Consolidated Guidelines

The successful implementation of this recommendation will depend on the availability of more providers trained specifically in the care of HIV and DR-TB, and drug–drug interactions. A substantial increase in the availability of and patient’s access to treatment, and additional support for ensuring adherence would probably be needed. The need for increased integration of HIV and TB care for effective patient management, prompt evaluation of adverse events and case-holding throughout treatment will necessitate more resources.

The strong recommendation for the use of ART is based in part on indirect evidence from its use in any patient with active TB, which shows large beneficial effects and a very high mortality when ART is not employed (120) particularly in highly immunocompromised patients (CD4 cell count <50 cells/mm3) (121, 122). In the absence of other data specific to patients with DR-TB receiving second-line antituberculosis medication, the decision on when to start ART should be no different from the approach to a patient living with HIV with drug-susceptible TB.

The pooled IPD from longitudinal cohort studies showed a lower risk of death and a higher likelihood of cure, and resolution of TB signs and symptoms in patients using ART, compared with those not using ART (low-quality evidence). There is very low certainty evidence for other outcomes that were considered critical or important for decision-making (e.g. severe adverse effects from second-line drugs for DR-TB, occurrence of sputum smear or culture conversion, interactions of ART with antituberculosis drugs and default from treatment).

The recommendation in this section addresses one PICO question:

PICO question (DR-TB, 2011): In patients with HIV infection and drug-resistant TB receiving antiretroviral therapy, is the use of drugs with overlapping and potentially additive toxicities, compared with their avoidance, more or less likely to lead to cure or other outcomes?⁴⁸

The rates of death in the IPD for surgical outcomes did not differ significantly between patients who underwent surgery and those who received medical treatment only. There were not enough data on adverse events, surgical complications or long-term sequelae – some of which may be fatal – to allow a meaningful analysis. Despite the unknown magnitude of perioperative complications, the GDG assumed that, overall, there is a net benefit from surgery.

Partial lung resection for patients with MDR-TB is to be considered only under conditions of good surgical facilities and trained and experienced surgeons, and with careful selection of candidates.

The relative benefits of surgery are expected to depend substantially on the population subgroups that are targeted. The analysis could not provide a refined differentiation of the type of patient who would be best suited to benefit from the intervention or the type of intervention that would have the most benefit. The effect is expected to be moderate in the average patient considered appropriate for surgery.

The recommendation in this section addresses one PICO question:

PICO question (DR-TB, 2016): Among patients on MDR-TB treatment, are the following two interventions (delay in start of treatment and elective surgery) likely to lead to cure and other outcomes?⁴⁹