HIV and TB

What are PrEP (Pre-Exposure Prophylaxis) options?

• Tenofovir disoproxil fumarate 300 mg + emtricitabine 200 mg PO daily

• Tenofovir alafenamide 25 mg + emtricitabine 200 mg PO daily (only in individuals assigned male at birth due to unclear effectiveness in preventing HIV from receptive vaginal sex; unknown whether reaches high enough concentrations in vaginal tissue)

• Cabotegravir 600 mg in months 1 and 2, then every 8 weeks thereafter (optional oral lead-in)

What is on demand PrEP (not currently FDA or CDC approved)?

Option for those who are MSM who do not wait daily PrEP dosing, who have sex infrequently, and who can anticipate when they will have sex

Tenofovir disoproxil fumarate 300 mg plus emtricitabine 200 mg, administered as 2-1-1 dosing:

• Two doses 2 to 24 hours before sex (closer to 24 hours preferred), followed by

• One dose 24 hours after the first dose, and then

• One dose 48 hours after the first dose

Which lab values should be checked before PrEP initiation and at least every 6 to 12 months?

• Renal fx with tenofovir

• Bacterial sexually transmitted infection screening

• Lipid profile

What is the goal of HIV “Treatment as Prevention”?

Maintaining HIV RNA less than 200 copies/mL with ARVs prevents HIV transmission to sexual partners

When should IV HIV medications be administered for pregnant women with HIV in labor (with or without therapy during pregnancy)?

IV zidovudine should be administered if the HIV RNA is >1000 copies/mL or unknown HIV RNA near delivery

What is the preferred regimen and duration for post-exposure prophylaxis (PEP)?

Begin prophylaxis within 72 hours and treat for 4 weeks

Preferred regimen:

TDF/FTC daily + RAL twice daily OR TDF/FTC + DTG daily

What is the alternate regimen and duration for post-exposure prophylaxis (PEP)?

Begin prophylaxis within 72 hours and treat for 4 weeks

Alternate regimen:

DRV/r daily + TDF/FTC daily

What are all the nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) products?

• Abacavir

• Emtricitabine

• Lamivudine

• Zidovudine

• Tenofovir disoproxil fumarate

• Tenofovir alafenamide

What are all the NON-nucleoside/nucleotide reverse transcriptase inhibitor (NNRTI) products?

• Doravirine

• Efavirenz

• Etravirine

• Nevirapine

• Rilpivirine

What are all the Protease Inhibitor (PI) products?

• Atazanavir

• Darunavir

• Lopinavir/ritonavir

• Ritonavir (booster)

What are all the Integrase Inhibitor (INSTI) products?

• Bictegravir

• Dolutegravir

• Elvitegravir (needs to be boosted w/ cobicistat)

• Raltegravir

• Cabotegravir

What are all the Entry Inhibitor products?

• Enfuvirtide

• Ibalizumab

• Lenacapavir

• Maraviroc

• Fostemsavir

What are recommended initial regimens for most patients with HIV?

Optimal ARVs for a tx-naive patient include 2 NRTIs in combo w/ an INSTI

• BIC/TAF/FTC

• DTG + TDF/FTC

• DTG/ABC/3TC, only for patients who are HLA-B*5701 negative

• DTG + 3TC; except for individuals with HIV RNA >500K copies/mL, with HBV coinfection, or when ARVs are to be initiated before results of HIV genotypic resistance testing for reverse transcriptase or HBV testing are available

What is the definition of AIDS (Acquired Immunodeficiency Syndrome)?

The progression from HIV to AIDS is defined by either a decline in CD4 count to <200 cells/mm3, or the onset of opportunistic infection(s), irrespective of CD4 count

At which CD4 count do we need prophylaxis for P. jiroveccii Pneumonia (PJP)?

CD4 <200

What is the prophylaxis regimen for Pneumocystis jiroveci pneumonia?

SMX/TMP SS (400 mg SMX/80 mg TMP) once daily

SMX/TMP DS (800 mg SMX/160 mg TMP) once daily

Alternative: SMX/TMP DS three times/week

How is an active Pneumocystis jiroveci pneumonia fungal infection treated?

High-dose Bactrim + corticosteroids to reduce lung inflammation (if PaO2 is less than 70 mm Hg)

15 to 20 mg/kg/day of TMP divided every 6 to 8 hours x 21 days (IV for mod to severe PJP);SMX/TMP DS 2 tablets 3x/daily or weight based for mild-to-moderate PJP

What are alternative options for PJP treatment?

Clindamycin and primaquine

Atovaquone

Pentamidine

Trimethoprim and dapsone

At which CD4 count do we need prophylaxis for toxoplasmosis gondii (protozoan)?

CD4 count <100 cells/mm3 plus Toxoplasma IgG-positive

What is the prophylaxis regimen for Toxoplasmosis gondii?

SMX/TMP DS once daily

OR dapsone/pyrimethamine/leucovorin or atovaquone ± pyrimethamine at doses used for PJP prophylaxis

What is the preferred regimen for active tx of toxoplasmosis gondii?

Pyrimethamine 50 to 75 mg/day (loading dose 200 mg) PLUS Sulfadiazine 1000 to 1500 mg q6 hours (watch crystalluria)

Duration: At least 6 weeks and after signs and symptoms resolve

At which CD4 count do we need prophylaxis for Mycobacterium avium Complex?

CD4 <50

What are regimens for MAC ppx?

• Azithromycin 1,200 mg PO once weekly, or

• Clarithromycin 500 mg PO BID, or

• Azithromycin 600 mg PO twice weekly

What are regimens for tx of active MAC infection?

Preferred regimen is azithrocmyin (macrolide) + ethambutol

Clarithromycin 500 mg (7.5 to 15 mg/ kg) twice daily or azithromycin 500 to 600 mg/d (10 to 20 mg/kg) (if drug interactions or intolerance of clarithromycin) plus ethambutol 15 mg/kg/d for at least 12 months 

What are dosing regimens to tx TB for patients who are not infected with HIV?

• Rifapentine 900 mg plus isoniazid 900 mg weekly for 12 weeks (as directly observed therapy [DOT] or self-administered therapy) 

• Rifampin 600 mg daily for 4 months 

• Rifampin 600 mg daily plus isoniazid 300 mg daily for 3 months 

What are dosing regimens to tx TB for patients who have HIV coinfection?

• Rifapentine 900 mg orally plus isoniazid 15 mg/kg orally (900 mg maximum) plus pyridoxine 50 mg orally, all once weekly for 12 weeks; only recommended for patients who are virally suppressed receiving an efavirenz-, raltegravir-, or once-daily dolutegravir-based regimen 

• Isoniazid 300 mg orally plus rifampin 600 mg orally plus pyridoxine 25 to 50 mg orally, all daily for 3 months (watch for drug interactions with rifampin) 

What are first-line agents for tx of TB?

What are DDIs with garlic?

Garlic is a CYP3A4 and PGP inducer

Which ART are susceptible to acid-suppressing agents (H2RA, PPI)?

Atazanavir

Rilpivirine

Which ART drugs have hepatitis B activity?

Tenofovir

Lamivudine

Emtricitabine

When to discontinue OI ppx?

What is the maintenance regimen for Cryptococcus meningitis?

Fluconazole 200 mg/day for at least 1 year (12 months)

What is the treatment regimen for toxoplasma encephalitis?

Pyrimethamine and sulfadiazine are the first-line agents for toxoplasmosis; however, leucovorin should always be used with pyrimethamine to prevent myelosuppression

If a patient is on ART and develops pulmonary TB, how should you modify their overall regimen?

Because of the risk of IRIS, initiation of rifabutin and isoniazid concomitantly with any ARVs is not recommended for the first 2 months of anti-TB therapy

What is the treatment regimen for active TB infection?

**Note: Guidelines were changed in 2025!

The recommended therapy for active TB is

Which OI do you need to delay or hold ART in patients living with HIV?

Tuberculosis (2 months)

Crytococcus meningitis (2 to 10 weeks)

In lieu of primary prophylaxis, what is recommended for patients with CD4 counts less than 50?

For CMV, patients with CD4 counts less than 50 cells/ mm3 should receive regular funduscopic examinations.

A fundoscopic examination (or ophthalmoscopy) is a non-invasive diagnostic procedure that uses a light and magnifying lens to view the back interior wall of the eye (the fundus). It evaluates the retina, optic nerve, macula, and blood vessels to detect eye diseases and systemic conditions like diabetes and hypertension.

What is the treatment regimen for active cryptococcal meningitis infection?

Induction + Consolidation therapy

Patients with cryptococcal meningitis should ideally be treated with liposomal amphotericin and flucytosine for

at least 2 weeks, followed by fluconazole for at least 8 weeks

What is the preferred drug regimen for treating latent TB in patients who are not infected with HIV?

Isoniazid 900 mg orally weekly + rifapentine 900 mg oreally weekly x 3 months

What is the preferred drug regimen for treating latent TB in patients who are coinfected with HIV?

Compared to non-HIV, you would add pyridoxine:

Rfampin + isoniazid + pyridoxine all daily for 3 months

What is the preferred drug regimen for treating active TB in patients who are not infected with HIV?

**Guidelines were changed in 2025!

In patients 12+ years with drug-susceptible pulmonary TB, recommended 4-month regimen of isoniazid, rifapentine, moxifloxacin, and pyrazinamide

This is reduced from previous 6 months that included a 4-component initial phase followed by 2-component continuation phase, and the moxifloxacin replaces ethambutol

In which deficiency is dapsone contraindicated?

Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency

Which drugs should be avoided in patients with G6PD deficency?

High-risk drugs to avoid include primaquine, dapsone, nitrofurantoin, methylene blue, phenazopyridine (Pyridium), and rasburicase