Infants and children diagnosed with TB and HIV
Concomitant rifampicin substantially decreases concentration of both Nevirapine (NVP) and PI due to induction of P450 enzyme. Plasma levels of NNRTIs are decreased by 25-35% and plasma levels of PIs are decreased by more than 80%. Thus PIs should be avoided when a child is on rifampicin and rifabutin should be used as it does not induce the P450 enzymes and thus does not alter the levels of PIs. Dose of NVP should be increased by 20-30% when used concomitant with rifampicin to maintain the drug levels in the therapeutic range. However a watch should be kept for hepatic toxicity.
Any child with active TB disease should begin TB treatment immediately, and start ART as soon as tolerated in the first 8 weeks of TB therapy, irrespective of CD4 count and clinical stage. The preferred first-line ARV regimen for infants and children less than 3 years of age, who are taking a rifampicin-containing regimen for TB, is 2 NRTIs + NVP. The preferred first-line ARV regimen for children more than 3 years of age, who are taking a rifampicin-containing regimen for TB, is 2 NRTIs + EFV. The preferred first-line ARV regimen for infants and children less than 2 years of age, who have been exposed to NVP and are taking a rifampicin-containing regimen for TB, is a triple NRTI regimen.
Children with anemia
For a child or adolescent with severe anemia (<7.5 g/dl) or severe neutropenia (<500 cells/mm3), zidovudine (AZT) should be avoided.
Hepatitis B Co-infection
For adolescents more than 12 years of age with hepatitis B co-infection, the preferred regimen NRTI backbone is tenofovir (TDF) + emtricitabine (FTC).
References
- Shah Ira , Katira B. Tuberculosis Co-Infection in HAART Naïve HIV Infected Children. Accepted for publication. Indian Journal of Pediatrics. 20-08-2008
- Shah Ira , Swaminathan S, Ramachandran G, Hemanth Kumar AK, Goray A, Chaddha U, Tayal S, Lala M. Nevirapine and efavirenz blood concentrations and effect of concomitant use of rifampicin in HIV infected children on antiretroviral therapy. Indian Pediatr. Accepted for publication 26 November 2010 (Ref.No. IP/2010/276)