Management of HIV Patients with Latent TB on Antiretroviral Therapy

Introduction to Latent TB Treatment in HIV Patients

• The American Thoracic Society recommends a 1-month course of daily rifapentine plus isoniazid for latent TB in persons with HIV, which is equivalent to 9 months of isoniazid 1, 2
• The Centers for Disease Control and Prevention suggest that latent TB treatment should be initiated promptly to prevent progression to active disease, especially in HIV-infected patients 3

Antiretroviral Therapy Regimen Selection

• The American College of Cardiology is not relevant here, instead the HIV guidelines from the Department of Health and Human Services recommend dolutegravir 50mg twice daily with TDF/FTC as the regimen when rifamycin-based therapy is needed 1
• TDF (tenofovir disoproxil fumarate) does not require dose adjustment with rifamycins and is the preferred tenofovir formulation in this setting, according to the World Health Organization 1

Important Clinical Considerations for Regimen Switching

• HIV viral load assessment is recommended 1 month after switching regimens, as suggested by the Infectious Diseases Society of America 4
• The patient's current viral suppression must be maintained during the switch, and the patient should continue current ART until the new regimen is available to avoid any treatment interruption, as recommended by the American Academy of HIV Medicine 5

Common Pitfalls to Avoid in HIV and Latent TB Management

• The Centers for Disease Control and Prevention advise against continuing bictegravir with any rifamycin-based regimen without switching ART, as this will result in subtherapeutic bictegravir levels and potential virologic failure 1, 6
• The World Health Organization recommends against using TAF-containing regimens with rifamycins; TDF is the preferred tenofovir formulation in this setting 1, 2

Administration Guidelines for Tenofovir/Lamivudine/Dolutegravir (TLD)

Food Requirements

• TLD may be administered with or without food; dolutegravir does not require a specific meal size or caloric intake, providing flexibility compared with other antiretrovirals. 7

Antacids and Mineral Supplements

• When TLD is taken once daily, no timing restrictions or dose adjustments are needed for concomitant calcium, iron, magnesium, or aluminum supplements, and the clinical impact of these interactions is minimal. 7

Missed Dose Management

• If a missed dose is remembered within 12 hours of the scheduled time, the patient should take the dose immediately and then continue the regular dosing schedule. 7
• If more than 12 hours have passed since the scheduled dose, the patient should skip the missed dose and take the next dose at the usual time, without doubling the dose. 7