With regard to HIV infection, a specific recommendation was made in 2011 on the use of ART in all patients with HIV and DR-TB (68, 115):
6.1. ART is recommended for all patients with HIV and drug-resistant TB requiring second-line anti-tuberculosis drugs irrespective of CD4 cell count, as early as possible (within the first 8 weeks) following initiation of anti-tuberculosis treatment (Strong recommendation, very low quality of evidence)
Delaying ART increases the risk of dying among TB patients living with HIV; therefore, ART should be started in all TB patients living with HIV, regardless of their CD4 cell count. The therapy should be initiated as soon as possible within the first 8 weeks of TB treatment, or within the first 2 weeks in patients with profound immunosuppression (e.g. CD4 counts <50 cells/mm3). In children with HIV and active TB, ART should be initiated as soon as possible and within 8 weeks following the initiation of anti-TB treatment, regardless of the CD4 cell count and clinical stage (144).
There may be a potential for overlapping, additive toxicities or drug–drug interactions between some antiretroviral medicines and the injectable agents, moxifloxacin and clofazimine; however, there are usually no grounds to warrant modifications of the MDR-TB or the ART regimens. It is not recommended to use bedaquiline and efavirenz in combination (Web Annex 2). Web Annex 1 provides information on individual medicines used to treat MDR/RR-TB and their drug interactions. In addition, information on HIV drug interactions is available on the HIV drug interactions webpage (145). Antiretroviral treatment regimens need to be optimized, and should be initiated early, in accordance with WHO recommendations (17, 68). Close monitoring for response and toxicity is advised for patients on both TB and HIV treatment. Other comorbidities (e.g. diabetes and mental health disorders) should be managed accordingly (17).