Children and adolescents living with HIV are 8–20 times more likely to develop TB disease than those without HIV infection and should be prioritized for systematic evaluation and TPT in all settings (15, 46). Despite major progress in access to and effectiveness of ART, TB is the most frequent cause of acquired immunodeficiency syndrome (AIDS)-related deaths worldwide (47). It was estimated that in 2020, TB caused over 21 000 deaths among children and adolescents aged under 15 years living with HIV, and about 10% of all HIV-related TB deaths in this group (1). Evidence shows that TPT increases the survival of people living with HIV even when they are on ART (48). TPT also provides additional protection when given immediately after the successful completion of treatment for TB disease among people living with HIV (48–50). Box 3.2 presents relevant recommendations from the 2020 WHO guideline on TPT (28).
TPT should be considered in infants aged under 12 months living with HIV who have a history of close contact with a person with infectious TB. Children living with HIV aged 12 months and over should be considered for TPT, irrespective of contact with a person with TB. TPT is recommended for children living with HIV, regardless of whether they are on ART or not. The evidence for additive benefit of TPT among children living with HIV on ART is limited, but it is plausible given the efficacy observed among adults with HIV receiving ART plus TPT. Similarly, the effect of TPT in children living with HIV after successful completion of TB treatment is largely extrapolated from benefits observed in adults exposed to reinfection and recurrence of TB.
Similar to infants aged under 12 months who are living with HIV, infants born to women living with HIV are vulnerable to early TB infection due to the mother’s risk of contracting TB disease (51, 52). Given the poor outcomes of TB disease in infancy, it is important to consider TPT for such infants who show no signs of TB disease. Programmes for prevention of mother-to-child transmission of HIV offer an important platform to screen infants exposed to HIV for TB disease and provide TPT for those without TB disease. A strong linkage should therefore be established between mother-to-child
prevention services and NTPs (53).
WHO recommends provision of TPT among children living with HIV who have successfully completed treatment for TB disease. People living with HIV face higher risk of recurrence of TB disease compared with HIV-negative people. A complete course of TB treatment with a four-medicine regimen is shown to have a very high treatment success rate and very low incidence (2–3%) of recurrence. In people living with HIV, the risk is several times higher, possibly due to treatment failure, emergence of drug resistance during treatment, or reinfection with a new strain of M. tuberculosis (54–57). In a study
among people living with HIV whose initial episode of TB was deemed cured, 14% experienced a recurrence of TB, of which close to 90% were due to reinfection with a different strain of M. tuberculosis (58). Key interventions to minimize recurrence of TB include ensuring completion of the initial course of TB treatment, effective infection control measures in clinical and community settings frequented by people living with HIV, and TPT after completion of a course of TB treatment (59, 60).