused by organisms that are known or presumed
to be susceptible to first-line drugs) is a 6-month regimen consisting
- An initial phase of isoniazid (INH), a rifamycin
(see Drug Interactions below), pyrazinamide (PZA), and ethambutol
(EMB) for the first 2 months.
- A continuation phase of INH and a rifamycin
for the last 4 months.
Patients with advanced HIV (CD4 counts < 100/µl) should be treated
with daily or three-times-weekly therapy in both the initial and
the continuation phases. Twice weekly therapy may be considered
in patients with less-advanced immunosuppression (CD4 counts ≥
100/µl). Once-weekly INH/rifapentine in the continuation
phase should not be used in any HIV-infected patient.
Six months should be considered the minimum duration of treatment
for adults with HIV, even for patients with culture-negative TB.
Prolonging treatment to 9 months (extend continuation phase to 7
months) for HIV-infected patients with delayed response to therapy
(e.g., culture positive after 2 months of treatment) should be strongly
A major concern in treating TB in HIV-infected persons is the
interaction of rifampin (RIF) with certain antiretroviral agents
(some protease inhibitors [PIs] and nonnucleoside reverse transcriptase
inhibitors [NRTIs]). Rifabutin, which has fewer
problematic drug interactions, may be used as an alternative to
As new antiretroviral agents and more pharmacokinetic data become
available, these recommendations are likely to be modified.
Directly observed therapy (DOT) and other adherence promoting
strategies should be used in all patients with HIV-related TB. Whenever
possible, the care for HIV-related TB should be provided by or in
consultation with experts in management of both TB and HIV. The
care for persons with HIV-related TB should include close attention
to the possibility of TB treatment failure, antiretroviral treatment
failure, paradoxical reactions of TB (e.g., temporary worsening
of signs or symptoms of TB), side effects for all drugs used, and
drug toxicities associated with increased serum concentrations of
For More Information
for Disease Control and Prevention. Treatment of Tuberculosis.
MMWR 2003;52(No. RR-11).
documents for the medical management of HIV
Guidelines for the Use of Rifamycins for the Treatment of Tuberculosis
Among HIV-Infected Patients Taking Protease Inhibitors or Nonnucleoside
Reverse Transcriptase Inhibitors. MMWR 2004: 53 (No.
Managing Drug Interactions in the Treatment of HIV-Related Tuberculosis
Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention