BCG in children living with HIV
Children known to be living with HIV should not receive BCG vaccination because they are at increased risk of developing disseminated BCG disease. However, if they are receiving ART, are clinically well and immunologically stable they should be vaccinated. Immunologically stable children have a CD4% over 25% (children aged under 5 years) or a CD4 count of 200/mm3 or higher (children aged over 5 years). In settings without access to CD4 testing, immunological stability may be assessed clinically, based on the absence of new opportunistic infections and any other symptoms. If viral load testing is available, an undetectable viral load in combination with the child being clinically well without new opportunistic infections satisfies this requirement (31).
BCG in neonates
Neonates born to women with unknown HIV status should receive BCG vaccination. Neonates with unknown HIV status born to women living with HIV should be vaccinated, provided they have no clinical evidence suggestive of HIV infection, irrespective of the mother’s ART status. All mothers living with HIV should be offered treatment to reduce the risk of vertical HIV transmission.
Neonates diagnosed with HIV infection, as confirmed by early virological testing, should not receive BCG at birth. Vaccination should be delayed until ART has been started and the infant is confirmed to be immunologically stable (CD4% over 25% in children aged under 5 years; CD4 count of 200/mm3 or higher in children aged over 5 years).
Neonates born to women with bacteriologically confirmed PTB who do not have TB symptoms should receive TPT after exclusion of TB disease. The infant should be regularly followed up and monitored for the development of symptoms and signs suggestive of TB. If the infant remains asymptomatic and is HIV-negative, BCG vaccination should be provided using a normal infant dose 2 weeks after completion of the full course of TPT (31). See Section 7.2 on management of neonates exposed to mothers with infectious TB.