FeedbackChildren living with HIV should be followed up closely in the health care system. Those living in high TB incidence settings should be screened for TB at every contact with the health care system. Given the high risk of progression to TB disease and the high mortality rate, combined symptom screening should also be done at every contact with the health care system, including events such as vaccination days, maternal health appointments, nutritional screening and food support programme visits. The combined symptom screen has low specificity, which may lead to a large number of false-positive screens and further diagnostic testing. Nevertheless, given the high mortality due to untreated TB among children living with HIV, the risk of over-investigation and treatment is generally outweighed by the benefits of TB treatment. HCWs should closely monitor TPT or TB treatment and remain vigilant to the possibility of alternative diagnoses.
It may be difficult to determine whether a child has had close contact with a person with TB. It is important to take a careful history of the known exposures of the parent or caregiver and child. Household contacts are often considered, but, particularly in areas with a high TB incidence, close contact can occur in a variety of community settings, including school, daycare and religious settings. A study in South Africa indicated that only half of children with TB had a known household contact with a person with TB, and even young children had a high risk of being infected in the community outside the household (30). A high index of suspicion of TB in young children should be maintained, especially for children living with HIV or of unknown HIV status in settings with a high TB incidence. Children living with HIV who are found not to have TB disease should receive TPT as per WHO guidelines (15, 28).