B20.0
DESCRIPTION
TB and HIV are often co-morbid conditions. Exclude TB by history of TB contacts, clinical examination, chest X-ray, tuberculin skin test (TST), M. tuberculosis PCR test and mycobacterial culture (where TB disease is suspected on clinical or radiological grounds) in all patients before starting ART. Every attempt should be made to obtain microbiologic specimens for TB testing (sputums, NGAs or other, as applicable), as this presents the opportunity to prove TB disease in the child.
Re-evaluate the risk for TB and TB contact at each visit on history (including contact history) and clinical examination.
MEDICINE TREATMENT
TB prophylaxis
Give TB prophylaxis to all HIV-infected children, and all uninfected children < 5 years, exposed to a close contact with an infectious pulmonary TB case (sputum microscopy smear-positive, culture-positive or M. tuberculosis PCR test positive), or who are newly found to be TST positive, but in whom no evidence of TB disease is present.
- Isoniazid, oral, 10 mg/kg/dose once daily for 6 months.
- Maximum dose: 300 mg daily.
Repeat the course if an HIV-infected patient, irrespective of age, is re-exposed to a TB contact at any point after completing TB treatment or prophylaxis.
If patient has been exposed to a known MDR or XDR-TB source case or the contact case has failed standard TB treatment, refer for expert opinion. See Chapter: Tuberculosis, Tuberculosis, pulmonary
TB treatment
If the child is not yet on ART:
- Commence TB treatment first. Follow with cART, usually after 2-4 weeks. In children with TB meningitis, start cART at 4 weeks regardless of CD4 count to avoid IRIS.
- Check ALT before commencing cART. If the ALT is raised discuss this with an expert as it may not be an absolute contraindication to treatment.
- Assess the child for possible disseminated TB disease.
- Be aware of the possibility of Immune Reconstitution Inflammatory Syndrome (IRIS).
If the child is already on cART:
- Commence TB treatment, taking into consideration possible drug interactions and need for cART dosage adaptations.
If the child needs to take concomitant cART and rifampicin-containing treatment:
- Efavirenz: use the normal recommended dosage as per dosing table.
- Abacavir and lamivudine: no adjustment of dosages.
- Lopinavir/ritonavir: refer to dosage table for the ritonavir boosting doses.
- Avoid using double-dose lopinavir/ritonavir solution in young children. If Lopinavir/ritonavir solution is not available, consult an expert.
- Give pyridoxine (vitamin B6 ) to all children on TB and ARV treatment, due to shared toxicities of the regimens.