Chapter 3: management of TB in the HIV-infected child

Human immunodeficiency virus (HIV) infected children are at risk of a range of lung diseases related to HIV infection, including tuberculosis (TB). As in non-HIV-infected children, the presence of three or more of the following four features strongly suggests the diagnosis of TB: 1) chronic symptoms suggestive of TB; 2) physical changes highly suggestive of TB; 3) a positive tuberculin skin test; 4) a chest radiograph suggestive of TB. Every effort must be made to expedite the process of making the diagnosis, as TB may be rapidly progressive in HIV-infected children. As many children who present with chronic symptoms suggestive of TB may not have been tested for HIV infection, in high HIV prevalence settings (and in all settings where HIV is suspected in a child) children and their families should be offered HIV counselling and testing as part of a full TB work-up. Most current international guidelines recommend that TB in HIV-infected children, as in non-HIV-infected children, should be treated with a 6-month regimen containing rifampicin throughout. All HIV-infected children with advanced immunosuppression, including many with TB, should receive cotrimoxazole prophylaxis. Although the optimal timing for the initiation of antiretroviral treatment (ART) during TB treatment is not known, the decision to initiate ART should take into consideration the degree of immune suppression and the child's progress during TB treatment.