In patients with HIV-related TB, the priority is to treat TB, especially smear-positive PTB (on account of the need to stop TB transmission). However, patients with HIV-related TB can have ART and anti-TB treatment at the same time, if managed carefully. Careful evaluation is necessary in judging when to start ART. In the case, for example, of a patient with a high risk of death during the period of TB treatment (i.e. disseminated TB and/or CD4 count <200/mm3), it may be necessary to start ART concomitantly with TB treatment. On the other hand, for a patient with smear-positive PTB as the first manifestation of HIV
infection, who does not appear to be at high risk of dying, it may be safer to defer ART until the initial phase of TB treatment has been completed. This decreases the risk of immune reconstitution syndrome and avoids the risk of drug interaction between rifampicin and a PI.
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