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Updated January 17, 2012

Newly Diagnosed HIV and Active Tuberculosis: Antiretroviral Therapy and Co-trimoxazole Prophylaxis

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A 42-year-old man from Ethiopia presents with a 2-week history of fever, cough, pleuritic chest pain, dyspnea on exertion, and weight loss. He has never had an HIV test. His chest radiograph (Figure 1) shows patchy infiltrates in the right upper lobe concerning for tuberculosis. A sputum sample shows 2+ acid-fast bacilli by Auramine stain and he is diagnosed presumptively with tuberculosis. An HIV antibody test is performed and is positive. The patient's CD4 count is 37 cells/mm3.

Which one of the following options would you recommend regarding initiation of antiretroviral therapy for this patient?

A Start antiretroviral therapy after he has completed treatment for TB (6 months of directly observed therapy).
B Start antiretroviral therapy after he has completed the first 2 months of directly observed therapy for TB.
C Start antiretroviral therapy as soon as possible (within 2 to 8 weeks) following initiation of directly observed therapy for TB.
D Start antiretroviral therapy immediately and interrupt TB therapy until his CD4 count has risen to at least 200 cells/mm3.

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    Figure 1. Chest Radiograph of Patient at Initial Presentation

    Chest radiographic changes in a patient co-infected with HIV and TB.
    Source: David Spach, MD

    Figure 1