Children and Adolescents

In people with TB/HIV coinfection, the dose of DTG needs to be doubled by giving it twice instead of once a day because of drug–drug interactions with rifampicin. This extra dose of DTG is well tolerated, with equivalent efficacy in viral suppression and recovery of CD4 cell count compared with EFV (182, 183).

Table 7.2 summarizes changes needed to ART regimens for neonates, children and adolescents who are on ART when TB treatment is started, or who start ART while on TB treatment.

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).

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).

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 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).

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.