When to Start Antiretroviral Therapy in HIV-Associated Tuberculosis

The optimal time to initiate antiretroviral therapy (ART) in patients presenting with HIV-associated tuberculosis has been a controversial issue. Early initiation of ART may be complicated by high pill burden, overlapping drug toxicities, and an increased risk of immune reconstitution inflammatory syndrome. Delayed initiation of ART may result in progressive immune decline, HIV-associated complications and death. Retrospective studies of HIV/TB coinfected patients suggested that initiation of ART during TB treatment might be beneficial. Emerging evidence from recent randomised controlled trials supports early ART initiation in HIV/TB patients with advanced immunosuppression, apart from those presenting with tuberculous meningitis. However, current guidelines for antiretroviral therapy vary in their recommendations for timing of ART initiation in HIV-associated TB.