| A. Identifying at-risk populations for LTBI testing and treatment | 1.1. Identifying populations for LTBI testing and TB preventive treatment |
|---|
| People living with HIV | People living with HIV |
|---|
| Adults and adolescents living with HIV, with unknown or a positive tuberculin skin test (TST) and who are unlikely to have active TB should receive preventive treatment of TB as part of a comprehensive package of HIV care. Treatment should be given to these individuals irrespective of the degree of immunosuppression and also to those on antiretroviral treatment (ART), those who have previously been treated for TB and pregnant women. | 1. Adults and adolescents living with HIV who are unlikely to have active TB should receive TB preventive treatment as part of a comprehensive package of HIV care. Treatment should also be given to those on antiretroviral treatment, to pregnant women and to those who have previously been treated for TB, irrespective of the degree of immunosuppression and even if LTBI testing is unavailable. (language editing) |
| Infants aged < 12 months living with HIV who are in contact with a case of TB and are investigated for TB should receive 6 months of isoniazid preventive treatment (IPT) if the investigation shows no TB disease. | 2. Infants aged < 12 months living with HIV who are in contact with a person with TB and who are unlikely to have active TB on an appropriate clinical evaluation or according to national guidelines should receive TB preventive treatment. (language editing) |
| Children aged ≥ 12 months living with HIV who are considered unlikely to have TB disease on the basis of screening for symptoms and who have no contact with a case of TB should be offered 6 months of IPT as part of a comprehensive package of HIV prevention and care if they live in a setting with a high prevalence of TB. | 3. Children aged ≥ 12 months living with HIV who are considered unlikely to have active TB on an appropriate clinical evaluation or according to national guidelines should be offered TB preventive treatment as part of a comprehensive package of HIV prevention and care if they live in a setting with high TB transmission, regardless of contact with TB. (refers to setting with high TB transmission rather than prevalence) |
| All children living with HIV who have successfully completed treatment for TB disease may receive isoniazid for an additional 6 months. | 4. All children living with HIV who have successfully completed treatment for TB disease may receive TB preventive treatment. (language editing) |
| HIV-negative household contacts | Household contacts (regardless of HIV status) |
|---|
| HIV-negative children aged < 5 years who are household contacts of people with bacteriologically confirmed pulmonary TB and who are found not to have active TB on an appropriate clinical evaluation or according to national guidelines should be given TB preventive treatment. | 5. Children aged < 5 years who are household contacts of people with bacteriologically confirmed pulmonary TB and who are found not to have active TB on an appropriate clinical evaluation or according to national guidelines should be given TB preventive treatment even if LTBI testing is unavailable. (language editing) |
| In countries with a low TB incidence, children, adolescents and adults who are household contacts of people with bacteriologically confirmed pulmonary TB should be systematically tested and treated for LTBI. | Incorporated into the following recommendation and its accompanying commentary 6. Children aged ≥ 5 years, adolescents and adults who are household contacts of people with bacteriologically confirmed pulmonary TB who are found not to have active TB by an appropriate clinical evaluation or according to national guidelines may be given TB preventive treatment. |
| In countries with a high TB incidence, children aged ≥ 5 years, adolescents and adults who are household contacts of people with bacteriologically confirmed pulmonary TB who are found not to have active TB by an appropriate clinical evaluation or according to national guidelines may be given TB preventive treatment. |
| In selected high-risk household contacts of patients with multidrug-resistant tuberculosis, preventive treatment may be considered based on individualised risk assessment and a sound clinical justification. | 7. In selected high-risk household contacts of patients with multidrug-resistant tuberculosis, preventive treatment may be considered based on individualized risk assessment and a sound clinical justification. (no change) |
| Other at-risk groups | Other people at risk |
|---|
| Patients initiating anti-TNF treatment, patients receiving dialysis, patients preparing for an organ or haematological transplant and patients with silicosis should be systematically tested and treated for LTBI. | 8. People who are initiating anti-TNF treatment, or receiving dialysis, or preparing for an organ or haematological transplant, or who have silicosis should be systematically tested and treated for LTBI. (language editing) |
| In countries with a low TB incidence, systematic testing for and treatment of LTBI may be considered for prisoners, health workers, immigrants from countries with a high TB burden, homeless people and people who use illicit drugs. | 9. Systematic LTBI testing and treatment may be considered for prisoners, health workers, immigrants from countries with a higher TB burden, homeless people and people who use drugs. (language editing; restriction by TB burden setting removed) |
| Systematic testing for LTBI is not recommended for people with diabetes, people with harmful alcohol use, tobacco smokers and underweight people unless they are already included in the above recommendations. | 10. Systematic LTBI testing and treatment is not recommended for people with diabetes, people who engage in the harmful use of alcohol, tobacco smokers and underweight people unless they also belong to other risk groups included in the above recommendations. (language editing) |
| B. Algorithms to rule out active TB disease | 1.2. Algorithms to rule out active TB disease |
|---|
| Adults and adolescents living with HIV should be screened for TB according to a clinical algorithm. Those who do not report any of the symptoms of current cough, fever, weight loss or night sweats are unlikely to have active TB and should be offered preventive treatment, regardless of their ART status. | 11. Adults and adolescents living with HIV should be screened for TB according to a clinical algorithm. Those who do not report any of the symptoms of current cough, fever, weight loss or night sweats are unlikely to have active TB and should be offered preventive treatment, regardless of their ART status. (no change) |
| Adults and adolescents living with HIV who are screened for TB according to a clinical algorithm and who report any of the symptoms of current cough, fever, weight loss or night sweats may have active TB and should be evaluated for TB and other diseases that cause such symptoms. | 12. Adults and adolescents living with HIV who are screened for TB according to a clinical algorithm and who report any of the symptoms of current cough, fever, weight loss or night sweats may have active TB and should be evaluated for TB and other diseases and offered preventive treatment if active TB is excluded. (language editing) |
| Chest radiography may be offered to people living with HIV and on ART and preventive treatment given to those with no abnormal radiographic findings. | 13. Chest radiography may be offered to people living with HIV on ART and preventive treatment given to those with no abnormal radiographic findings. (no change) |
| Infants and children living with HIV who have poor weight gain, fever or current cough or who have a history of contact with a case of TB should be evaluated for TB and other diseases that cause such symptoms. If the evaluation shows no TB, these children should be offered preventive treatment, regardless of their age. | 14. Infants and children living with HIV who have poor weight gain, fever or current cough or who have a history of contact with a person with TB should be evaluated for TB and other diseases that cause such symptoms. If TB disease is excluded after an appropriate clinical evaluation or according to national guidelines, these children should be offered TB preventive treatment, regardless of their age. (language editing) |
| The absence of any symptoms of TB and the absence of abnormal chest radiographic findings may be used to rule out active TB disease among HIV-negative household contacts aged ≥ 5 years and other at-risk groups before preventive treatment. | 15. The absence of any symptoms of TB and the absence of abnormal chest radiographic findings may be used to rule out active TB disease among HIVnegative household contacts aged ≥ 5 years and other risk groups before preventive treatment. (no change) |
| C. Testing for LTBI | 1.3. Testing for LTBI |
|---|
| Either a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) can be used to test for LTBI. | 16. Either a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) can be used to test for LTBI. (no change) |
| People living with HIV who have a positive test for LTBI benefit more from preventive treatment than those who have a negative LTBI test; LTBI testing can be used, where feasible, to identify such individuals. | Incorporated into the implementation considerations |
| LTBI testing by TST or IGRA is not a requirement for initiating preventive treatment in people living with HIV or child household contacts aged < 5 years. |
| D. Treatment options for LTBI | 1.4. TB preventive treatment options |
|---|
| Isoniazid monotherapy for 6 months is recommended for treatment of LTBI in both adults and children in countries with high and low TB incidence. | Incorporated into a single recommendation, applicable to all settings 17. The following options are recommended for the treatment of LTBI regardless of HIV status : 6 or 9 months of daily isoniazid, or a 3-month regimen of weekly rifapentine plus isoniazid, or a 3 month regimen of daily isoniazid plus rifampicin. A 1-month regimen of daily rifapentine plus isoniazid or 4 months of daily rifampicin alone may also be offered as alternatives. |
| Rifampicin plus isoniazid daily for 3 months should be offered as an alternative to 6 months of isoniazid monotherapy as preventive treatment for children and adolescents aged < 15 years in countries with a high TB incidence. |
| Rifapentine and isoniazid weekly for 3 months may be offered as an alternative to 6 months of isoniazid monotherapy as preventive treatment for both adults and children in countries with a high TB incidence. |
| The following options are recommended for treatment of LTBI in countries with a low TB incidence as alternatives to 6 months of isoniazid monotherapy: 9 months of daily isoniazid, or a 3-month regimen of weekly rifapentine plus isoniazid, or a 1-month regimen of daily rifapentine plus isoniazid, or 3-4 months of daily isoniazid plus rifampicin, or 3-4 months of rifampicin alone. |
| In settings with high TB incidence and transmission, adults and adolescents living with HIV who have an unknown or a positive TST and are unlikely to have active TB disease should receive at least 36 months of IPT, regardless of whether they are receiving ART. IPT should also be given irrespective of the degree of immunosuppression, history of previous TB treatment and pregnancy. | 18. In settings with high TB transmission, adults and adolescents living with HIV who have an unknown or a positive LTBI test and are unlikely to have active TB disease should receive at least 36 months of daily isoniazid preventive therapy (IPT). Daily IPT for 36 months should be given whether or not the person is on ART, and irrespective of the degree of immunosuppression, history of previous TB treatment and pregnancy in settings considered to have a high TB transmission as defined by national authorities. (refers to setting with high TB transmission only) |
