HAART and IRIS

[MicA]

Hi

Are there any guidelines on when to start HAART with certain opportunistic infections like TB and PCP to try and avoid IRIS? We were taught that for TB sometimes you have to wait until the initial treatment is over before initiating HAART, but are there any clear WHO guidelines?

 

[MicA]

Answered by one of my lecturers today. For anyone interested:

For TB and most other opportunistic infections immediately initiate HAART with the therapy to treat the infection.
For cryptococcus delay HAART treatment due to risk of increased ICP leading to death.

Apparently these guidelines have changed because before it was suggested to not initiated HAART with TB therapy.

In the words of one of my lecturers: "The only side effect of HAART is that people get fat and look well."

 

[bluntdissector]

Answered by one of my lecturers today. For anyone interested:

For TB and most other opportunistic infections immediately initiate HAART with the therapy to treat the infection.
For cryptococcus delay HAART treatment due to risk of increased ICP leading to death.

Apparently these guidelines have changed because before it was suggested to not initiated HAART with TB therapy.

In the words of one of my lecturers: "The only side effect of HAART is that people get fat and look well."

Despite the neat "bumper-sticker" words of the lecturer, HAART can have some pretty serious side effects. 🙂

Quite some time ago people did go for "sequential" rather than "integrated" therapy, but the current guidelines (both from the WHO and more local South African authorities) advocate integrated therapy. My understanding was that most experts would wait +/- two weeks after the initiation of TB Rx to start HAART, provided the CD4 isn't REALLY low (<100). I makes IRIS less likely, allows one to sort out drug side-effects easier, etc...

 

[osumc2014]

jw, anyway to treat IRIS?

 

[bluntdissector]

jw, anyway to treat IRIS?

It's such a heterogenous entity, that it would depend on the organ system, underlying disease, severity, etc. In bad PML-IRIS, you can give steroids, for instance. If your chest X-ray goes bonkers after TB and HAART initiation, but clinically it ain't that bad, you can just treat through it. If the LN enlarge and compress the airway, give some steroids, etc...