Operational Handbooks

Also known as a paradoxical reaction, IRIS is a temporary clinical deterioration that may occur within 3 months (most commonly within the first month) of starting ART. As the immune system starts to recover after ART is initiated, the CD4 count increases and the viral load is suppressed. This reconstitution of cell-mediated immunity in response to mycobacterial antigens can trigger an inflammatory reaction to TB antigens at the sites of TB disease. This causes either deterioration of a treated infection or new presentation of a previously subclinical infection (6, 184, 185).

ART in children and adolescents living with HIV aims to improve the length and quality of life, reduce HIV-related morbidity and mortality by reducing the incidence of opportunistic infections (including TB), reduce the viral load, restore and preserve immune function, and restore and preserve normal growth and development. ART improves TB treatment outcomes for children and adolescents living with HIV (6).

Children living in settings where the prevalence of HIV is high or who are living with HIV should be treated for TB with a four-medicine regimen (isoniazid, rifampicin, pyrazinamide and ethambutol) for 2 months followed by a two-medicine regimen (isoniazid and rifampicin) for 4 months or 2 months (for non-severe TB) at standard dosages given daily.

The approach to diagnosing TB in children and adolescents living with HIV is essentially the same as diagnosing TB in HIV-negative children (see Chapter 4). Diagnosis of TB in children and adolescents living with HIV can be more challenging than in HIV-negative children, however (6):

Global efforts to control the co-epidemics of TB and HIV will benefit children and adolescents. They include the expansion of prevention of mother-to-child transmission programmes, which will reduce the number of new HIV infections in young children. In addition, all children living with HIV should be screened for TB, and all children and their families with TB should be offered HIV testing and counselling in settings of high HIV prevalence.

Because of their increased risk for TB, children aged under 10 years living with HIV should be screened for TB at every encounter with a HCW, with the following screen: cough, fever, poor weight gain or close contact with a person with TB (see Chapter 2 on screening). For recommendations on screening tools for adolescents aged 10–19 years living with HIV, see Box 2.7 in Chapter 2 (13).

This section outlines how to screen for, prevent and manage TB/HIV coinfection in children and adolescents living with HIV (CALHIV).

This chapter covers a range of special situations related to the management of TB in children and adolescents:

Health emergencies, such as the COVID-19 pandemic, are associated with a disruption in health service delivery, either directly due to the focused attention given to the emergency or indirectly due to measures implemented to control the emergency.

Countries may have DSD policies in place, but children, adolescents and people living with HIVassociated TB are often excluded. DSD has primarily focused on people living with HIV who are established on ART (79). It is therefore important that the NTP works closely with the national HIV programme to ensure children and adolescents are able to access these patient-centred approaches.