Impact of human immunodeficiency virus 1 infection on clinical presentation, treatment outcome and survival in a cohort of Ethiopian children with tuberculosis

Mortality of children and adolescents co-infected with tuberculosis and HIV: a systematic review and meta-analysis

OBJECTIVE

Children and adolescents with HIV infection are well known to face a heightened risk of tuberculosis. However, the exact mortality rates and temporal trends of those with HIV-tuberculosis (TB) co-infection remain unclear. We aimed to identify the overall mortality and temporal trends within this population.

METHODS

PubMed, Web of Science, and Embase were employed to search for publications reporting on the mortality rates of children and adolescents with HIV-TB co-infection from inception to March 2, 2024. The outcome is the mortality rate for children and adolescents with HIV-TB co-infection during the follow-up period. In addition, we evaluate the temporal trends of mortality.

RESULTS

During the follow-up period, the pooled mortality was 16% [95% confidence interval (CI) 13-20]. Single infection of either HIV or TB exhibit lower mortality rates (6% and 4%, respectively). We observed elevated mortality risks among individuals aged less than 12 months, those with extrapulmonary TB, poor adherence to ART, and severe immunosuppression. In addition, we observed a decreasing trend in mortality before 2008 and an increasing trend after 2008, although the trends were not statistically significant ( P  = 0.08 and 0.2 respectively).

CONCLUSIONS

Children and adolescents with HIV-TB co-infection bear a significant burden of mortality. Timely screening, effective treatment, and a comprehensive follow-up system contribute to reducing the mortality burden in this population.

A comparison of chest radiographic findings in human immunodeficiency virus-positive and -negative children with pulmonary tuberculosis

AIM

To compare chest radiography (CXR) findings in human immunodeficiency virus (HIV)-positive and HIV-negative children who had microbiologically confirmed pulmonary tuberculosis (PTB).

MATERIALS AND METHODS

Retrospective analysis of CXRs from children with known HIV status and microbiologically confirmed PTB (culture or GeneXpert Xpert MTB/RIF positive), who were hospitalised or seen at a primary healthcare centre over a 5-year period. Radiological findings were compared according to HIV and nutritional status.

RESULTS

CXRs of 130 children were analysed from 35 (27%) HIV- positive and 95 (73%) HIV-negative children with confirmed PTB, median age 45.7 months (interquartile range [IQR] 18-81.3 months). CXR changes consistent with PTB were reported in 21/35 (60%) of HIV-positive and 59/95 (62%) of HIV-negative patients, (p=0.81). Normal CXR was identified in 3/35 (8.6%) of HIV-positive and 5/95 (5.3%) of HIV-negative patients (p=0.81). Airway compression was present in 3/35 (8.6%) of HIV-positive and 7/95 (7.4%) of HIV-negative patients (p>0.99). Overall, lymphadenopathy was identified in 42/130 (32.3%) of patients, 11/35 (31.4 %) were HIV-positive compared with 31/95 (32.6%) HIV-negative patients. Airspace consolidation was present in 60% of both HIV-positive (21/35) and HIV-negative patients (57/95). Pleural effusion was present in 2/35 (5.7 %) of HIV-negative and 9/95 (9.5 %) of HIV-negative patients. There were no statistically significant radiological differences by HIV group.

CONCLUSION

There were no significant differences in the CXR findings between the HIV-positive and HIV-negative children with confirmed PTB.

Host Immunity to Mycobacterium tuberculosis Infection Is Similar in Simian Immunodeficiency Virus (SIV)-Infected, Antiretroviral Therapy-Treated and SIV-Naïve Juvenile Macaques

Pre-existing HIV infection increases tuberculosis (TB) risk in children. Antiretroviral therapy (ART) reduces, but does not abolish, this risk in children with HIV. The immunologic mechanisms involved in TB progression in both HIV-naive and HIV-infected children have not been explored. Much of our current understanding is based on human studies in adults and adult animal models. In this study, we sought to model childhood HIV/Mycobacterium tuberculosis (Mtb) coinfection in the setting of ART and characterize T cells during TB progression. Macaques equivalent to 4 to 8 year-old children were intravenously infected with SIVmac239M, treated with ART 3 months later, and coinfected with Mtb 3 months after initiating ART. SIV-naive macaques were similarly infected with Mtb alone. TB pathology and total Mtb burden did not differ between SIV-infected, ART-treated and SIV-naive macaques, although lung Mtb burden was lower in SIV-infected, ART-treated macaques. No major differences in frequencies of CD4+ and CD8+ T cells and unconventional T cell subsets (Vγ9+ γδ T cells, MAIT cells, and NKT cells) in airways were observed between SIV-infected, ART-treated and SIV-naive macaques over the course of Mtb infection, with the exception of CCR5+ CD4+ and CD8+ T cells which were slightly lower. CD4+ and CD8+ T cell frequencies did not differ in the lung granulomas. Immune checkpoint marker levels were similar, although ki-67 levels in CD8+ T cells were elevated. Thus, ART treatment of juvenile macaques, 3 months after SIV infection, resulted in similar progression of Mtb and T cell responses compared to Mtb in SIV-naive macaques.

HIV matters when diagnosing TB in young children: an ancillary analysis in children enrolled in the INPUT stepped wedge cluster randomized study

BACKGROUND

Children under age five years, particularly those living with HIV (CLHIV), are at risk for rapid progression of tuberculosis (TB). We aimed to describe TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV compared to children without HIV in Cameroon and Kenya.

METHODS

This sub-analysis of a cluster-randomized trial evaluating the integration of pediatric TB services from May 2019 to March 2021 enrolled children age < 5 years with TB. We estimated the HIV infection rate with 95% confidence interval (CI). We compared TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV and children without HIV. Finally, we investigated whether HIV infection was associated with a shorter time to TB diagnosis (≤ 3 months from symptoms onset) after adjusting for covariates. Univariable and multivariable logistic regression analysis were performed with adjusted odds ratios (AORs) presented as measures of the association of covariates with HIV status and with shorter time to TB diagnosis.

RESULTS

We enrolled 157 children with TB (mean age was 1.5 years) and 22/157 (14.0% [9.0-20.4%]) were co-infected with HIV. CLHIV were more likely to initially present with acute malnutrition (AOR 3.16 [1.14-8.71], p = 0.027). Most TB diagnoses (140/157, 89%) were made clinically with pulmonary TB being the most common presentation; however, there was weak evidence of more frequent bacteriologic confirmation of TB in CLHIV, 18% vs. 9% (p = 0.067), due to the contribution of lateral-flow urine lipoarabinomannan to the diagnosis. HIV positivity (AOR: 6.10 [1.32-28.17], p = 0.021) was independently associated with a shorter time to TB diagnosis as well as fatigue (AOR: 6.58 [2.28-18.96], p = 0.0005), and existence of a household contact diagnosed with TB (AOR: 5.60 [1.58-19.83], p = 0.0075), whereas older age (AOR: 0.35 [0.15-0.85], p = 0.020 for age 2-5 years), night sweats (AOR: 0.24 [0.10-0.60], p = 0.0022) and acute malnutrition (AOR: 0.36 [0.14-0.92], p = 0.034) were associated with a delayed diagnosis. The case fatality rate was 9% (2/22) in CLHIV and 4% (6/135) in children without HIV, p = 0.31.

CONCLUSIONS

These results altogether advocate for better integration of TB services into all pediatric entry points with a special focus on nutrition services, and illustrate the importance of non-sputum-based TB diagnostics especially in CLHIV.

TRIAL REGISTRATION

NCT03862261, first registration 05/03/2019.

Two-year retention in care for adolescents on antiretroviral therapy in Ehlanzeni district, South Africa: a baseline cohort analysis

Adolescents living with HIV (ALHIV) struggle to remain engaged in HIV-related care and adhere to antiretroviral treatment (ART) due to a myriad of physical, psychological and cognitive-developmental challenges. We report on the profile of ALHIV aged 10-19 years on ART and the clinical factors associated with their retention in care. A retrospective cohort analysis was conducted with 16,108 ALHIV, aged 10-19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Anonymised data were obtained from electronic medical records (Tier.net). Trends in retention in care among adolescents on ART was described using Kaplan-Meier survival estimates. Cox proportional analysis was performed to identify factors associated with retention in care over 2 years. More than half (53%) were females, and median duration on ART was 8 months. Retention in care among adolescents at months 6, 12, 18 and 24 was 90.5%, 85.4%, 80.8% and 76.2%, respectively. After controlling for confounders, risk of dying or lost to follow up increased for female adolescents (aHR = 1.28, 95% CI 1.10-1.49); being initiated on ART while pregnant (aHR = 2.72, 95% CI 1.99-3.69); history of TB infection (aHR = 1.71, 95% CI 1.10-2.65); and started ART at age 10-14 years (aHR = 2.45, 95% CI 1.96-3.05), and 15-19 years (aHR = 9.67, 95% CI 7.25-12.89). Retention in care among adolescents on ART over two-year period was considerably lower than the UNAIDS 2030 target of 95%. Of particular concern for intervention is the lower rates of retention in care among females and pregnant adolescents and starting ART between the ages of 10 and 19 years. Family or caregivers and peer support groups centred interventions designed to promote early initiation and retention in care through early case identification are needed.

Immunopathogenesis in HIV-associated pediatric tuberculosis

Tuberculosis (TB) is an increasing global emergency in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients, in which host immunity is dysregulated and compromised. However, the pathogenesis and efficacy of therapeutic strategies in HIV-associated TB in developing infants are essentially lacking. Bacillus Calmette-Guerin vaccine, an attenuated live strain of Mycobacterium bovis, is not adequately effective, which confers partial protection against Mycobacterium tuberculosis (Mtb) in infants when administered at birth. However, pediatric HIV infection is most devastating in the disease progression of TB. It remains challenging whether early antiretroviral therapy (ART) could maintain immune development and function, and restore Mtb-specific immune function in HIV-associated TB in children. A better understanding of the immunopathogenesis in HIV-associated pediatric Mtb infection is essential to provide more effective interventions, reducing the risk of morbidity and mortality in HIV-associated Mtb infection in infants. IMPACT: Children living with HIV are more likely prone to opportunistic infection, predisposing high risk of TB diseases. HIV and Mtb coinfection in infants may synergistically accelerate disease progression. Early ART may probably induce immune reconstitution inflammatory syndrome and TB pathology in HIV/Mtb coinfected infants.

Incidence and predictors of mortality among children co-infected with tuberculosis and human immunodeficiency virus at public hospitals in Southern Ethiopia

Background

Tuberculosis and human immune deficiency virus co-infections remained the most common cause of child mortality for the last ten years. Globally, 1.2 million cases of tuberculosis occurred in patients living with HIV/AIDS, of which 1.0 million cases occurred in children. The public health impact of tuberculosis and human immune deficiency virus co-infection among children is high in developing countries and Sub-Saharan Africa accompanied three fourth of the global burden. However, there are limited studies that assess the incidence and predictors of mortality among tuberculosis and human immune deficiency virus co-infected children in Ethiopia.

Methods

A facility-based retrospective cohort study was conducted at Public hospitals in Southern Ethiopia with a total of 286 randomly selected records of ART enrolled children from 1st January 2009 to 31^stDecember 2018. Data were entered into Epi Data version 3.1 and exported to STATA version 14 for analysis. Bivariate and multivariable Cox proportional hazards model was fitted to identify the predictors of mortality. Variables that had a p-value<0.05 at 95%CI in the multivariable cox proportional hazard model were considered as statistically significant.

Results

A total of 274 tuberculosis and human immunodeficiency virus co-infected children’s records were reviewed. The incidence of mortality among tuberculosis and human immunodeficiency virus co-infected children was 17.15 per 100 children. The overall incidence density rate of mortality was 2.97(95%CI: 2.2, 3.9) per 100 child year of observation and being anemic (AHR: 2.6; 95%CI: 1.28, 5.21), not initiating isoniazid prophylaxis therapy (AHR: 2.8; 95%CI: 1.44, 5.48), developing extrapulmonary tuberculosis (AHR: 5.7; 95%CI: 2.67, 12.56) and non-adherence (AHR: 5.2; 95%CI: 2.19, 12.39) were independent predictors of mortality.

Conclusion

Mortality rate was high among TB/HIV co-infected children at the public hospitals in Southern Ethiopia. Extra-pulmonary tuberculosis, anemia, non-adherence, and isoniazid preventive therapy use were statistically significant predictors of mortality among TB/HIV co-infected children. Therefore, extra pulmonary tuberculosis, and anemia should be closely monitored to increase their adherence as well as they should be provided with isoniazid preventive therapy.

Abnormal Tryptophan Metabolism in HIV and Mycobacterium tuberculosis Infection

Host metabolism has recently gained more attention for its roles in physiological functions and pathologic conditions. Of these, metabolic tryptophan disorders generate a pattern of abnormal metabolites that are implicated in various diseases. Here, we briefly highlight the recent advances regarding abnormal tryptophan metabolism in HIV and Mycobacterium tuberculosis infection and discuss its potential impact on immune regulation, disease progression, and neurological disorders. Finally, we also discuss the potential for metabolic tryptophan interventions toward these infectious diseases.

Childhood tuberculosis treatment outcome and its association with HIV co-infection in Ethiopia: a systematic review and meta-analysis

Background

Tuberculosis is the second leading cause of death from an infectious disease worldwide, next to HIV. Hence, initiating and determining the national tuberculosis treatment program and outcome is crucial. However, the childhood tuberculosis treatment outcome in Ethiopia was not investigated.

Objective

This study determined the pooled estimate of childhood tuberculosis treatment outcome and its association with HIV co-infection.

Methods

PubMed, Google Scholar, Web of Science, reference lists of included studies, and Ethiopian institutional research repositories were used to retrieve all available studies. Searching was limited to the studies that had been conducted in Ethiopia and published in the English language. In this study, observational studies, including cohort, cross-sectional, and case-control studies, were included. The estimate of childhood tuberculosis treatment outcome was determined using a weighted inverse variance random-effects model. The overall variation between studies was checked by the heterogeneity test (I ²). The Joanna Briggs Institute (JBI) quality appraisal criteria were used for quality assessment of the studies. The summary estimates were presented with forest plots and tables. Publication bias was also checked with the funnel plot and Egger's regression test. The outcome measures were successful and unsuccessful treatment outcomes. Successful treatment outcomes are defined as patients who are cured and treatment completed, whereas, an unsuccessful treatment outcome means those patients with defaulter, failure, and death treatment outcomes.

Result

To estimate the overall pooled estimate of successful treatment outcome, 6 studies with 5389 participants were considered. Consequently, the overall pooled estimate of successful treatment outcome was 79.62% (95% CI 73.22, 86.02) of which 72.44% was treatment completed. On the other hand, unsuccessful treatment outcomes, including treatment failure, defaulter, and death, were 0.15%, 5.36%, and 3.54%, respectively. Moreover, this study found that HIV co-infection was significantly associated with childhood tuberculosis treatment outcomes. Poor treatment outcome was higher among children with HIV co-infection with an odds ratio of 3.15 (95% CI 1.67, 5.94) compared to that of HIV-negative children.

Conclusion

The summary estimate of successful childhood tuberculosis treatment outcome was low compared to the threshold suggested by the World Health Organization. HIV co-infection is significantly associated with poor treatment outcome of childhood tuberculosis. Therefore, special attention is better to be given to children infected with HIV. Moreover, adherence to anti-TB has to be strengthened.

Trial registration

The protocol has been registered in PROSPERO with a registration number of CRD42018110570.

Effect of First-Line Antituberculosis Therapy on Nevirapine Pharmacokinetics in Children Younger than Three Years Old

Nevirapine-based antiretroviral therapy (ART) is one of the limited options in HIV-infected children younger than 3 years old (young children) with tuberculosis (TB) coinfection. To date, there are insufficient data to recommend nevirapine-based therapy during first-line antituberculosis (anti-TB) therapy in young children. We compared nevirapine pharmacokinetics (PK) in HIV-infected young children with and without TB coinfection. In the coinfected group, nevirapine PK was evaluated while on anti-TB therapy and after completing an anti-TB therapy regimen. Of 53 participants, 23 (43%) had TB-HIV coinfection. While the mean difference in nevirapine PK parameters between the two groups was not significant (P > 0.05), 14/23 (61%) of the children with TB-HIV coinfection and 9/30 (30%) with HIV infection had a nevirapine minimum concentration (Cmin) below the proposed target of 3.0 mg/liter (P = 0.03). In multivariate analysis, anti-TB therapy and the CYP2B6 516G>T genotype were joint predictors of nevirapine PK parameters. Differences in nevirapine PK parameters between the two groups were significant in children with CYP2B6 516GG but not the GT or TT genotype. Among 14 TB-HIV-coinfected participants with paired data, the geometric mean Cmin and area under the drug concentration-time curve from time zero to 12 h (AUC0-12) were about 34% lower when patients were taking anti-TB therapy, while the nevirapine apparent oral clearance (CL/F) was about 45% higher. While the induction effect of anti-TB therapy on nevirapine PK in our study was modest, the CYP2B6 genotype-dependent variability in the TB drug regimen effect would complicate any dose adjustment strategy in young children with TB-HIV coinfection. Alternate ART regimens that are more compatible with TB treatment in this age group are needed. (This study has been registered at ClinicalTrials.gov under identifier NCT01699633.).

The burden of vaccine-preventable diseases among HIV-infected and HIV-exposed children in sub-Saharan Africa: a systematic review and meta-analysis

There are knowledge gaps regarding evidence-based research on the burden of vaccine-preventable diseases among human immunodeficiency virus (HIV)-infected and HIV-exposed children aged <18 years in sub-Saharan Africa. It is therefore essential to determine the trend and burden of vaccine-preventable diseases. We completed a systematic review and meta-analysis to identify the incidence, prevalence and case-fatality rates (CFR) attributed to various vaccine-preventable diseases among HIV-infected and HIV-exposed children in sub-Saharan Africa. The trends in the prevalence of vaccine-preventable diseases among HIV-infected and HIV-exposed children were also determined. Nine studies on tuberculosis (TB) were pooled to give an overall incidence rate estimate of 60 (95% confidence interval [CI] 30-70) per 1,000 child-years. The incidence of pneumococcal infections varied between 109-1509 per 100,000 while pertussis was between 2.9 and 3.7 per 1000 child-year. Twenty-two TB prevalence studies reported an estimated prevalence of 16%. Fifteen prevalence studies on hepatitis B infection were pooled together with an estimated prevalence of 5%. The pooled prevalence for pneumococcal infections was 2% while rotavirus diarrhoea reported a prevalence of 13%. Twenty-nine studies on TB were pooled to give an overall CFR estimate of 17% while pneumococcal infections in HIV-infected and exposed children were pooled together with a resultant rate of 15%. Some of the vaccine-preventable diseases still have high incidences, prevalence and CFR among HIV-infected and HIV-exposed children. There is also a dearth of research data on the burden of several vaccine-preventable diseases among HIV-infected and exposed children and a need for more studies in this area.

Effect of Rifampin-Isoniazid-Containing Antituberculosis Therapy on Efavirenz Pharmacokinetics in HIV-Infected Children 3 to 14 Years Old

We compared efavirenz pharmacokinetic (PK) parameters in children with tuberculosis (TB)/human immunodeficiency virus (HIV) coinfection on and off first-line antituberculosis therapy to that in HIV-infected children. Children 3 to 14 years old with HIV infection, with and without TB, were treated with standard efavirenz-based antiretroviral therapy without any efavirenz dose adjustments. The new World Health Organization-recommended antituberculosis drug dosages were used in the coinfected participants. Steady-state efavirenz concentrations after 4 weeks of antiretroviral therapy were measured using validated liquid chromatography with tandem mass spectrometry (LC-MS/MS) assays. Pharmacokinetic parameters were calculated using noncompartmental analysis. Between groups, PK parameters were compared by Wilcoxon rank-sum test and within group by signed-rank test. Of the 105 participants, 43 (41.0%) had TB coinfection. Children with TB/HIV coinfection compared to those with HIV infection were younger, had lower median weight-for-age Z score, and received a higher median efavirenz weight-adjusted dose. Geometric mean (GM) efavirenz peak concentration (Cmax), concentration at 12 h (C12h), Cmin, and total area under the curve from time 0 to 24 h (AUC0-24h) values were similar in children with HIV infection and those with TB/HIV coinfection during anti-TB therapy. Geometric mean efavirenz C12h, Cmin, and AUC0-24h values were lower in TB/HIV-coinfected patients off anti-TB therapy than in the children with HIV infection or TB/HIV coinfection on anti-TB therapy. Efavirenz clearance was lower and AUC0-24h was higher on than in patients off anti-TB therapy. Reduced efavirenz clearance by first-line anti-TB therapy at the population level led to similar PK parameters in HIV-infected children with and without TB coinfection. Our findings do not support modification of efavirenz weight-band dosing guidelines based on TB coinfection status in children. (The study was registered with ClinicalTrials.gov under registration number NCT01704144.).

Treatment of tuberculosis infection in children

INTRODUCTION

Identifying and treating children with tuberculosis (TB) infection in both low and high-TB burden settings will decrease the incidence of TB disease worldwide. Areas covered: This review covers each of the available TB infection treatment options for children based on effectiveness, safety, tolerability and treatment completion rates. Six to 9 months of daily administered isoniazid is no longer the treatment of choice for many children with TB infection. Shorter, rifamycin based, TB infection treatment regimens are effective, safe and easier for children to complete. Fluroquinolone-based regimens are recommended for the treatment of children infected by a source case with drug-resistant TB. Directly observed therapy (DOT) programs improve childhood TB infection treatment completion rates. Expert commentary: As shorter, rifamycin-based, TB infection treatment regimens offer superior treatment success rate in both adults and children; the widespread use of these regimens has huge potential to decrease the burden of TB disease worldwide. The implementation of these programs will involve improving patient access to the medications, decreasing their cost to the patient, and the use of novel electronic methods to document patient treatment completion.

Survival and predictors of mortality among children co-infected with tuberculosis and human immunodeficiency virus at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. A retrospective follow-up study

BACKGROUND

Tuberculosis (TB) is the leading cause of death in Human immunodeficiency virus (HIV) infected children globally. The aims of this study were to determine the mortality rate and to identify the predictors of mortality among TB/HIV co-infected children at University of Gondar Comprehensive Specialized Hospital.

METHOD

A retrospective follow-up study was conducted among TB/HIV co-infected children from February 2005 to March 2017. A Kaplan-Meier curve was used to estimate the median survival time. Bivariate and multivariable Cox proportional hazards models were fitted to identify the predictors of mortality.

RESULTS

A total of 271 TB/HIV co-infected children were included in the analysis. Of these, 38(14.02%) children were died during the follow-up period. This gives a total of 1167.67 child-years of observations. The overall mortality rate was 3.27(95%CI: 2.3-4.5) per 100 child-years. The independent predictors of time to death were age 1-5 years (as compared to age <1 year) (AHR = 0.3; 95%CI:0.09-0.98)), being anemic (AHR = 2.6; 95%CI:1.24-5.3), cotrimoxazole preventive therapy(CPT) non-users (AHR = 4.1; 95%CI:1.4-16.75), isoniazid preventive therapy(IPT) non-users (AHR = 2.95; 95%CI:1.16-7.5), having extra pulmonary tuberculosis(EPTB) (AHR = 2.43; 95%CI:1.1-5.3)) and fair or poor adherence to Anti-Retroviral Therapy (ART)(AHR = 3.5; 95%CI:1.7-7.5).

CONCLUSION

Mortality rate among TB/HIV co-infected children was high at University of Gondar Comprehensive Specialized Hospital. Age, extra-pulmonary tuberculosis, anemia, adherence, CPT and IPT were the independent predictors of mortality.

Mortality and its determinants in antiretroviral treatment-naive HIV-infected children with suspected tuberculosis: an observational cohort study

BACKGROUND

Tuberculosis is a major cause of morbidity and mortality in HIV-infected children, but is difficult to diagnose. We studied mortality and its determinants in antiretroviral treatment (ART)-naive HIV-infected children presenting with suspected tuberculosis.

METHODS

In this observational cohort study, HIV-infected children aged 13 years or younger with suspected tuberculosis were followed up for 6 months as part of the ANRS 12229 PAANTHER 01 cohort in eight hospitals in four countries (Burkina Faso, Cambodia, Cameroon, and Vietnam). Children started ART and antituberculosis treatment at the clinician's discretion and were retrospectively classified into one of three groups by tuberculosis documentation: confirmed by culture or Xpert MTB/RIF, unconfirmed, and unlikely. We assessed mortality and associated factors using Kaplan-Meier methods and Cox proportional hazard models. The ANRS 12229 PAANTHER 01 study is registered at ClinicalTrials.gov, number NCT01331811.

FINDINGS

266 (61%) of 438 children enrolled in the study between April 27, 2011, and May 31, 2014, were ART-naive and included in the analysis (40 had confirmed tuberculosis, 119 unconfirmed tuberculosis, and 107 unlikely tuberculosis). 112·5 person-years of follow-up were available. 154 children (58%) started antituberculosis treatment and 212 (80%) started ART. 50 children (19%) died. Mortality by 6 months was higher in children with confirmed tuberculosis (14 deaths; 2 month survival probability 65·0% [95% CI 50·2-79·8]) compared with unconfirmed tuberculosis (19 deaths; 83·5% [76·8-90·3]) and unlikely tuberculosis (17 deaths; 83·5% [76·3-90·7]; log-rank p=0·0141) and was lower in children with confirmed or unconfirmed tuberculosis who started antituberculosis treatment (p<0·0001 for both). In a multivariate analysis, ART started during the first month of follow-up (hazard ratio 0·08; 95% CI 0·01-0·67), confirmed tuberculosis (6·33; 2·15-18·64), young age (5·90; 2·02-17·19), CD4 less than 10% (2·63; 1·25-5·53), miliary features (4·08; 1·56-10·66), and elevated serum transaminases (4·40; 1·82-10·65) were all independently associated with mortality.

INTERPRETATION

In our cohort, mortality was high in the first 6 months after suspicion of tuberculosis in ART-naive children. ART should be started early, particularly in children with factors associated with high mortality. Documented or empirical tuberculosis treatment decision should be accelerated to reduce mortality and allow early ART initiation.

FUNDING

ANRS and Fondation Total.

Assessment of airway compression on chest radiographs in children with pulmonary tuberculosis

BACKGROUND

Because small, pliable paediatric airways are easily compressed by enlarged lymph nodes, detection of radiographic airway compression might be an objective criterion for diagnosing pulmonary tuberculosis.

OBJECTIVE

To investigate the frequency and inter-observer agreement of airway compression on chest radiographs in children with pulmonary tuberculosis compared to those with a different lower respiratory tract infection.

MATERIALS AND METHODS

Chest radiographs of children with suspected pulmonary tuberculosis were read by two readers according to a standardised format and a third reader when there was disagreement. Radiographs of children with proven pulmonary tuberculosis were compared to those with a different lower respiratory tract infection. We evaluated frequency and location of radiographic airway compression. Findings were correlated with human immunodeficiency virus (HIV) status and age. We assessed inter-observer agreement using kappa statistics.

RESULTS

We reviewed radiographs of 505 children (median age 25.9 months, interquartile range [IQR] 14.3-62.2). Radiographic airway compression occurred in 54/188 (28.7%) children with proven pulmonary tuberculosis and in 24/317 (7.6%) children with other types of lower respiratory tract infection (odds ratio [OR] 4.9; 95% confidence interval [CI] 2.9-8.3). A higher frequency of radiographic airway compression occurred in infants (22/101, or 21.8%) compared to older children (56/404, or 13.9%; OR 1.7; 95% CI 1.0-3.0). We found no association between airway compression and HIV infection. Inter-observer agreement ranged from none to fair (kappa of 0.0-0.4).

CONCLUSION

There is a strong association between airway compression on chest radiographs and confirmed pulmonary tuberculosis. However this finding's clinical use as an objective criterion for diagnosis of pulmonary tuberculosis in children is limited by poor inter-observer agreement.

Isoniazid for preventing tuberculosis in HIV-infected children

BACKGROUND

Tuberculosis (TB) is an important cause of illness and death in HIV-positive children living in areas of high TB prevalence. We know that isoniazid prophylaxis prevents TB in HIV-negative children following TB exposure, but there is uncertainty related to its role in TB preventive treatment in HIV-positive children.

OBJECTIVES

To summarise the effects of TB preventive treatment versus placebo in HIV-positive children with no known TB contact on active TB, death, and reported adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, Embase and two trial registers up to February 2017.

SELECTION CRITERIA

We included trials of HIV-positive children with and without known TB exposure, randomized to receive TB preventive treatment or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently used the study selection criteria, assessed risk of bias, and extracted data. We assessed effects using risk, incidence rate and hazard ratios and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included three trials, involving 991 participants, below the age of 13 years, from South Africa and Botswana. Children were randomized to isoniazid prophylaxis or placebo, given daily or three times weekly. The median length of follow-up ranged from 5.7 to 34 months; some were on antiretroviral therapy (ART).In HIV-positive children not on ART, isoniazid prophylaxis may reduce the risk of active TB (hazard ratio (HR) 0.31, 95% confidence interval (CI) 0.11 to 0.87; 1 trial, 240 participants, low certainty evidence), and death (HR 0.46, 95% CI 0.22 to 0.95; 1 trial, 240 participants, low certainty evidence). One trial (182 participants) reported number of children with laboratory adverse events, which was similar between the isoniazid prophylaxis and placebo groups. No clinical adverse events were reported.In HIV-positive children on ART, we do not know if isoniazid prophylaxis reduces the risk of active TB (risk ratio (RR) 0.76, 95% CI 0.50 to 1.14; 3 trials, 737 participants, very low certainty evidence) or death (RR 1.45, 95% CI 0.78 to 2.72; 3 trials, 737 participants, very low certainty evidence). Two trials (714 participants) reported number of clinical adverse events and three trials (795 participants) reported number of laboratory adverse events; for both categories, the number of adverse events were similar between the isoniazid prophylaxis and placebo groups.

AUTHORS' CONCLUSIONS

Isoniazid prophylaxis given to all children diagnosed with HIV may reduce the risk of active TB and death in HIV-positive children not on ART in studies from Africa. For children on ART, no clear benefit was detected. .

The impact of HIV and antiretroviral therapy on TB risk in children: a systematic review and meta-analysis

BACKGROUND

Children (<15 years) are vulnerable to TB disease following infection, but no systematic review or meta-analysis has quantified the effects of HIV-related immunosuppression or antiretroviral therapy (ART) on their TB incidence.

OBJECTIVES

Determine the impact of HIV infection and ART on risk of incident TB disease in children.

METHODS

We searched MEDLINE and Embase for studies measuring HIV prevalence in paediatric TB cases ('TB cohorts') and paediatric HIV cohorts reporting TB incidence ('HIV cohorts'). Study quality was assessed using the Newcastle-Ottawa tool. TB cohorts with controls were meta-analysed to determine the incidence rate ratio (IRR) for TB given HIV. HIV cohort data were meta-analysed to estimate the trend in log-IRR versus CD4%, relative incidence by immunological stage and ART-associated protection from TB.

RESULTS

42 TB cohorts and 22 HIV cohorts were included. In the eight TB cohorts with controls, the IRR for TB was 7.9 (95% CI 4.5 to 13.7). HIV-infected children exhibited a reduction in IRR of 0.94 (95% credible interval: 0.83-1.07) per percentage point increase in CD4%. TB incidence was 5.0 (95% CI 4.0 to 6.0) times higher in children with severe compared with non-significant immunosuppression. TB incidence was lower in HIV-infected children on ART (HR: 0.30; 95% CI 0.21 to 0.39). Following initiation of ART, TB incidence declined rapidly over 12 months towards a HR of 0.10 (95% CI 0.04 to 0.25).

CONCLUSIONS

HIV is a potent risk factor for paediatric TB, and ART is strongly protective. In HIV-infected children, early diagnosis and ART initiation reduces TB risk.

TRIAL REGISTRATION NUMBER

CRD42014014276.

Pharmacokinetics of the First-Line Antituberculosis Drugs in Ghanaian Children with Tuberculosis with or without HIV Coinfection

Although human immunodeficiency virus (HIV) coinfection is the most important risk factor for a poor antituberculosis (anti-TB) treatment response, its effect on the pharmacokinetics of the first-line drugs in children is understudied. This study examined the pharmacokinetics of the four first-line anti-TB drugs in children with TB with and without HIV coinfection. Ghanaian children with TB on isoniazid, rifampin, pyrazinamide, and ethambutol for at least 4 weeks had blood samples collected predose and at 1, 2, 4, and 8 hours postdose. Drug concentrations were determined by validated liquid chromatography-mass spectrometry methods and pharmacokinetic parameters calculated using noncompartmental analysis. The area under the concentration-time curve from 0 to 8 h (AUC0-8), maximum concentration (Cmax), and apparent oral clearance divided by bioavailability (CL/F) for each drug were compared between children with and without HIV coinfection. Of 113 participants, 59 (52.2%) had HIV coinfection. The baseline characteristics were similar except that the coinfected patients were more likely to have lower weight-for-age and height-for-age Z scores (P < 0.05). Rifampin, pyrazinamide, and ethambutol median body weight-normalized CL/F values were significantly higher, whereas the plasma AUC0-8 values were lower, in the coinfected children than in those with TB alone. In the multivariate analysis, drug dose and HIV coinfection jointly influenced the apparent oral clearance and AUC0-8 for rifampin, pyrazinamide, and ethambutol. Isoniazid pharmacokinetics were not different by HIV coinfection status. HIV coinfection was associated with lower plasma exposure of three of the four first-line anti-TB drugs in children. Whether TB/HIV-coinfected children need higher dosages of rifampin, pyrazinamide, and ethambutol requires further investigation. (This study has been registered at ClinicalTrials.gov under identifier NCT01687504.).

Mortality in children diagnosed with tuberculosis: a systematic review and meta-analysis

BACKGROUND

Case fatality ratios in children with tuberculosis are poorly understood-particularly those among children with HIV and children not receiving tuberculosis treatment. We did a systematic review of published work to identify studies of population-representative samples of paediatric (ie, <15 years) tuberculosis cases.

METHODS

We searched PubMed and Embase for reports published in English, French, Portuguese, or Spanish before Aug 12, 2016, that included terms related to tuberculosis, children, mortality, and population representativeness. We also reviewed our own files and reference lists of articles identified by this search. We screened titles and abstracts for inclusion, excluding studies in which outcomes were unknown for 10% or more of the children and publications detailing non-representative samples. We used random-effects meta-analysis to produce pooled estimates of case fatality ratios from the included studies, which we divided into three eras: the pre-treatment era (ie, studies before 1946), the middle era (1946-80), and the recent era (after 1980). We stratified our analyses by whether or not children received tuberculosis treatment, age (0-4 years, 5-14 years), and HIV status.

FINDINGS

We identified 31 papers comprising 35 datasets representing 82 436 children with tuberculosis disease, of whom 9274 died. Among children with tuberculosis included in studies in the pre-treatment era, the pooled case fatality ratio was 21·9% (95% CI 18·1-26·4) overall. The pooled case fatality ratio was significantly higher in children aged 0-4 years (43·6%, 95% CI 36·8-50·6) than in those aged 5-14 years (14·9%, 11·5-19·1). In studies in the recent era, when most children had tuberculosis treatment, the pooled case fatality ratio was 0·9% (95% CI 0·5-1·6). US surveillance data suggest that the case fatality ratio is substantially higher in children with HIV receiving treatment for tuberculosis (especially without antiretroviral therapy) than in those without HIV.

INTERPRETATION

Without adequate treatment, children with tuberculosis, especially those younger than 5 years, are at high risk of death. Children with HIV have an increased mortality risk, even when receiving tuberculosis treatment.

FUNDING

US National Institutes of Health, Janssen Global Public Health.

Mortality among pulmonary tuberculosis and HIV-1 co-infected Nigerian children being treated for pulmonary tuberculosis and on antiretroviral therapy: a retrospective cohort study

BACKGROUND

Mortality data, including the risk factors for mortality in HIV-infected children with pulmonary TB (PTB) being treated for PTB and who are on antiretroviral therapy (ART), are scarce in Nigeria. We determined the mortality rate and risk factors for mortality among such children, at the pediatric HIV clinic of the Jos University Teaching Hospital (JUTH) in Jos, Nigeria.

METHODS

We performed a retrospective cohort study on 260 PTB-HIV-1 co-infected children, aged 2 months to 13 years, being treated for PTB and on ART from July 2005 to March 2013. The mortality rate and associated risk factors were determined using multivariate Cox proportional hazards modelling.

RESULTS

The mortality rate for the study cohort was 1.4 per 100 child-years of follow-up. Median follow-up time was 5.2 years (IQR, 3.5-6.0 years) with total study time being 1159 child-years. The median age of those who died was lower than that of survivors, 1.9 years (IQR, 0.6-3.6 years) versus 3.8 years (IQR, 1.8-6.0 years), p=0.005). The majority of the deaths occurred in males (13, 81.2%), those <5 years of age (14, 87.4%) and those who had severe immunosuppression (11, 68.8%). Risk factors for death were age (with the risk of dying decreasing by 25% for every 1 year increase in age, adjusted hazard ratio (AHR)=0.75 [0.58-0.98], p=0.032), male gender (AHR=3.80 [1.07-13.5], p=0.039) and severe immunosuppression (AHR=3.35 [1.16-9.66], p=0.025).

CONCLUSION

In our clinic setting, mortality among our PTB-HIV co-infected children being treated for PTB and on ART was low. However, those presenting with severe immunosuppression and who are males and very young, should be monitored more closely during follow-up in order to further reduce mortality.

Pharmacokinetics of First-Line Antituberculosis Drugs Using WHO Revised Dosage in Children With Tuberculosis With and Without HIV Coinfection

BACKGROUND

Pharmacokinetic data on the first-line antituberculosis drugs using the World Health Organization (WHO) revised dosages for children are limited. We investigated the pharmacokinetics of these drugs in children who were mostly treated with revised dosages.

METHODS

Children with tuberculosis on first-line therapy for at least 4 weeks had blood samples collected at predose, 1, 2, 4, and 8 hours postdose. Drug concentrations were determined by validated liquid chromatography mass spectrometry methods, and pharmacokinetic parameters were calculated using noncompartmental analysis. Factors associated with plasma peak concentration (C_max) and the area under the time-concentration curve 0-8 hours (AUC_0-8h) of each drug was examined using univariate and multivariate analysis.

RESULTS

Of the 62 children, 32 (51.6%) were male, 29 (46.8%) were younger than 5 years old, and 28 (45.2%) had human immunodeficiency virus (HIV) coinfection. Three patients had undetectable pyrazinamide and ethambutol concentrations. The median (interquartile range) AUC_0-8h for isoniazid was 17.7 (10.2-23.4) µg·h mL^-1, rifampin was 26.0 (15.3-36.1) µg·h mL^-1, pyrazinamide was 144.6 (111.5-201.2) µg·h mL^-1, and ethambutol was 6.7 (3.8-10.4) µg·h mL^-1. Of the children who received recommended weight-band dosages, 44/51 (86.3%), 46/56 (82.1%), 27/56 (48.2%), and 21/51 (41.2%) achieved target C_max for isoniazid, pyrazinamide, ethambutol, and rifampin, respectively. In multivariate analysis, age, sex, HIV coinfection status, and drug dosage in milligrams per kilogram were associated with the drugs' plasma drug C_max or AUC_0-8h.

CONCLUSIONS

The revised dosages appeared to be adequate for isoniazid and pyrazinamide, but not for rifampin or ethambutol in this population. Higher dosages of rifampin and ethambutol than currently recommended may be required in most children.

Tuberculosis, before and after Antiretroviral Therapy among HIV-Infected Children in Nigeria: What Are the Risk Factors?

INTRODUCTION

In Nigeria, there is a dearth of pediatric data on the risk factors associated with tuberculosis (TB), before and after antiretroviral therapy (ART).

METHODOLOGY

A retrospective observational cohort study, between October 2010 and December 2013, at the Federal Medical Centre, Makurdi, Nigeria. TB was noted among children less than 15 years of age at ART enrolment (prevalent TB-PrevTB), within 6 months (early incident tuberculosis-EITB) and after 6 months (late incident tuberculosis-LITB) of a 12-month follow-up on ART. Potential risk factors for PrevTB and incident TB were assessed using the multivariate logistic and Cox regression models respectively.

RESULTS

Among 368 HIV-1 infected children, PrevTB was diagnosed in 73 children (19.8%). Twenty-eight EITB cases were diagnosed among 278 children over 132 person-years (py) with an EITB rate of 21.2/100 py. Twelve LITB cases were seen among 224 children over 221.9 py with a LITB rate of 5.4/100 py. A significant reduction in the incidence rates of TB was found over time (75%, p˂ 0.001). Young age of children (12-35 months, aOR; 24, 95% CI; 4.1-146.6, p ˂ 0.001; 36-59 months, aOR;21, 95%CI;4.0-114.3, p ˂ 0.001); history of TB in children (aOR; 29, 95% CI; 7.3-119.4, P˂ 0.001); severe immunosuppression (aOR;38, 95% CI;12-123.2,p ˂ 0.001); oropharyngeal candidiasis (aOR;3.3, 95% CI; 1.4-8.0, p = 0.009) and sepsis (aOR; 3.2, 95% CI;1.0-9.6, p = 0.043) increased the risk of PrevTB. Urban residency was protective against EITB (aHR; 0.1, 95% CI; 0.0-0.4, p = 0.001). Virological failure (aHR; 4.7, 95% CI; 1.3-16.5, p ˂ 0.001) and sepsis (aHR; 26, 95% CI; 5.3-131.9, p ˂ 0.001) increased the risk of LITB.

CONCLUSIONS

In our cohort of HIV-infected children, a significant reduction in cases of incident TB was seen following a 12-month use of ART. After ART initiation, TB screening should be optimized among children of rural residency, children with sepsis, and those with poor virological response to ART.

Treatment Outcomes of Childhood TB in Lagos, Nigeria

BACKGROUND

: Treatment outcomes of tuberculosis (TB) in children are rarely evaluated by most national TB programmes in sub-Saharan Africa. This study evaluated the treatment outcomes of children treated for TB in Lagos State, Nigeria.

METHODS

A retrospective review of programme data of the Lagos state TB and the Leprosy control programme in Nigeria from 1 January 2012 to 31 December 2012. Treatment outcomes were categorized according to the national TB guidelines.

RESULTS

A total of 535 cases of childhood TB were notified in 2012, representing 6.3% of the total TB cases notified in Lagos state in 2012. The prevalence of TB/HIV co-infection was 29%. The treatment success rate was 79.2% in TB/HIV-negative children compared with 73.4% in TB/HIV-positive children (p = 0.1268). Children <1 year had the worst treatment outcomes (p < 0.001).

CONCLUSION

There is a need to intensify effort at improving notification and treatment outcomes in children.

Prevalence, incidence, and associated risk factors of tuberculosis in children with HIV living in the UK and Ireland (CHIPS): a cohort study

BACKGROUND

Tuberculosis is the most common serious co-infection in people living with HIV worldwide, but little is known about its incidence in HIV-infected children living in high-resource settings with low tuberculosis prevalence. We aimed to assess the incidence and prevalence of tuberculosis in children with HIV living in the UK and Ireland to understand rates, risk factors, and outcomes of the disease in this group.

METHODS

We did an analysis of children enrolled in CHIPS, an observational multicentre cohort of children receiving HIV care in the UK and Ireland. We assessed characteristics and prevalence of tuberculosis at baseline, measured incidence of disease through the follow-up period using the CHIPS database, and calculated associated risk factors in these children with multivariable logistic and Cox regression models.

FINDINGS

Between Jan 1, 1996, to Sept 18, 2014, data for 1848 children with 14 761 years of follow-up were reported to CHIPS. 57 (3%) children were diagnosed with tuberculosis: 29 children had tuberculosis at presentation (prevalent tuberculosis) and 29 had the disease diagnosed during follow-up (incident tuberculosis), including one child with recurrent tuberculosis events. Median age at diagnosis was 9 years (IQR 5-12). 25 (43%) children had pulmonary tuberculosis, 24 (41%) had extrapulmonary tuberculosis with or without pulmonary involvement, and the remainder (n=9; 16%) had unspecified-site tuberculosis. The overall incidence rate for the follow-up period was 196 cases per 100 000 person-years (95% CI 137-283). In our multivariable model, tuberculosis at presentation was associated with more severe WHO immunological stage at baseline (odds ratio 0·25, 95% CI 0·08-0·74; p=0·0331; for none vs severe) and being born abroad (odds ratio 0·28, 0·10-0·73; p=0·0036; for UK and Ireland vs abroad). Incident tuberculosis was associated with time-updated more severe WHO immunological stage (hazard ratio 0·15, 95% CI 0·06-0·41; p=0·0056; for none vs severe) and older age at baseline (1·11, 0·47-2·63; p=0·0027; for age >10 years vs 5-9 years).

INTERPRETATION

Tuberculosis rates in HIV-infected children in the UK and Ireland were higher than those reported in the general paediatric population. Further study is warranted of tuberculosis screening and preventive treatment for children at high-risk of this disease to avoid morbidity and mortality in this population.

FUNDING

NHS England, PENTA Foundation.

Implementing a tuberculosis child contact register to quantify children at risk for tuberculosis and HIV in Eldoret, Kenya

SETTING

Tuberculosis (TB) clinic in Eldoret, Kenya.

OBJECTIVE

To identify TB exposed children through the implementation of a child contact register (CCR). To assess the demographics of children exposed to TB and the potential for initiation of isoniazid preventive therapy (IPT) in this cohort.

METHODS

A CCR was implemented in routine care with health care workers querying index cases regarding child contacts. Data were retrospectively analyzed.

RESULTS

In 12 months, the CCR revealed 580 children exposed to TB. Of these, 58% were exposed to smear-positive TB and 30% were aged <5 years. Of those exposed to smear-positive TB, 15% may have qualified for IPT initiation. Only 6 (1%) child contacts were screened for TB disease. More than 50% of the children with human immunodeficiency virus (HIV) positive mothers had not been HIV tested.

CONCLUSION

Implementation of a CCR is a possible first step in child contact identification and management, which requires minimal resources and identifies children at risk for TB and HIV. Child contact screening and IPT initiation remain a challenge, and additional strategies are urgently needed.

The chest X-ray features of chronic respiratory disease in HIV-infected children--a review

Several features of human immunodeficiency virus (HIV) infection contribute to the development of chronic respiratory disease in children. These include the frequency and severity of acute chest infections, as well as the increased risk of pulmonary tuberculosis, aspiration, cardiovascular disease, lymphocytic interstitial pneumonitis or pulmonary neoplasia. The chest radiograph (CXR) remains the most accessible investigation for respiratory disease and plays an important role in the baseline assessment and follow-up. This review focuses on the CXR abnormalities of HIV-related chronic respiratory disease in children. The most commonly documented chronic CXR abnormalities are homogeneous opacification and pulmonary nodules, with pulmonary tuberculosis and lymphocytic interstitial pneumonitis the leading respective causes. Deficiencies in radiographic reporting methodology and relative paucity of radiographic data contribute to current limitations in knowledge and understanding of this field. The review highlights the need for standardised terminology and systematic reporting methodology in future studies. Prospective research on the natural history of lymphocytic interstitial pneumonitis, response to anti-tuberculous therapy, the impact of anti-retroviral therapy and HIV-associated bronchiectasis are needed.

Pharmacokinetics of first-line antituberculosis drugs in HIV-infected children with tuberculosis treated with intermittent regimens in India

The objective of this report was to study the pharmacokinetics of rifampin (RMP), isoniazid (INH), and pyrazinamide (PZA) in HIV-infected children with tuberculosis (TB) treated with a thrice-weekly anti-TB regimen in the government program in India. Seventy-seven HIV-infected children with TB aged 1 to 15 years from six hospitals in India were recruited. During the intensive phase of TB treatment with directly observed administration of the drugs, a complete pharmacokinetic study was performed. Drug concentrations were measured by high-performance liquid chromatography. A multivariable regression analysis was done to explore the factors impacting drug levels and treatment outcomes. The proportions of children with subnormal peak concentrations (Cmax) of RMP, INH, and PZA were 97%, 28%, and 33%, respectively. Children less than 5 years old had a lower median Cmax and lower exposure (area under the time-concentration curve from 0 to 8 h [AUC0-8]) of INH (Cmax, 2.5 versus 5.1 μg/ml, respectively [P=0.016]; AUC0-8, 11.1 versus 22.0 μg/ml·h, respectively [P=0.047[) and PZA (Cmax, 34.1 versus 42.3 μg/ml, respectively [P=0.055]; AUC0-8, 177.9 versus 221.7 μg/ml·h, respectively [P=0.05]) than those more than 5 years old. In children with unfavorable versus favorable outcomes, the median Cmax of RMP (1.0 versus 2.8 μg/ml, respectively; P=0.002) and PZA (31.9 versus 44.4 μg/ml, respectively; P=0.045) were significantly lower. Among all factors studied, the PZA Cmax influenced TB treatment outcome (P=0.011; adjusted odds ratio, 1.094; 95% confidence interval, 1.021 to 1.173). A high proportion of children with HIV and TB had a subnormal RMP Cmax. The PZA Cmax significantly influenced treatment outcome. These findings have important clinical implications and emphasize that drug doses in HIV-infected children with TB have to be optimized.

How to manage TB in children? Problems and solutions in four cases

Children bear a substantial part of the tuberculosis (TB) epidemic worldwide, and it is estimated that there were ≅ 500.000 childhood TB cases globally in 2010, although accurate data are problematic to obtain given the many difficulties associated with TB diagnosis in children and the weaknesses of surveillance systems in countries where TB is endemic. The World Health Organization is working hard in order to reduce the TB prevalence rates and deaths by half by 2015. In this challenge, general practitioners and pediatricians play a key role in detecting early cases of suspected TB and sending them to experts in infectious diseases. This will reduce delayed diagnosis and the spread of disease, which is especially important now that the prevalence of multidrug resistant TB is increasing. For this reason, the purpose of this report was to delineate the characteristic clinical features of the most common forms of pediatric TB and to suggest a rational and practical approach to the disease underlining the role of patients and parents personal and clinical history.

Quantiferon Gold-in-tube assay for TB screening in HIV infected children: influence of quantitative values

BACKGROUND

HIV infected children are at increased risk of TB disease and require annual TB screening. Data on use of IGRA for TB screening in them are limited. We retrospectively evaluated the usefulness of Quantiferon Gold-in-tube test (QFT), an IGRA in screening for LTBI in relatively healthy, immunologically stable HIV infected children.

METHODS

HIV infected children with no prior history of TB were screened for latent TB as part of routine care. They underwent risk of TB assessment, TST and QFT. QFT was repeated twice or three times depending on the quantitative values. Independent test validation was also performed.

RESULTS

Eighty one children had 109 QFT tests. All had adequate mitogen responses. The initial QFT was positive in 15 (18.5%) children; quantitative IGRA responses were 0.35-1.0 IU/mL in 9 (60%), 1.0-10 IU/mL in5 (33.3%) and >10 IU/mL in 1 (6.7%). None that tested positive had documented TB exposure or TB disease. Baseline characteristics in the QFT positive and negative groups were similar. Repeat testing within 17 weeks demonstrated reversion to negative in 79% of cases. Repeat blinded independent testing of all QFT positive results and a random selection of initial negative tests demonstrated concordance in 96% of cases. Seven children (QFT > 1.0 IU/mL or positive TST) were offered INH preventive therapy. In no case has TB disease developed in 2 years of close follow-up.

CONCLUSIONS

QFT is a valid method for LTBI screening relatively healthy, immunologically stable HIV infected children. However, reversion to negative on repeat testing and lack of correlation with TST results and risk of TB exposure makes interpretation difficult.

Yield of screening for TB and HIV among children failing to thrive in Botswana

BACKGROUND

Failure to thrive (FTT) is a sign of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. We assessed TB and HIV prevalence in children with FTT at one clinic in Botswana.

METHODS

In July 2010, we screened all children attending a 'Well Child' clinic for FTT. Children with FTT were referred to a paediatrician who: (i) assessed causes of FTT, (ii) evaluated for HIV and TB and (iii) reviewed the patient chart for evaluations for TB and HIV.

RESULTS

Of 919 children screened, 176 (19%) had FTT. One hundred eighteen (67%) children saw a paediatrician, and of these, 95 (81%) completed the TB evaluation. TB was newly diagnosed in 6 of 95 (6%). At review, HIV status was known in 23 of 118 (19%). Ninety-five had an unknown HIV status. Forty-five (47%) tested for HIV; all tested HIV-negative.

CONCLUSION

TB and HIV screening among children with FTT diagnosed TB in 6% of cases completing an evaluation, but no new HIV infections.

Tuberculosis and HIV co-infection in children

HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes. Paediatric tuberculosis and HIV have overlapping clinical manifestations, which could lead to missed or late diagnosis. Although every effort should be made to obtain a microbiologically-confirmed diagnosis in children with tuberculosis, in reality this may only be achieved in a minority, reflecting their paucibacillary nature and the difficulties in obtain samples. Rapid polymerase chain reaction tests, such as Xpert MTB/RIF assay, are increasingly used in children. The use of less or non invasive methods of sample collection, such as naso-pharyngeal aspirates and stool samples for a polymerase chain reaction-based diagnostic test tests and mycobacterial cultures is promising technique in HIV negative and HIV positive children. Anti-tuberculosis treatment should be started immediately at diagnosis with a four drug regimen, irrespective of the disease severity. Moreover, tuberculosis disease in an HIV infected child is considered to be a clinical indication for initiation of antiretroviral treatment. The World Health Organization recommends starting antiretroviral treatment in children as soon as anti-tuberculosis treatment is tolerated and within 2- 8 weeks after initiating it. The treatment of choice depends on the child's age and availability of age-appropriate formulations, and potential drug interactions and resistance. Treatment of multidrug resistant tuberculosis in HIV-infected children follows same principles as for HIV uninfected children. There are conflicting results on effectiveness of isoniazid preventive therapy in reducing incidence of tuberculosis disease in children with HIV.

CONCLUSION

Data on HIV/TB co-infection in children are still lacking. There are on-going large clinical trials on the prevention and treatment of TB/HIV infection in children that hopefully will help to guide an evidence-based clinical practice in both resource-rich and resource-limited settings.HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes.

Prevalence, characteristics, management, and outcome of pulmonary tuberculosis in HIV-infected children in the TREAT Asia pediatric HIV Observational Database (TApHOD)

A multicenter, retrospective, observational study was conducted to determine prevalence, characteristics, management, and outcome of pulmonary tuberculosis (PTB) in Asian HIV-infected children in the TREAT Asia Pediatric HIV Observational Database (TApHOD). Data on PTB episodes diagnosed during the period between 12 months before antiretroviral therapy (ART) initiation and December 31, 2009 were extracted. A total of 2678 HIV-infected children were included in TApHOD over a 13-year period; 457 developed PTB, giving a period prevalence of 17.1% (range 5.7-33.0% per country). There were a total of 484 PTB episodes; 27 children had 2 episodes each. There were 21 deaths (4.3%). One third of episodes (n=175/484) occurred after ART initiation at a median of 14.1 months (interquartile range [IQR] 2.5-28.8 months). The median (IQR) CD4+ values were 9.0% (3.0-16.0%) and 183.5 (37.8-525.0) cells/mm(3) when PTB was diagnosed. Most episodes (n=424/436, 97.3%) had abnormal radiographic findings compatible with PTB, whereas half (n=267/484, 55.2%) presented with clinical characteristics of PTB. One third of those tested (n=42/122, 34.4%) had bacteriological evidence of PTB. Of the 156 episodes (32.2%) that were accompanied with extrapulmonary TB, pleuritis was the most common manifestation (81.4%). After treatment completion, most episodes (n=396/484, 81.9%) were recorded as having positive outcomes (cured, treatment completed and child well, and improvement). The prevalence of PTB among Asian HIV-infected children in our cohort was high. Children with persistent immunosuppression remain vulnerable to PTB even after ART initiation.

HIV infection in severely malnourished children in Kumasi, Ghana: a cross-sectional prospective study

Background

The Human Immunodeficiency Virus (HIV) epidemic has adversely affected the nutritional status and mortality of children in Africa. This study assessed the disease burden, predictive clinical features and outcomes for children with severe acute malnutrition (SAM) and concomitant HIV infection.

Methods

This was a cross-sectional prospective study of children with SAM aged between 3 months and 13 years admitted to the nutritional rehabilitation unit (NRU) of Komfo Anokye Teaching Hospital. Socio-demographic, anthropometric and clinical data were documented and HIV serostatus established with 2 rapid HIV antibody tests and Enzyme-linked immunosorbent assay, if indicated. HIV viral polymerase chain reaction testing was not available at the time of the study. Logistic regression analyses were used to identify significant clinical predictors of HIV seropositivity.

Results

Sixty-seven (27.2%, 95% CI = 21.8-33.3%) of the 246 study children had positive HIV antibody results. Uptake of provider-initiated HIV testing and counselling was 100%. Amongst children aged 18 months and over, the HIV seroprevalence was 28.3% (30/106). HIV seropositivity was strongly associated with prolonged fever, cough and diarrhoea; oral thrush, generalised lymphadenopathy and pulmonary tuberculosis (p value < 0.001 for all parameters). The presence of ≥ 3 of the first 5 aforementioned parameters was highly specific (98.3-100%) for HIV seropositivity in study children. HIV seropositivity was also significantly associated with cough, vomiting, lethargy/altered consciousness, skin rash and hepatomegaly (p value < 0.05 for all parameters). Overall mortality rate was 17.5%, with HIV seropositive children having a significantly higher mortality rate (37.8% versus 10.1%; p value < 0.001) and a lower rate of weight gain (2.4 g/kg/day versus 7.0 g/kg/day; p value < 0.001).

Conclusions

HIV testing was well accepted by parents/carers and should be offered in all NRUs. There was a high HIV seroprevalence among children with SAM and a significantly poorer outcome in mortality and weight gain. Some clinical features were identified to be predictive of HIV seropositivity and could be useful as indicators to prompt further investigation and/or referral in resource limited settings where HIV test kits are unavailable. This would aid in the early detection and comprehensive management of the HIV seropositive child with SAM.

Diversity of disease in childhood pulmonary tuberculosis

Many factors can influence the dynamic balance that exists between the host and the pathogen (M. tuberculosis), but the host immune response seems to be the most important. This is illustrated by the vulnerability of immune-compromised individuals to develop tuberculosis and by the age-related spectrum of disease witnessed in immune-competent children. This age-related spectrum of disease reflects the ontogeny of the host immune response towards M. tuberculosis. Renewing our focus on the ontogeny of the immune response in children might provide valuable insights to direct future research regarding tuberculosis prevention, vaccine development and treatment.

Tuberculosis among children in Kenya: epidemiology and impact of HIV in two provinces

We collected clinical register data on children in two provinces of Kenya and conducted bivariate and multivariate analyses to assess characteristics associated with death. Among 987 children with tuberculosis (TB), pulmonary disease was diagnosed in 689 (70%) children. Final outcomes were known for 830 children, 40 (5%) of whom died during TB treatment. HIV test results were available for 670 (68%) children; 371 (55%) of whom tested positive. Only 63 of 134 (47%) of children <1 year were tested for HIV. There were no data on CD4 or anti-retroviral use. The relative risk for death for HIV-infected children compared to HIV-uninfected children was 9.3 for children <1 year [95% confidence interval (CI) 1.2-69.2], 3.9 for children aged 1-4 (95% CI 0.9-17.7) and 0.9 for children aged 5-14 (95% CI 0.3-2.6). In Kenya, HIV infection in children with TB is common, and our data suggest that HIV is particularly deadly in TB patients <1 year, the group with the lowest rate of testing. Poor data recording and reporting limit our understanding of TB in this age group. Expansion of HIV testing may improve survival, and more complete data recording and reporting will enhance our understanding of pediatric TB.

CT features of lymphobronchial tuberculosis in children, including complications and associated abnormalities

BACKGROUND

Lymphobronchial tuberculosis (TB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children.

OBJECTIVE

To describe CT findings of lymphobronchial TB in children, the parenchymal complications and associated abnormalities.

MATERIALS AND METHODS

CT scans of children with lymphobronchial TB were reviewed retrospectively. Lymphadenopathy, bronchial narrowing, parenchymal complications and associations were documented.

RESULTS

Infants comprised 51% of patients. The commonest site of lymphadenopathy was the subcarinal mediastinum (97% of patients). Bronchial compression was seen in all children (259 bronchi, of these 28% the bronchus intermedius) with severe or complete stenosis in 23% of affected bronchi. Parenchymal complications were present in 94% of patients, including consolidation (88%), breakdown (42%), air trapping (38%), expansile pneumonia (28%), collapse (17%) and bronchiectasis (9%), all predominantly on the right side (63%). Associated abnormalities included ovoid lesions, miliary nodules, pleural disease and intracavitary bodies.

CONCLUSION

Airway compression was more severe in infants and most commonly involved the bronchus intermedius. Numerous parenchymal complications were documented, all showing right-side predominance.

[The impact of HIV infection on childhood tuberculosis in Yaounde, Cameroon]

OBJECTIVES

To define the prevalence of HIV infection in childhood tuberculosis and investigate its impact on the clinical presentation, radiographic findings and outcomes among children suffering from tuberculosis in Yaounde.

METHODS

The medical records of 101 children aged less than 15years, hospitalized with tuberculosis in the chest clinic of the Yaounde Jamot Hospital between January 2005 and June 2010, were retrospectively reviewed.

RESULTS

Twenty-five (24.8%) of the 101 patients were HIV positive. The occurrence of concomitant intrathoracic and extrathoracic tuberculosis was more frequently observed in HIV infected children (P=0.021). Parenchymal pulmonary lesions were bilateral in 20 (90.9%) of the HIV infected children against 31 (56.1%) in the non-infected children (P=0.003). Cavitating lesions were present in 49.1% of the cases in HIV negative group versus 13.6% in HIV positive group (P=0.004), but sub-group analysis restricted to those with confirmed tuberculosis no longer showed a significant difference. The success rate of treatment was 78.9% among HIV negative patients and 56% among HIV positive patients (P=0.024).

CONCLUSION

HIV infection modifies the clinical presentation and radiographic features of tuberculosis in children. The treatment success rate is lower in HIV positive children, indicating a stricter medical supervision of these children and more targeted education of their parents.

A systematic review of clinical diagnostic systems used in the diagnosis of tuberculosis in children

Background. Tuberculosis (TB) is difficult to diagnose in children due to lack of a gold standard, especially in resource-limited settings. Scoring systems and diagnostic criteria are often used to assist in diagnosis; however their validity, especially in areas with high HIV prevalence, remains unclear. Methods. We searched online bibliographic databases, including MEDLINE and EMBASE. We selected all studies involving scoring systems or diagnostic criteria used to aid in the diagnosis of tuberculosis in children and extracted data from these studies. Results. The search yielded 2261 titles, of which 40 met selection criteria. Eighteen studies used point-based scoring systems. Eighteen studies used diagnostic criteria. Validation of these scoring systems yielded varying sensitivities as gold standards used ranged widely. Four studies evaluated and compared multiple scoring criteria. Ten studies selected for pulmonary tuberculosis. Five studies specifically evaluated the use of scoring systems in HIV-positive children, generally finding the specificity to be lower. Conclusions. Though scoring systems and diagnostic criteria remain widely used in the diagnosis of tuberculosis in children, validation has been difficult due to lack of an established and accessible gold standard. Estimates of sensitivity and specificity vary widely, especially in populations with high HIV co-infection.

Nutritional status and its response to treatment of children, with and without HIV infection, hospitalized for the management of tuberculosis

BACKGROUND

The association of childhood tuberculosis (TB) and malnutrition is known, but treatment response, the influence of the acute-phase response (APR) and concomitant HIV infection are not well documented.

AIM

To evaluate the nutritional response and APR in HIV-infected and uninfected children hospitalised for the treatment of TB and receiving standard anti-tuberculosis chemotherapy.

METHODS

During a study of the pharmacokinetics of standard anti-tuberculosis agents, anthropometric parameters were measured and blood concentrations of nutrients and C-reactive protein (CRP) determined at 1 and 4 months after initiation of chemotherapy.

RESULTS

24 HIV-infected and 34 HIV-uninfected children were studied. On enrollment, 31.6% of HIV-infected and 2.9% of HIV-uninfected children were underweight, and 31.6% and 14.7%, respectively, were stunted. Mean values of weight, height/length, head circumference and mid-upper-arm circumference on enrollment and at 4-month assessment in HIV-infected and uninfected children did not differ. Mean triceps skinfold (TSF) (8.17 and 9.73 cm) and subscapular skinfold (SSF) thicknesses (5.75 and 7.5 cm) on enrollment differed significantly (P = 0.03 and P = 0.003); by 4 months, TSF had declined to 5.97 cm (P<0.001) and 8.87 cm (P = 0.05), respectively, and SSF to 5.57 cm (P = 0.79) and 6.73 cm (P = 0.04); the arm muscle area (AMA) was low in a majority of children on enrollment and remained so at the second assessment. CRP was raised in 66.6% and 53.3% of HIV-infected and -uninfected children on enrollment, but at 4-month assessment was raised in 63.2% and 15.2%, respectively. Other micronutrient and haematological findings probably reflect an APR, but no children had sub-normal zinc or magnesium values; most selenium and vitamin C and E values were normal. An elevated platelet count (> 420 × 10(9)/L) was significantly more common in HIV-uninfected children, and was still raised in 39% at 4 months.

CONCLUSION

A majority of HIV-infected and uninfected children had an APR but it had resolved by 4 months in most HIV-uninfected children. In both groups, low and declining skinfolds and a persistently low AMA indicate a persistent disturbance of fat and protein metabolism, despite successful chemotherapy.

A proposed comprehensive classification of tuberculosis disease severity in children

BACKGROUND

Tuberculosis (TB) in children has conventionally been classified as pulmonary TB (PTB) and extrapulmonary TB (EPTB) disease, including disseminated TB (TB meningitis and miliary disease). There is no existing approach that comprehensively characterizes the spectrum and severity of pediatric TB. This limits accurate classification of patients and comparison across cohorts.

AIMS

To develop a classification of pediatric TB that reflects the spectrum and severity of clinical disease better than currently available approaches.

METHODS

We propose a framework for the standard classification of TB disease severity in children. From a literature search, the following sources of information were used: clinical data, bacteriologic, histopathologic, and imaging data (including information from chest radiography, computerized tomography, and bronchoscopy). Each individual disease entity was systematically considered. Based on the extent and the presence of complications, each entity was then classified as "severe" or "nonsevere." As an initial application, we compared the proposed classification with the convention (PTB, EPTB) in a cohort of HIV-infected and -uninfected infants with culture-confirmed TB. Agreement between the 2 systems was poor.

CONCLUSIONS

The proposed comprehensive disease classification system may more accurately reflect the clinical TB disease spectrum in children, is relevant to clinical management, and may be valuable to inform research on diagnostic tools and TB treatment strategies in children. Prospective studies are required to evaluate this approach in representative pediatric populations, correlating TB disease severity with diagnostic yield, treatment response, and application in existing and novel treatment strategies.

Vaccination in HIV-infected individuals

Vaccinations are key to limiting the increased risk of severe infectious diseases in HIV-infected patients for whom the risk–benefit ratio has been re-evaluated. Vaccine safety and immunogenicity depend on both vaccine type and immune deficiency, while vaccine-induced immune activation promotes a transient increase in viral load. Vaccine immunogenicity is reduced and wanes more rapidly, strengthening the need for revaccination. While inactivated vaccines are safe, attenuated vaccines are theoretically contraindicated, but the risk of infectious diseases outweighs the risks of severe adverse events in endemic areas, where the majority of HIV-infected individuals live, thus allowing their use when immune deficiency is moderate. Immune reconstitution with HAART has improved vaccine immune response, highlighting the importance of global access to and early initiation of therapy.

Treatment of paediatric TB: revised WHO guidelines

The World Health Organization has recently revised the recommended dosages of the main first-line anti-tuberculosis drugs for use in children. The recommended dosages and range of isoniazid, rifampicin, pyrazinamide and ethambutol have been increased from the previous recommended dosages. Ethambutol is now recommended for use in children of all ages including those of less than 5 years of age. This review explains the rationale for these recent revisions. Children require higher dosages than adults to achieve the same serum concentrations. Available data in HIV-uninfected children suggest that the revised dosages are within limits that have a very low risk of toxicity. An important challenge will be to examine the impact of higher dosages on clinical response, drug-drug interactions and risk of toxicity in HIV-infected children.

Antiretroviral therapy outcomes in HIV-infected children after adjusting protease inhibitor dosing during tuberculosis treatment

BACKGROUND

Modification of ritonavir-boosted lopinavir (LPV/r)-based antiretroviral therapy is required for HIV-infected children co-treated for tuberculosis (TB). We aimed to determine virologic and toxicity outcomes among TB/HIV co-treated children with the following modifications to their antiretroviral therapy (ART): (1) super-boosted LPV/r, (2) double-dose LPV/r or (3) ritonavir.

METHODS AND FINDINGS

A medical record review was conducted at two clinical sites in Johannesburg, South Africa. The records of children 6-24 months of age initiating LPV/r-based therapy were reviewed. Children co-treated for TB were categorized based on the modifications made to their ART regimen and were compared to children of the same age at each site not treated for TB. Included are 526 children, 294 (56%) co-treated for TB. All co-treated children had more severe HIV disease, including lower CD4 percents and worse growth indicators, than comparisons. Children in the super-boosted group (n = 156) were as likely to be virally suppressed (<400 copies/ml) at 6 months as comparisons (69.2% vs. 74.8%, p = 0.36). Children in the double-dose (n = 47) and ritonavir groups (n = 91) were significantly less likely to be virally suppressed at 6 months (53.1% and 49.3%) than comparisons (74.8% and 82.1%; p = 0.02 and p<0.0001, respectively). At 12 months only children in the ritonavir group still had lower rates of virological suppression relative to comparisons (63.9% vs 83.3% p<0.05). Grade 1 or greater ALT elevations were more common in the super-boosted (75%) than double-dose (54.6%) or ritonavir (33.9%) groups (p = 0.09 and p<0.0001) but grade 3/4 elevations were observed in 3 (13.6%) of the super-boosted, 7 (15.9%) of the double-dose and 5 (8.9%) of the ritonavir group (p = 0.81 and p = 0.29).

CONCLUSION

Good short-term virologic outcomes were achieved in children co-treated for TB and HIV who received super-boosted LPV/r. Treatment limiting toxicity was rare. Strategies for increased dosing of LPV/r with TB treatment warrant further investigation.

Flow cytometric measurements of TB-specific T cells comparing with QuantiFERON-TB gold

BACKGROUND

Interferon-gamma (IFN-gamma) release assays and the detection of IFN-gamma synthesis in the cytoplasm of activated CD4+ T cells by flow cytometry have recently been used for tuberculosis (TB) diagnosis. The aim of this study was to compare the performance of IFN-gamma assay between ELISA (QuantiFERON-TB Gold, QFT) and intracellular cytokine flow cytometry (ICCFC), and to investigate the significance of an optimal gating strategy in ICCFC.

METHODS

The CD4+ T cell response to TB antigens was measured using the intracellular cytokine staining technique and four color FC (CD3, CD4, IFN-gamma, and tumor necrosis factor-alpha (TNF-alpha)) on whole blood samples. The results were compared with those of QFT.

RESULTS

Regarding sensitivity in the TB group, patients in the QFT positive TB group (N = 22) were all ICCFC positive and 9 patients (64%) in the QFT negative TB group (N = 14) were ICCFC positive. In all test tubes (N = 72), sensitivity of "targeted" gating for TNF-alpha+ IFN-gamma+ CD4+ T cells was significantly higher than customary gating (72%, 54%, respectively, P = 0.001).

CONCLUSIONS

The diagnostic sensitivity of ICCFC was further confirmed to be much higher than that of QFT. In the ICCFC analysis, TNF-alpha+ IFN-gamma+ CD4+ T cells should be sequentially gated through appropriately defined regions, minimizing interferents and reflecting characteristics of light scatter and marker expressions of CD4+ T cells activated by TB antigens.

Human immunodeficiency virus and tuberculosis coinfection in children: challenges in diagnosis and treatment

The burden of childhood tuberculosis (TB) is influenced by the human immunodeficiency virus (HIV) epidemic and this dangerous synergy affects various aspects of both diseases; from pathogenesis and the epidemiologic profile to clinical presentation, diagnosis, treatment, and prevention. HIV-infected infants and children are at increased risk of developing severe forms of TB. The TB diagnosis is complicated by diminished sensitivity and specificity of clinical features and diagnostic tools like the tuberculin skin test and chest x-ray. Although alternative ways of pulmonary sampling and the development of interferon-γ assays have shown to lead to some improvement of TB diagnosis in HIV-infected children, new diagnostic tools are urgently needed. Coadministration of anti-TB treatment and antiretroviral drugs induces severe complications, and this highlights the need to define optimal treatment regimens. Practical implementation of these regimens in TB control programs should be combined with isoniazid preventive therapy in TB-exposed HIV-infected children. The risk of severe complications after Bacille Calmette-Guérin vaccination of HIV-infected children emphasizes the need for new nonviable vaccines. This article reviews the current status of pediatric HIV-TB coinfection with specific emphasis on the diagnosis and treatment.

Low rates of hepatotoxicity in HIV-infected children on anti-retroviral therapy with and without isoniazid prophylaxis

This study investigates the incidence of hepatotoxicity in HIV-infected children during anti-retroviral therapy (ART) and the impact of concomitant use of isoniazid preventive therapy. It is a retrospective cohort analysis of HIV-infected children who commenced ART or were followed up between September 1998 and November 2005. Alanine transferase levels were measured at baseline, at 1, 3 and 6 months and then 6 monthly thereafter. Of the 598 children included in the study, 425 were taking ART alone, 73 ART and isoniazid, 39 isoniazid alone and 61 neither isoniazid nor ART. There was no increased risk of hepatotoxicity with ART with or without isoniazid compared to the control group over a 2-year period. Grade 3 or 4 ALT elevations occurred in 19 (3.4%) children, with no cases of fulminant hepatic failure. Severe hepatic events are uncommon in children on ART or isoniazid. There is no increased risk of hepatotoxicity with ART and concurrent isoniazid preventive therapy.