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.
Eligibility for the 4-month treatment regimen depends on the severity of disease and can be determined using CXR features or clinical criteria described in Chapter 5.
The child should be assessed 2 weeks after the start of TB treatment and then reviewed monthly with clinical monitoring, which should include symptom assessment, weight measurement, assessment of adherence to treatment, and enquiry about any adverse events. Dosages of TB medicines should be adjusted to account for any weight gain.
Most children living with HIV with drug-susceptible TB who are adherent to treatment have a good response to the 6-month regimen. Possible reasons for treatment failure are non-adherence to treatment, DR-TB or alternative diagnoses (e.g. incorrect diagnosis of TB).
All children living with HIV who have successfully completed treatment for TB disease may receive TPT.
Response to TB treatment and treatment outcomes are poorer for children living with HIV than for HIV-negative children. Before the wide availability of ART, many deaths in children with TB/HIV coinfection occurred in the first 2 months following the start of TB treatment. Medical risk factors for poor treatment response and mortality include severe malnutrition, coinfections, severe immunosuppression and high viral load.
Additional therapy recommended for children living with HIV who have TB, which may help improve TB treatment outcomes include CPT (see Section 7.1.6), early start of ART (see Section 7.1.7), and pyridoxine supplementation and nutritional support.