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. Author manuscript; available in PMC: 2014 Nov 1.
Published in final edited form as: Pediatr Infect Dis J. 2013 Nov;32(0 2):i–KK4. doi: 10.1097/01.inf.0000437856.09540.11

Table.

Summary of Recommendations for Concurrent Use of Antiretroviral Therapy and TB Treatment

Age/Weight Combination Antiretroviral Therapy (cART)a
Aged <3 years or weight <10 kg Retain or Start the Following Regimens

  • NRTI backbone; use 2 NRTIs

Third Drug
If Receiving NVP, Consider:

  • Switching to lopinavir/ritonavir (Kaletra®) with additional ritonavir to achieve mg-for-mg parity with lopinavir and continue for 1–2 weeks after treatment for TB has been stopped

  • If not possible, continue NVP dose at the upper end of the dosage scale

If Receiving Lopinavir/Ritonavir (Kaletra®):

  • Use additional ritonavir as above

  • If ritonavir boosting is not possible, substitute NVP for lopinavir/ritonavir (preferably only if undetectable viral load and if not previously exposed to NVP through PMTCT or prior treatment regimen) dose at the upper end of the dosage scale

For cART Initiation

  • Triple NRTI therapy is an option, if baseline viral load <100,000 copies/mL
Aged ≥3 years and weight ≥ 10 kg Retain or Start the Following Regimens

  • 2 NRTIs as backbone

Third drug
If Receiving EFV:

  • Retain efavirenz (no dosage adjustment necessary)

If Receiving NVP:

  • Substitute efavirenz for nevirapine

  • If efavirenz not available, continue nevirapine; dose at the upper end of the dosage scale

If Receiving Lopinavir/Ritonavir (Kaletra®):

  • Consider substituting efavirenz for lopinavir/ritonavir, preferably only if viral load is undetectableb and no prior NNRTI exposure

  • Alternatively use additional ritonavir as above

  • If starting efavirenz or ritonavir boosting is not possible, start NVP in place of lopinavir/ritonavir, preferably only if undetectable viral load and no prior NNRTI exposure; dose at the upper end of the dosage scale

For Initiation:

  • Triple NRTI therapy is an option if baseline viral load <100,000 copies/mL
Treatment for TB is not adjusted and should be initiated as soon as the diagnosis is made.
No cART adjustment is necessary with INH preventive therapy

Monitoring:

  • If previously on cART, monitor clinically for signs of drug toxicity; routine liver function testing every 2–3 months is advisable for all children on cART; no routine additional testing beyond what is done for routine HIV care and treatment is advised unless clinically indicated (BIIl).

  • If cART newly initiated—Liver chemistry tests (such as serum ALT concentration) should be performed before initiation and after 2, 4, and 8 weeks of treatment for TB (the same for cART initiation while receiving treatment for TB) (Blll). Beyond 2 months, routine testing every 2–3 months is advisable for all children on cART; no routine additional testing beyond what is done for routine HIV care and treatment is advised unless clinically indicated (BIIl).
a

TB patients newly diagnosed with HIV should receive cART as soon as possible, after completing the first 2 weeks of treatment for TB (earlier if clinically justified); efavirenz is preferred third drug with concurrent rifampin-based treatment for TB, but alternative options need to be considered in children aged <3 years and in those for whom efavirenz is not a preferred option.

b

Children established on cART should be assessed for therapeutic failure. Do not exchange only a single drug in children whose viral load is not suppressed; rather, consider a full regimen change.

Adapted from Marais, Rabie, Cotton (2011)

Key to Acronyms: cART = combined antiretroviral therapy; EFV = efavirenz; NRTI = nucleoside reverse transcriptase inhibitor; NVP = nevirapine; TB = tuberculosis