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Lancet HIV. 2019 Mar;6(3):e201-e204. doi: 10.1016/S2352-3018(19)30035-9.

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

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Division of Pulmonary, Allergy, and Critical Care Medicine, and Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA; CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa. Electronic address:
CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa; McGill International TB Centre and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
Division of Clinical Pharmacology and Infectious Diseases, Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
School of Public Health, University of Michigan, Ann Arbor, MI, USA.
Yale School of Medicine, New Haven, CT, USA.


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.

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