CHAPTER
Management algorithms for
27 tuberculosis where there are few
or no diagnostic facilities
Jan van den Hombergh
BACKGROUND
An algorithm is a finite set of well-defined instructions for accom-
plishing a task or solving a particular problem which, given an ini-
tial state, will terminate in a defined end-state. An algorithm must
be specified exactly, so there can be no doubt about what to do
next and it has a finite number of steps that iterate and require
decisions. The concept of an algorithm is often illustrated by the
example of a recipe or a flow chart, although many algorithms
are more complex. This definition implies that many procedures
related to TB control could be referred to as algorithms, such as
standard operating procedures (SOPs), guidelines, score charts,
decision trees, and flow charts.
This chapter will be confined to a limited number of diagnostic
algorithms frequently used (and often modified) in guidelines,
manuals, and education tools for TB control in resource-limited
settings.
The absence of adequate diagnostic facilities in areas where TB is
most prevalent reflects a sobering reality. In most countries where
TB incidence is high and often accompanied by a human immuno-
deficiency virus (HIV) epidemic, sputum smear microscopy and chest
radiography remain the most important and widely available diagnos-
tic methods. Both methods are neither fully sensitive nor specific, a
shortcoming further compounded by concomitant HIV infection.
In situations where there are no diagnostic tests available at all, the
diagnosis of TB rests purely on clinical judgement, possibly with
support of a practical tool, such as clinical guidelines, criteria, score
charts, or other algorithms. Being developed with the aim to assist
health workers to arrive at the diagnosis of TB with an acceptable
level of accuracy, most of these tools have never been adequately
validated. In order to increase specificity, complex algorithms have
been developed, with often the consequence that substantial periods
of time are required to reach the definitive outcome. In high-burden,
low-resource settings, this unfortunately provides opportunities for
drop-out of suspect patients (due to, for example, financial or logistic
constraints, but also because of premature death in the case of HIV
coinfection). Diagnostic algorithms are not meant to be technical
instruments to replace sound clinical judgement and rational think-
ing in the management of TB, but rather provide useful support in
a decision process, thus maximizing identification of true TB cases.
As a consequence the number of TB cases missed in the process
could be minimized, whereas non-TB cases will not be misclassified
as TB and subjected to long treatment, unnecessarily straining human
and financial resources.
316
Most algorithms for TB are based on the TB case definitions
developed by the World Health Organization (WHO) and the
International Union against Tuberculosis and Lung Disease
(IUATLD) that are presented in the International Standards for
Tuberculosis Care.1 In a situation of a patient with symptoms sugges-
tive of pulmonary TB and the availability of sputum microscopy,
any diagnostic algorithm is short and conclusive when the sputum
smear for acid-fast bacilli (AFB) is positive.
However, the accuracy and validity is decreasing in those patients
who present with an atypical clinical picture and negative AFB smear
(e.g. TB–HIV coinfected patients). Since the sensitivity of sputum
smear ranges from 30% to 70%,2 many pulmonary TB patients will
have a negative sputum smear. In particular TB–HIV coinfected
patients are more frequently sputum microscopy smear-negative
and in children less than 5 years of age a positive sputum smear is rare.
For extrapulmonary TB there are no generic algorithms devel-
oped, with the exception for lymph node TB, the most frequent
manifestation of extrapulmonary TB. Hence the diagnosis of extra-
pulmonary TB rests on case definitions and clinical judgement.
The typical starting point for any algorithm in TB is a patient with
symptoms suggestive of TB, mostly referred to as a ‘TB suspect’. How-
ever, the symptoms and signs may as well be part of the algorithm itself.
The most commonly used definition of a (pulmonary) TB suspect is
any person with a cough for 2–3 weeks or longer and any constitu-
tional symptoms such as fever, weight loss, or night sweats. There is
no definition of a TB suspect that has both high sensitivity and speci-
ficity. Depending on the purpose and the consequent algorithm for
which the TB suspect needs to be defined, a combination of symp-
toms, clinical signs, and investigations such as sputum smear and chest
radiograph may be used, with a large range of predictive values. The
definition therefore differs, e.g. for TB diagnosis in patients, detection
of TB in prevalence surveys, and exclusion of TB in persons eligible
for isoniazid preventive treatment (IPT), as well as other active case-
finding activities.3,4
PULMONARY TUBERCULOSIS IN ADULTS
A standardized schematic algorithm for the diagnosis of pulmonary
TB is presented in Fig. 27.1. This was originally developed by the
WHO and the IUATLD,5 and is now the recommended manage-
ment approach for TB and is included in the International Standards
for Tuberculosis Care. A national adaptation of this algorithm from
National TB Control Guidelines in Ethiopia is presented as an
example in Fig. 27.2.6 It includes both smear-negative and -positive
 CHAPTER

Management algorithms for tuberculosis where there are few or no diagnostic facilities 27

All patients suspected of Patient with symptoms

having pulmonary TB suggestive for TB

Sputum microscopy 2 or 3 positive Sputum smear All negative

for AFB (three specimens)

Only 1 positive Both

Three negative smears
1 or 2 positive Examine 2 additional negative
sputum specimens
Broad-spectrum antimicrobials
(excluding anti-TB drugs and
fluoroquinolones) Treat with non-specific
broad-spectrum
antibiotics for 7–10 days
No improvement Improvement (not a fluoroquinolone)
Unchanged
or worse
Repeat sputum microscopy Review after 2 – 4 weeks

1 or more positive smears All smears negative Repeat sputum smear

Chest radiograph and
physician’s judgement
TB No TB
AFB = acid-fast bacilli; TB = tuberculosis
Fig. 27.1 An illustrative approach to the diagnosis of sputum smear-
negative pulmonary TB.5
TB and does not differentiate between settings with a differing prev-
alence of HIV infection.
In order to appropriately apply this algorithm, sputum smear
microscopy and chest radiography are assumed to be available. For
resource-constrained settings, e.g. many of the high-burden countries,
this implies a number of potential obstacles for patients with symptoms
suggestive of TB who present at health facilities where these diagnos-
tics are not available. Sputum can be transported to the nearest health
facilities with microscopy available but in practice this does not hap-
pen. Rather the patient will be referred as is the case when a chest
radiograph is required. This will result in delay and additional costs
for the patient. Waiting for better diagnostic tools, wide distribution,
and decentralization of sputum microscopy services is still the standing
recommendation in settings where this algorithm is used.
The diagnostic algorithm is combined with management algo-
rithms for the follow-up of TB patients under treatment, with cure,
death, or failure as an outcome. These are presented in Figs. 27.3
and 27.4. In case of treatment interruption for more than 2 months
or when follow-up sputum smears are not carried out according to
the recommended schedule (second to third month, fifth and sixth
to eighth month), outcome can be default, transfer out, or completion
of treatment, respectively. In case of recurrence of TB (after treatment
completion) or return after treatment interruption, different algo-
rithms apply and can be derived from current WHO guidelines.
EXTRAPULMONARY TUBERCULOSIS
Definitive and rapid diagnosis of extrapulmonary TB remains a
challenge in the absence of appropriate diagnostic tools. Even less
sophisticated conventional techniques such as fine needle aspiration
(three specimens) All Cured or
negative improved
1–3
Chest radiograph and
positive*
physician’s judgement:
Yes No
suggestive for TB?
Treat as Treat as Treatment based Discharge
smear-positive smear-negative on clinical
pulmonary TB* * pulmonary TB evaluation
* If initially all three smears are negative but after antibiotics only one repeat smear appears
positive, it is advised to carry out two additional smears. If one or both are positive, proceed
with TB treatment. If both are negative proceed with a chest radiograph and evaluation for
conditions other than TB.
** If the patient was never treated before, register and treat as a new pulmonary TB smear-positive
patient. If the patient has been treated before, register for re-treatment regimen. If possible,
send a sputum specimen for culture and drug susceptibility testing.
Fig. 27.2 Standard algorithm for the diagnosis of pulmonary TB as
adapted for the National TB Control Programme in Ethiopia.6
and cytology (FNAC), biopsy, pathology examination, and/or cul-
ture have limitations and are often not available in resource-limited
settings. Among extrapulmonary TB cases, lymph node TB and
pleuritic TB are by far the most common presentations. In practice
the diagnosis of extrapulmonary TB will often be based on clinical
judgement only. The algorithm in Fig. 27.5 can be of support in
the diagnosis of lymph node TB. It is strongly recommended to
offer an HIV test to the patient, since extrapulmonary TB is a fre-
quent manifestation of an underlying HIV infection. It is noted
that this algorithm includes always a sputum examination to
exclude concomitant pulmonary involvement.
TUBERCULOSIS AND HIV COINFECTION
The diagnosis of TB being straightforward for patients who are
sputum smear-positive, the basic algorithms leave many questions
for those patients who turn out to be smear-negative. In the past
decades specific algorithms for detecting sputum smear-negative
TB have been developed to address the diagnostic dilemmas and
to avoid the risk of overdiagnosis. Initially these tools included as
many as two courses of antibiotics,7,8 repeated sputum smears,
and chest radiographs.9 Robust validation has never been achieved
and increasing reports of early mortality in HIV-coinfected TB

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4 GENERAL CLINICAL FEATURES AND DIAGNOSIS

patients have prompted adaptation of the approach towards the Smear-negative pulmonary TB patient, Category III treatment
diagnosis of smear-negative TB, in particular in areas with high
HIV prevalence and consequently high TB–HIV coinfection rates.
The specific characteristics of TB in HIV-infected patients have Good response to treatment No response to treatment or worsening
necessitated revisiting earlier versions of the pulmonary smear-neg-
ative diagnostic approach. With the aim to minimize delay in TB Continue and At 2 months of treatment
treatment and the associated mortality, new algorithms to be used complete treatment
in high TB and HIV prevalence settings have been proposed by
the WHO.10,11 Check 3 sputum smears for AFB
Continue treatment and refer to
Figures 27.6 and 27.7 present algorithms for ambulatory and physician to be re-assessed:
seriously ill patients who have a positive HIV test result or are clin- • Initial diagnosis may have been
wrong If only 1 AFB-
ically likely to be HIV-infected (adapted from the WHO recom- AFB-negative
• ‘Paradoxical worsening’ of TB positive, repeat
mendations for HIV-prevalent and resource-constrained settings). or (usually in the first 6 weeks
These guidelines are applicable in countries with an HIV preva- of treatment)
lence of  1% in pregnant women and  5% in TB patients.11 • Other complicating disease or Further AFBs If a 2nd AFB is
OI may have occurred are negative also positive
The essential difference with earlier guidelines is that one (instead
of two) positive smear for AFB can prompt the definite diagnosis
and initiation of treatment for TB. Antibiotics have become part At 3 months after start Prolong intensive phase drugs 4 weeks
of the management of the HIV-infected patient, rather than a cri- continuation phase and then start continuous phase
terion on which TB is defined or refuted.
An alternative approach to the diagnosis of smear-negative TB, Check 3 sputum smears for AFB AFB-negative
specifically for HIV-infected adults, has been recently proposed
and is based on a case definition algorithm and includes the diagno-
Continue and complete TB treatment,
sis of common forms of extrapulmonary TB, such as lymph node If only 1 AFB-positive, repeat
unless there is certainty that patient has
TB. This algorithm includes a standardized response to treatment no TB but confirmed other condition
to increase the specificity of the case definitions.3 A 2nd AFB Other AFBs
is positive are negative Cured

Treatment failure Start re-treatment (Category II)

New smear-positive PTB 1 follow-up sputum specimen
Category I treatment for AFB at 2 months
AFB: Acid-fast bacilli; OI: Opportunistic infection

Fig. 27.4 Algorithm for the follow-up of a smear-negative pulmonary TB

Start continuous phase AFB-negative AFB-positive patient.5

1 sputum smear follow-up at

5 months of treatment. Same Repeat 2 smears Any HIV-infected person without TB (sputum smear-negative/
procedure as at 2 months chest radiograph negative), jaundice or known liver problems, or
Add 4 weeks of
heavy alcohol use and willing to take 6 months of anti-TB prophy-
AFB-
intensive drug phase laxis is eligible for starting the isoniazid preventive treatment.
AFB-positive AFB-negative positive

Failure: start Continue Start the continuous phase after

re-treatment treatment this extra month (no sputum)
ALGORITHMS FOR THE MANAGEMENT OF
TUBERCULOSIS IN HIV-INFECTED PATIENTS
1 sputum smear follow-up at 1 sputum follow-up after 3 months UNDER CARE
7 months of treatment. Follow of continuation phase. Same
same procedure as at 2 months procedure as at 2 months
In the context of increasing availability of antiretroviral therapy (ART)
in low-resource settings, a number of practical algorithms for the co-
AFB-negative 2 smears AFB-positive AFB-negative management of TB and HIV are presented in Tables 27.1–27.6. These
describe the different scenarios and options for co-treatment when the
people living with HIV/AIDS (PLWHA) and developing active TB
Outcome: Cured Failure: start re-treatment Continue treatment
are already receiving ART or are not yet on ART.
Table 27.1 describes the steps to be followed to reassess a PLWHA
Continue treatment AFB-positive 1 sputum follow-up already on ART, who develops active TB disease. If an episode of
for 4 weeks, at 8 months. Same TB occurs during the first 6 months following the initiation of
discharge Cured AFB-negative procedure as at
2 months
ART, this should not be considered a treatment failure event and
the ART regimen should be adjusted for co-administration with a
PTB: Pulmonary tuberculosis; AFB: Acid-fast bacilli rifampicin-containing regimen.
Fig. 27.3 Algorithm for the follow-up of a new smear-positive If an episode of TB develops more than 6 months after the initia-
pulmonary TB patient.5 tion of ART and data on the CD4 cell count and viral load are

318
 Patient with enlarged lymph nodes HIV-infected(a) patient with cough for 2 – 3 weeks and no danger signs(b)

Sputum smear microscopy for AFB

Lymph nodes are hard and Lymph nodes are mobile, firm
fixed to underlying tissue or soft and /or fluctuant

1 or more smears AFB-positive 2 smears AFB-negative

Physician to rule out
inflammatory disease
or malignancies
Extra-inguinal site
Medical history for
symptoms and
examination for
clinical signs of TB
Inguinal site only
TB treatment and CPT(c) Clinical assessment and CXR
HIV assessment(d) Sputum culture
Physician to rule
out inflammatory
disease in legs, STI TB likely or culture-positive TB unlikely
or inguinal hernia

Treat for PCP No signs

PCP(e) signs of PCP
FNA cytology and /or excision FNA cytology and /or excision HIV assessment
biopsy services available biopsy services not available
HIV assessment and CPT
No or partial response
Treat for bacterial infection(f )
FNA for examination & AFB, sputum Sputum AFB 3¥, CXR
AFB 3¥, CXR and offer HIV test and offer HIV test Complete
Reassess for TB Response
treatment
(a)
In the absence of HIV testing, classifying a patient as HIV-infected depends on clinical
No Lymph node Lymph node Lymph node tuberculosis assessment in line with national and/or local policy.
lymph node tuberculosis tuberculosis likely or AFB-positive (b)
The danger signs include any one of: respiratory rate >30/minute, fever >39°C, pulse
tuberculosis confirmed inconclusive or CXR changes rate >120/min and unable to walk unaided.
(c)
Co-trimoxazole Preventive Therapy.
(d)
Assessment includes HIV clinical staging, determination of CD4 count if available and
referral for HIV care.
Antibiotics Full TB Broad-spectrum antibiotics Full TB (e)
Pneumocystis jiroveci pneumonia, Signs include: 1. chest radiograph: bilateral interstitial
and review treatment or review after 4 – 8 weeks treatment infiltrate. 2. exertional dyspnoea (onset <3 months). 3. hypoxia.
(f)
Antibiotics (except fluoroquinolones) to cover both typical and atypical bacteria should
be considered.
No
improvement Fig. 27.6 Algorithm for the diagnosis of TB in an ambulatory
No improvement Improvement Discharge HIV-infected patient.

Refer to specialist

AFB: Acid-fast bacilli; STI: Sexually transmitted infection; FNA: Fine-needle aspirate; HIV-infected(a) patient with cough for 2 - 3 weeks and danger signs(b)
CXR: Chest radiography

Fig. 27.5 Algorithm for the diagnosis of lymph node TB.13 Referral to higher level facility Immediate referral not possible

available, the decision about whether the TB diagnosis represents Parenteral antobiotic treatment(c) Parenteral antibiotic treatment(c)
ART failure is based on the CD4 cell count and, if available, the viral Sputum for AFB and culture Sputum for AFB and culture
Chest radiograph Consider treatment for PCP(d)
load. If a CD4 cell count is not available the decision on whether the
TB diagnosis constitutes ART failure depends on whether the TB is
pulmonary or extrapulmonary and whether there are other non-TB TB likely or 1 or 2 smears 2 smears
TB unlikely
WHO stage 3 or 4 HIV disease events. However, in general the culture positive AFB-positive AFB-negative
development of an episode of pulmonary TB after 6 months of
ART, without other clinical and immunological evidence of disease Assess for Start TB treatment & CPT(e) Does not Improved
progression, should not be regarded as representing ART failure. other HIV- Complete antibiotics improve in after 3 - 5
Extrapulmonary TB should be considered as indicating ART failure, related disease HIV and tuberculosis care(f) 3 - 5 days days
although simple lymph node TB or uncomplicated pleural disease may
be less significant than disseminated TB. If there is a good response to Reassess Complete
TB unlikely TB likely for TB antibiotics
TB therapy the decision to switch to a second-line regimen can be
delayed until short-course TB therapy has been completed.
Table 27.2 describes the specific therapeutic options if the (a)
In the absence of HIV testing, classifying a patient as HIV-infected depends on clinical
PLWHA develop TB within 6 months of starting ART. assessment in line with national and/or local policy.
(b)
If the patient develops TB after 6 months of starting ART and The danger signs include any one of: respiratory rate >30/minute, fever >39⬚C, pulse
rate >120/min and unable to walk unaided.
there is evidence of clinical/immunological failure, the possibility (c)
Antibiotics (except fluoroquinolones) to cover both typical and atypical bacteria should
of ART failure must be considered and the ART regimen should be (d)
be considered.
Pneumocystis jiroveci pneumonia.
switched to second-line drugs (two nucleoside reverse transcriptase (e)
Co-trimoxazole Preventive Therapy.
inhibitors + protease inhibitors as lopinavir–ritonavir or saquinavir– (f)
Assessment includes HIV clinical staging, determination of CD4 count if available and
referral for HIV care.
ritonavir-based regimen). Whenever the HIV-infected patient
develops active TB but is not yet on ART, it is important to Fig. 27.7 Algorithm for the diagnosis of TB in a seriously ill HIV-infected
choose carefully the moment for concomitant ART/TB treatment. patient.

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4 GENERAL CLINICAL FEATURES AND DIAGNOSIS

Table 27.1 HIV-infected patient on ART suspected to have developed active tuberculosis

Signs/symptoms Step A Step B

Unremitting cough Fill out laboratory sputum request form and send to If one sputum specimen is AFB positive, treat as smear-
> 2 weeks and/or laboratory for morning/spot sputum examination positive TB and
 Persistent fever Or If on first-line ART < 6 months or > 6 months but without clinical
 Unexplained Refer to higher facility level, if not producing sputum or if and immunological evidence of disease progressiona:
weight loss symptoms and signs suggest extrapulmonary TB  Continue the same ART regimenb

 Severe under-  Clinical monitoring and laboratory monitoring

nutrition If all specimens are negative, do a CXR

 Suspicious nodes  If it is suggestive for TB treat as smear-negative pulmonary TB,

 Night sweats otherwise treat as other disease

 If CXR not suspect, treat with non-specific broad spectrum

antibiotics, review after 2–4 weeks, then:

 If unchanged or worse, repeat 3 sputum smears

 If all the specimens are negative, repeat CXR

 If 1 specimen is positive, treat as smear-positive pulmonary TB

 If improved, discharge

If patient develops lymph node TB or uncomplicated pleural

TB, treat as extrapulmonary TB and
If already on first-line ART < 6 months or > 6 months but without
clinical and immunological evidence of disease progressiona
 Continue the same ART regimenb

 Clinical monitoring and laboratory monitoring

If patient develops extrapulmonary TB other than lymph node

or pleural:
 Consider treatment failure after ruling out other causes (e.g. non-

adherence)
 Switch to second-line ART regimen

AFB, acid-fast bacilli; CXR, chest radiograph; ART, antiretroviral therapy.

a
If ART > 6 months with clinical (e.g. other non-TB stage 3 or 4 events) and immunological evidence of disease progression, regardless of the type of TB (pulmonary
or extrapulmonary), it may represent ART failure and it requires switching to a second-line ARV regimen (refer to Table 27.2). Non-adherence must be excluded.
b
If already second-line ART, refer to Table 27.2.

Co-treatment raises adherence issues emanating from an increased pill

Table 27.2 ART recommendations for patients who burden and could produce immune reconstitution inflammatory syn-
develop tuberculosis within 6 months of starting ART drome (IRIS, also referred to as paradoxical reactions). In patients with
HIV-related TB the priority is to treat the TB and ideally ARV treat-
First-line or ART regimen at Options
ment should be postponed. However, severely immunosuppressed
second-line the time TB
ART occurs
patients with HIV-related TB can have ART and TB treatment at
the same time if managed carefully.
First-line 2 NRTIs + EFV  Continue with 2 NRTIs + EFV People living with HIV/AIDS already diagnosed with TB and
ART 2 NRTIs + NVP  Substitute NVP to EFV or on TB treatment should be assessed about the ART eligibility on
 Substitute to triple NRTI or every visit, and the proper timing for starting the ART has to be
 Continue 2 NRTIs +NVP but do
decided (Tables 27.3 and 27.4).
liver function tests monthly
Alternative Triple NRTI  Continue triple NRTI
In general treatment can be deferred at least until the initial
first-line ART phase is completed if the patient is clinically stable; in contrast,
Second-line 2 NRTIs + Substitute to or continue (if ART is recommended to be started as soon as possible if the TB
ART boosted PI already taken) LPV-r or SQV-r patient has extrapulmonary TB, is clinically unstable, or is immu-
containing regimen-adjusting nologically seriously compromised (CD4 count < 200 cells/mm3).
dose of RTVa Table 27.5 summarizes common ART regimens to be used in
TB–HIV coinfected patients; the listed regimens must be used
NRTI, nucleoside reverse transcriptase inhibitor; EFV, efavirenz; NVP, according to the different scenarios described earlier.12
nevirapine; NNRTI, non-nucleoside reverse transcriptase inhibitor; PI, In pregnant women living with HIV and who have TB, the first
protease inhibitor; RTV, ritonavir; LPV-r, lopinavir–ritonavir; SQV-r,
priority is to treat the TB (Table 27.6). If a pregnant woman
saquinavir–ritonavir; ART, antiretroviral therapy.
a
In a setting where boosted PIs are not available and patients are on
receiving ART develops TB, such therapy should be continued,
unboosted PIs, switch PI to an NNRTI (EFV). although drug–drug interactions may necessitate the use of other
ARV drugs. If a woman is in the second or third trimester of

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Management algorithms for tuberculosis where there are few or no diagnostic facilities 27

Table 27.3 Evaluation of TB/HIV coinfected adult patient Table 27.6 Choose the appropriate TB-ART co-treatment
not on ART and CD4 not available regimen for pregnant women

Patient clinical status How to manage Options Comments

Smear-positive pulmonary TB only (no other Defer ART until TB Defer ART until the end of first EFV can be used in the second
signs of clinical WHO stage 3 or 4 HIV disease) treatment is trimester and third trimester
and patient is gaining weight on treatment completed Defer ART until the start of the Many countries use isoniazid and
Smear-negative pulmonary TB only (no Start ART after the continuation phase of TB ethambutol in the continuation
other signs of clinical WHO stage 3 or 4 HIV intensive phase of treatment if isoniazid and phase as the standard first-line TB
disease) and patient is gaining weight on TB treatment ethambutol is used treatment regimen
treatment Use triple NRTI regimen AZT + 3TC + ABC
Any pulmonary TB and patient has or develops Start ART as soon Use NVP-based regimen May be the only option in
signs of clinical WHO stage 4 disease or thrush, as TB treatment resource-poor settings
pyomyositis, recurrent pneumonia, persistent is tolerated
diarrhoea, new prolonged fever, or losing weight (2–8 weeks) See Table 27.5 for definitions of abbreviations.
on treatment or if no clinical improvement
Extrapulmonary TB (only isolated pleural or Start ART as soon
lymph node TB can be considered as as TB treatment Client or patient for HIV counselling and testing
uncomplicated TB, and ART can be deferred is tolerated
until after the intensive phase). (2–8 weeks)
Pre-testing counselling including description of services available
• Screening for TB disease • Psychosocial support
• STI syndromic evaluation • Condom provision
• ART • CPT and IPT

Table 27.4 Evaluation of TB/HIV coinfected adult patient At CT room, TB clinic, ward or OPD :
not on ART and CD4 available HIV testing

CD4 cell count ART Timing of ART in relation to

3
(cells/mm ) recommendations the start date of TB treatment History of cough of 32 weeks duration

< 200 Recommend ART Between 2 and 8 weeks

200–350 Recommend ART After 8 weeks intensive phase YES NO HIV-negative
> 350 Defer ART Re-evaluate patient at 8 weeks
and the end of TB treatment HIV-negative HIV-positive CT room :
Preventive
counselling
Preventive counselling CT room : Post-test and condom
and condom provision counselling provision
Table 27.5 Recommended ART regimens in TB/HIV General
AFB lab: Screen for active Screen for active TB according to OPD:
coinfected patients receiving rifampicin in treatment of
a TB according to NTP NTP guidelines and refer to CT
antituberculosis regimen guidelines, treat STIs room to evaluate the test results any STIs
First line TDF + 3TC (or FTC) + EFV or
AZT + 3TC (or FTC) + EFV or Investigate for other
No TB TB yes No TB
d4T + 3TC (or FTC) + EFV OIs and treat STIs
Alternative first line AZT + 3TC + ABC or
AZT + 3TC + TDF TB clinic: TB treatment
Discharge
Second line LPV-r or SQV-r-based regimen according to NTP guidelines OI no OI yes

TDF, tenofovir; 3TC, lamivudine; FTC, emtricitabine; d4T, stavudine; AZT, Co-trimoxazole preventive therapy for HIV CT room : Offer TB Care and
zidovudine; EFV, efavirenz; ABC, abacavir; LPV, lopinavir; SQV, saquinavir. positive TB patients. Treat any STIs. ART to preventive therapy support
Adapted from WHO.13 commence after TB treatment intensive phase
a
The table is based on current practice in 2006. However, new or after 2 – 3 weeks if patient is criticalyl ill
HIV-care clinic : ART and
antiretroviral drugs may be introduced and commonly used regimens CPT if CD4 is <200
may be adapted accordingly. DOTS care and support for other OIs

Becomes sick Remains healthy

pregnancy, an EFV-based ART regimen can be considered.
Changing from an EFV-based to an NVP-based ART regimen
could be considered once the TB treatment is completed. NVP-
based regimens can be started during the continuation phase of
TB treatment if these do not include rifampicin. An alternative
for women with TB is zidovudine + lamivudine + abacavir.
Figure 27.8 presents an algorithm for TB/HIV collaborative
activities. Box 27.1 lists the clinical stages of HIV in adults as
defined by the WHO.
Home-based care and Monthly control
psychosocial support visit
The services for the TB-HIV co-infected patient provided by the TB-clinic can as well be carried
out by the TB-HIV clinic or HIV-care clinic (where one is operational).
Fig. 27.8 Generic algorithm for TB/HIV collaborative service. ART,
antiretroviral therapy; CPT, cotrimoxazole preventive therapy; CT,
counseling and testing; DOTS, directly observed therapy, short course; IPT,
isoniazid preventive therapy; OI, opportunistic infection; OPD, outpatient
department; STI, sexually transmitted infection.
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4 GENERAL CLINICAL FEATURES AND DIAGNOSIS

14
Box 27.1 WHO HIV clinical staging (adults)

Stage I  Performance scale: bed-ridden < 50% of the day during the past
 Asymptomatic. month.
 Persistent generalized lymphadenopathy. Stage IV
  Wasting syndrome.
Performance scale: asymptomatic; normal activity.
Stage II  Pneumocystis jiroveci pneumonia.
 Toxoplasmosis of the brain.
 Weight loss < 10% of body weight.
 Minor mucocutaneous manifestation (seborrhoeic dermatitis, prurigo,  Cryptosporidiosis with diarrhoea > 1 month.
 Cryptococcus extrapulmonary.
fungal nail infection, recurrent oral ulceration, angular chelitis).
  Cytomegalovirus disease of any organs other than liver, spleen, and
Herpes zoster within the past 5 years.
 Recurrent upper respiratory tract infections. lymph nodes.
 Performance scale: symptomatic; normal activity.  Herpes simplex virus infection, mucocutaneous for > 1 month or visceral
Stage III any duration.
 Candida of the oesophagus, trachea, bronchi or lungs.
 Weight loss > 10% body weight.
 Atypical mycobacteriosis, disseminated.
 Unexplained chronic diarrhoea > 1 month.
 Extrapulmonary TB.
 Unexplained prolonged fever (intermittent or constant).
 Kaposi’s sarcoma.
 Oral candidiasis.
 HIV encephalopathy.
 Oral hairy leucoplakia.
 Pulmonary TB within the past year.
 Performance scale: bed-ridden > 50% of the day during last month.
 Severe bacterial infection (pneumonia, pyomyositis).

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microscopy after processing specimens with
C18-carboxypropylbetaine to detect acid-fast bacilli:
a study of United States-bound immigrants from
Vietnam. J Clin Microbiol 2005;43:3460–3462.
3. Wilson D, Nachega J, Morroni C, et al. Diagnosing
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