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6–76 | Clinical Manual for Management of the HIV-Infected Adult/2006
Young children do not produce sputum, and usually are
treated on the basis of clinical presentation and chest
x-ray findings. A point system has been used to assist in
selecting children for treatment, especially where x-ray
facilities are not available. However, this point system
may not be very specific in HIV-infected children, who
may have other illnesses unrelated to TB. Children
exposed to TB in the home need to be assessed for
symptoms and signs of active disease, and should receive
either IPT (see the Treatment of Latent Tuberculosis in
Resource-Limited Settings chapter) or empiric treatment
for active TB.
Treatment Adherence
Directly observed therapy—short course (DOTS)
is recommended. The DOTS framework includes
systems for
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Standardized short-course (6-month) chemotherapy
promoting adherence and observing each dose of
medication;
Access to quality-assured sputum microscopy;
Uninterrupted access to appropriate drugs;
A quality-assured data and monitoring system; and
The political will and resources to implement a
national TB control program.
Therapy may be directly observed by health care
workers, family members, lay community volunteers
or activists, or coworkers. The treatment supporter
documents the observation of doses using forms and
procedures analogous to those used for this purpose
by health care workers. The treatment supporter
accompanies the patient to the TB treatment visits,
bringing remaining medications and treatment
documentation paperwork each time.
Treatment Regimens
The TB treatment regimens recommended by the
WHO for HIV-infected persons are shown in Table
1. Where DOTS can be assured, regimens for new
patients are the same as those used in industrialized
countries. Fixed-dose combination (FDC) tablets
are available in some countries for both initial and
continuation phases of treatment, for both adults and
children, and may be available in blister packs. Use of
the FDCs reduces the time demands on health care
workers, ensures more accurate weight-based dosing,
simplifies assessment of adherence, and eliminates the
option for patients to avoid individual medications in
their regimen.
Patients who are smear positive after completing TB
treatment (“relapse”) or return after a 2-month gap
in treatment having had at least 1 month of prior
exposure to TB medications (“return from default”) are
considered retreatment cases (Category II; see Table
1) and receive an expanded and extended regimen. If
possible, sputum for culture and sensitivity is obtained
at the beginning of a retreatment regimen. In some
countries with high rates of multidrug resistance,
these patients may be referred directly to second-line
treatment (Category IV).
Ethambutol is included in regimens for HIV-infected
persons. However, it may be omitted in HIV-uninfected
persons with smear-negative pulmonary TB without
cavities and without suspicion of drug resistance. Some
countries do not include ethambutol in the treatment of
young children with TB.
TB meningitis is treated with streptomycin instead of
ethambutol during the initial phase of therapy.
Corticosteroids are recommended for patients with
TB meningitis, pericarditis, severe or bilateral pleural
effusions, TB laryngitis threatening the airway, massive
TB adenopathy with dangerous pressure effects, severe
IRS, and severe drug toxicity (prednisone 1 mg/kg
with tapering over the course of weeks to months). For
patients with adrenal insufficiency due to TB, stressdoses
of corticosteroids will need to be followed by
chronic replacement doses.
Thiacetazone was previously widely used in Africa as
part of TB treatment. Its use is discouraged now because
of a high rate of severe skin reactions including fatalities
from Stevens-Johnson syndrome and toxic epidermal
necrolysis, especially in HIV-infected persons.