Operational Handbooks

Adolescents with TB often present with bacteriologically infectious disease typical in adults (e.g. cavities seen on CXR) and therefore pose a high risk for transmission in households and congregate settings such as schools. Adolescents face unique challenges due to peer pressure and fear of stigma, increasing prevalence of comorbidities such as HIV, and risk behaviours such as use of alcohol, tobacco and other substances. People aged 10–19 years need adolescent-friendly services that include relevant psychosocial support and minimal disruption of education (5).

Palliative care for children with TB is similar to that for adults, but applied to the specific needs of this age group. While the definition and principles of palliative care described above apply to the entire lifespan, paediatric palliative care requires attention to physical, developmental, psychosocial, ethical, spiritual and relational phenomena unique to children and their families and caregivers (203). The following should be considered:

Palliative care for people with TB has not received adequate attention, as the focus has been on access to curative treatment. Palliative care aims to relieve suffering due to disease and illness and should be provided in conjunction with curative treatment. Although TB is curable, MDR/RR-TB (including pre-XDR and XDR-TB) is an increasing problem in many high TB burden and low- and middle-income countries, with poorer treatment outcomes reported for this group.

In 2014, World Health Assembly Resolution WHA67.19 called upon WHO and Member States to improve access to palliative care as a core component of health systems, with an emphasis on PHC and community- and home-based care (197). WHO is supporting integration of palliative care into all relevant global disease control and health system plans and is promoting improved access to palliative care for children, in collaboration with the United Nations Children’s Fund.

Figure 7.1. Palliative care

Pregnant women living with HIV are a key population for screening for TB disease, given the suppressed immune status of the mother and the importance of protecting the health of the fetus. TB screening for this population should be integrated with prevention of vertical transmission and antenatal care. Table 7.4 provides an overview of the diagnostic accuracy of different screening tools (13).

Table 7.4. Diagnostic accuracy of WHO-recommended screening tools in pregnant women living with HIV

The 2021 WHO consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring provide recommendations based on rapidly evolving evidence of safety and efficacy and programmatic experience using DTG and low-dose EFV in pregnant women and people (including children and adolescents) with TB/HIV coinfection (78).

WHO recommendations on the timing of ART for children and adolescents with TB were updated in 2021 (78). ART should be started as soon as possible within two weeks of initiating TB treatment, regardless of CD4 count, among adolescents and children living with HIV (except when signs and symptoms of meningitis are present). In children and adolescents living with HIV with TBM, ART should be delayed at least 4 weeks after treatment for TBM is initiated and initiated 4–8 weeks after starting TB treatment (see Box 7.3).

Co-trimoxazole is a broad-spectrum antimicrobial medicine that prevents a range of secondary bacterial and parasitic infections in eligible people living with HIV. Daily prophylaxis with CPT prolongs survival and reduces the incidence of comorbidities in children living with HIV. It also reduces the risk of coinfections such as pneumocystis pneumonia in infants exposed to HIV.

Children and adolescents living with HIV have an increased risk of TB exposure, infection, progression to disease, and TB-related morbidity and mortality. This risk is influenced by the degree of immune suppression. Childhood HIV infection is particularly common in settings where antenatal HIV prevalence is high and interventions for prevention of vertical transmission are not implemented widely. In these settings, the prevalence of HIV is particularly high among infants and young children, an age group that is also at risk for TB.