Bibliographic information
GuidelineWHO consolidated guidelines on tuberculosis: module 4: treatment and care
Year of Publication2025
Issuing InstitutionWorld Health Organization
Recommendation
New
In patients with MDR/RR-TB and HCV co-infection, the WHO suggests the co-administration of HCV and TB treatment over delaying HCV treatment until after treatment of MDR/RR-TB is completed.
Recommended in favor
Conditional
Certainty of evidence
Very low
Notes and Remarks
- 1.This recommendation applies to people with confirmed MDR/RR-TB and HCV.
- 2.Treatment initiation should take into account potential DDI and other comorbidities. Subgroup considerations Despite acknowledging the data limitations and very low certainty of the evidence, the GDG believed that extrapolating to broader patient groups, including children, is warranted, especially regarding the potential benefits of co-administration of both treatments. However, the absence of data for specific subgroups (e.g. pregnant women, PLHIV, younger children and patients with liver cirrhosis) necessitates caution in extrapolating the findings to all patients. The GDG discussed whether the specific findings could be applied to PLHIV, with reservations stemming from the absence of specific data on subgroups such as older individuals and people with comorbidities, and other factors that could not be obtained through the expert evidence survey. The GDG underscored the lack of comprehensive data for these subgroups and emphasized the necessity of cautiously approaching such extrapolations. Implementation considerations The GDG noted that clinicians should initiate co-administration of MDR-TB and HCV treatments in line with knowledge and consideration about DDIs and patients’ comorbidities. The group highlighted that, when implementing the recommendation, the type of evidence and very low certainty on which the recommendation is based should be made transparent and clearly communicated to patients during the decision-making process. Finally, when considering the implementation of the recommendation, it was highlighted that the unavailability of HCV treatment should not delay MDR/RR-TB treatment. Drug–drug interaction Although data on DDIs between newer HCV treatments (DAAs) and MDR-TB medications are limited, current evidence suggests minimal interactions. However, caution is still advised. Bedaquiline, a key component of most MDR-TB regimens, may increase the risk of liver toxicity, particularly when co-administered with some HCV treatments. Additionally, some MDR-TB drugs (e.g. ethionamide/prothionamide and clofazimine) might interact with specific DAAs (daclatasvir) by affecting how the body processes them, although this has not been proven (151). Owing to these potential interactions, consulting with a specialist is essential. The specialist can assess individual patient factors and recommend the optimal treatment plan that minimizes DDIs and maximizes treatment success for both HCV and MDR-TB (140). Patient-centred approach Efforts are required to provide patient support to enable full adherence to treatment. Supporting patient adherence may be important to retain patients on treatment even when a regimen is relatively short. WHO recommendations on care and support and a related handbook are available through the previously published WHO consolidated guidelines on tuberculosis. Module 4: Treatment – tuberculosis care and support (152) and in the chapter 3 of this consolidated document