Background:  TB is the most common opportunistic infection complicating ART, both in high-income and in resource-limited countries. Rapid scale-up of ART in resource-limited settings, where the burden of TB is particularly high, has resulted in very large numbers of patients needing to receive TB treatment and ART simultaneously. Concurrent drug treatment is a substantial challenge to clinical management in both settings, but especially in ART programs where the therapeutic options and the health care infrastructure to effectively deliver and monitor overlapping treatment are limited. Here, we review the issues of pharmacokinetic interactions, drug co-toxicity, and TB immune reconstitution disease. The currently available treatment options, optimal timing of ART initiation, and the effect of concurrent treatment on patient outcomes are discussed. The use of ART in the treatment of HIV-associated multi-drug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) will briefly be considered.

Conclusions:  Despite the challenges inherent in concurrent administration of TB treatment and ART, good treatment outcomes are nevertheless achievable. Increasing evidence shows that standard-dose NNRTI-based regimens can be effectively used with rifampicin-containing TB treatment with excellent virological outcomes. TB immune reconstitution disease presents a clinical challenge, but, so far, data suggest that it is not associated with a high-excess mortality and that it does not have a major effect on overall outcomes in ART programs. A major remaining therapeutic challenge is presented by the difficulties of combining TB treatment with second-line PI-containing ART regimens, especially where rifabutin is not available as an alternative to rifampicin. Much remains to be learned about combining treatment for drug-resistant TB with ART.