Immune reconstitution inflammatory syndrome in HIV-infected patients with tuberculosis

Tuberculosis (TB) remains an important problem in patients with human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS). Concomitant administration therapy of both TB and HIV is fraught with difficulties. Despite the fact that the use of highly active antiretroviral therapy (HAART) led to significant improve quality of life and decrease morbidity including mortality-associated to HIV/AIDS, adverse drug effects lead to interruptions in both HIV and TB therapy. In addition, an important problem when HAART is initiated in patients with TB is the possibility of developing immune reconstitution inflammatory syndrome (IRIS). A six-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutal for two months followed by isoniazid and rifampicin for four months is a standard regimen for the treatment of known or presumed drug-susceptible TB disease. The following strategy may minimize the risk of IRIS. Patients with CD4 cell counts < 100 cells/mm3, efavirenz-based HAART regimen is recommended and should be initiated as soon as the patients can tolerate TB treatment. Patients with CD4 cell counts 100-350 cells/mm3, HAART should be started at two months after TB treatment initiation. HAART should be deferred with closed follow-up of CD4 cell counts if patients have CD4 cell counts > 350 cells/mm3.