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Neftaly BHIVA guidelines for the management of tuberculosis in adults living with HIV

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Certainly! The South African (Neftaly) BHIVA guidelines for the management of tuberculosis (TB) in adults living with HIV** align with international standards but are adapted for local context and resource availability. Below is a summary of the key points from the BHIVA (British HIV Association) guidelines with considerations relevant to South Africa (Neftaly):

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Management of Tuberculosis in Adults Living with HIV (Based on BHIVA & adapted for South Africa):

1. Screening and Diagnosis

• All people living with HIV (PLHIV) should be routinely screened for TB symptoms (cough, fever, night sweats, weight loss).
• Use Xpert MTB/RIF as the first-line diagnostic test for TB (detects TB and rifampicin resistance).
• Additional tests: Chest X-ray, sputum culture, or urinary LAM (lipoarabinomannan) antigen test in severely immunocompromised patients (CD4 <100).
• Screen for latent TB infection in asymptomatic patients, especially those with high CD4 counts, using Tuberculin Skin Test (TST) or Interferon-Gamma Release Assays (IGRA), where available.

2. Treatment of Active TB

• Use the standard 6-month regimen:
  • Intensive phase (2 months): Isoniazid, Rifampicin, Pyrazinamide, Ethambutol (HRZE)
  • Continuation phase (4 months): Isoniazid and Rifampicin (HR)
• For rifampicin-resistant TB, follow local guidelines for multidrug-resistant TB (MDR-TB).
• Adjust antiretroviral therapy (ART) considering drug interactions:
  • Rifampicin is a potent inducer of cytochrome P450 enzymes and reduces the levels of many ART drugs.
  • Preferred ART regimens include Efavirenz-based or Dolutegravir-based regimens, with dosage adjustments as needed.
• Start ART as soon as possible within 2 weeks of starting TB treatment if CD4 <50 cells/mm³, and within 8 weeks if CD4 >50 cells/mm³.

3. ART and TB Treatment Drug Interactions

• Efavirenz: Generally compatible with rifampicin.
• Dolutegravir: Recommended with a dose adjustment (50 mg twice daily) during rifampicin use.
• Avoid protease inhibitors with rifampicin or adjust with rifabutin.

4. Management of TB Immune Reconstitution Inflammatory Syndrome (IRIS)

• Occurs typically 2-8 weeks after starting ART.
• Characterized by worsening symptoms/signs of TB.
• Management includes corticosteroids for moderate-severe cases and continuation of ART and TB treatment.

5. Preventive Therapy

• Offer Isoniazid Preventive Therapy (IPT) for 6 months to all PLHIV without active TB, regardless of ART status.
• Consider IPT after ruling out active TB using symptom screening and diagnostic tests.
• Continuous monitoring for TB symptoms during IPT.

6. Monitoring and Follow-up

• Regular clinical review to monitor adherence, side effects, and treatment response.
• Laboratory monitoring for liver toxicity and other adverse drug reactions.
• Monitor viral load and CD4 counts per standard HIV care guidelines.

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Summary Table

Aspect	Recommendation
TB Screening	Routine symptom screening; Xpert MTB/RIF first-line test
Active TB Treatment	6-month standard regimen (HRZE → HR)
ART Initiation Timing	Within 2 weeks if CD4 <50; within 8 weeks if CD4 >50
Preferred ART Regimens	Efavirenz-based or Dolutegravir with dose adjustments
TB Preventive Therapy	6 months Isoniazid for all without active TB
Manage IRIS	Corticosteroids if severe, continue ART and TB meds

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If you want, I can provide you with more detailed South African National TB and HIV guidelines or specific BHIVA guideline excerpts. Would you like that?

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