Antiretroviral switching and bedaquiline treatment of drug-resistant tuberculosis HIV co-infection

Abstract

Bedaquiline, a potent new therapy for drug-resistant tuberculosis, results in improved survival including in HIV patients with multidrug and extensively drug-resistant tuberculosis. In line with WHO recommendations, in South Africa and other low-income and middle-income settings, antiretroviral therapy is switched from generic fixed-dose combination efavirenz-containing regimens to twice-daily nevirapine with separate companion pills because of interactions between efavirenz and bedaquiline. Early data suggest a signal for low antiretroviral therapy adherence after this antiretroviral therapy switch. Mortality and other tuberculosis-specific benefits noted with bedaquiline treatment in multidrug and extensively drug-resistant tuberculosis HIV might be compromised by HIV viral failure, and emergent antiretroviral resistance. Programmatic responses, such as adherence support and dual pharmacovigilance, should be instituted; antiretroviral therapy initiation with fixed-dose combinations without bedaquiline drug interactions should be strongly considered.

Preparing the healthcare workforce in South Africa for short-course rifampicin-resistant TB treatment: inter-professional training and task-sharing considerations

“…It is also unclear the manner in which shorter treatment regimens with more potent antimicrobials would impact this outcome. While it is theorized that the newer short-course, all-oral, RR-TB regimen will improve adherence and reduce loss to follow-up, the treatment-related adverse events [ 14 ], drug–drug interactions [ 15 ] and pill burden [ 16 ] of an all-oral regimen may complicate treatment needs. Despite these challenges, data from SA and other sub-Saharan African countries on task-sharing between MOs and nurses are clear for both HIV [ 17 , 18 ] and drug-susceptible TB [ 19 ]—outcomes are equivalent.…”

Preparing the healthcare workforce in South Africa for short-course rifampicin-resistant TB treatment: Inter-professional training and task-sharing considerations

“…It is also unclear the manner in which shorter treatment regimens with more potent antimicrobials would impact this outcome. While it is theorized that the newer short-course, all oral, RR-TB regimen will improve adherence and reduce loss to follow-up, the treatment related adverse events (14), drug-drug interactions (15) and pill burden (16) of an all oral regimen may complicate treatment needs. Despite these challenges, data from SA and other Sub-Saharan African countries on task-sharing between MOs and nurses is clear for both HIV (17,18) and drug-susceptible TB (19) -outcomes are equivalent.…”

Preparing the healthcare workforce in South Africa for short-course rifampicin-resistant TB treatment: Inter-professional training and task-sharing considerations

“…It is also unclear the manner in which shorter treatment regimens with more potent antimicrobials would impact this outcome. While it is theorized that the newer short-course, all oral, RR-TB regimen will improve adherence and reduce loss to follow-up, the treatment related adverse events (14), drug-drug interactions (15) This evaluation has important limitations that future research should seek to explore. APPNs, by their own account, still require additional mentored clinical training.…”