Consolidated guidelines on tuberculosis. Module 6: tuberculosis and comorbidities, 2nd ed.

What this guideline says

GMJ summary

This second edition of WHO’s Module 6 consolidates evidence-based recommendations for preventing, screening, diagnosing, and treating tuberculosis in people living with HIV and those with undernutrition. The HIV section comprises 31 recommendations covering systematic TB screening at every visit using the four-symptom screen (cough, fever, weight loss, night sweats), C-reactive protein >5 mg/L, chest X-ray, or molecular rapid diagnostic tests; early ART initiation within two weeks of starting TB treatment regardless of CD4 count; and TB preventive treatment with multiple regimen options including 6–9 months isoniazid, 3-month rifapentine plus isoniazid, or 36 months isoniazid in high-transmission settings.

The guidelines emphasize integrated, people-centred service delivery with ART initiation in TB treatment settings and vice versa. Key interventions include universal HIV testing for all with presumptive or diagnosed TB, co-trimoxazole prophylaxis for all people living with HIV with active TB regardless of CD4 count, and a comprehensive package for advanced HIV disease including screening and prophylaxis for opportunistic infections. The document updates the 2012 TB/HIV policy with new evidence on diagnostic tools (LF-LAM in urine, molecular tests in blood), shorter TPT regimens, and CAD software for chest X-ray interpretation.

These consolidated guidelines serve as a one-stop reference for countries to scale up collaborative TB/HIV activities, complemented by an operational handbook providing practical implementation guidance and aligned with WHO’s Framework for collaborative action on tuberculosis and comorbidities.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Screen all people living with HIV for TB at every health facility visit using the four-symptom screen: current cough, fever, weight loss, or night sweats; any positive symptom requires TB evaluation
2. C-reactive protein >5 mg/L may be used for TB screening in adults and adolescents with HIV, with higher sensitivity (0.90) than the symptom screen alone
3. Use LF-LAM urine test to assist TB diagnosis in HIV-positive adults/adolescents with signs/symptoms of TB, advanced HIV disease, serious illness, or CD4 <200 cells/mm³ in inpatient settings (strong recommendation)
4. Initiate ART within two weeks of starting TB treatment regardless of CD4 count, except delay at least four weeks when TB meningitis is present
5. Offer TB preventive treatment to all adults/adolescents with HIV unlikely to have active TB: options include 6H, 9H, 3HP, 3HR, 1HP, or 4R regimens (strong recommendation)
6. In high TB transmission settings, provide at least 36 months of daily isoniazid for people living with HIV with unknown or positive TB infection test
7. Provide co-trimoxazole prophylaxis to all people living with HIV with active TB regardless of CD4 count to reduce mortality and morbidity
8. Test all individuals with presumptive or diagnosed TB for HIV; in high-burden settings offer HIV testing to all household/close contacts of TB patients

Diagnostic accuracy of the WHO four-symptom screen among different subpopulations of people living with HIV

Table extracted from the guideline

Source: World Health Organization, Consolidated guidelines on tuberculosis. Module 6: tuberculosis and comorbidities, 2nd ed.. Reproduced in summary form.

What changed in this edition

Versus the previous edition

• Added C-reactive protein (>5 mg/L), chest X-ray, CAD software for X-ray interpretation, and molecular rapid diagnostic tests as TB screening options beyond the four-symptom screen
• Updated ART timing: start within two weeks of TB treatment for all CD4 counts (previously two weeks only for CD4 ≤50 cells/mm³, eight weeks for others)
• Expanded LF-LAM recommendations with specific criteria for inpatient (strong) vs outpatient (conditional) settings based on symptoms, CD4 count, and illness severity
• Added new short-course TPT regimens: 1-month daily rifapentine plus isoniazid (1HP) and 4-month daily rifampicin (4R) as alternatives to traditional 6–9 month isoniazid
• Introduced M. tuberculosis antigen-based skin tests (TBSTs) as alternative to TST/IGRA for TB infection testing
• Strong recommendation for systematic mWRD testing (without prior symptom screening) for HIV-positive medical inpatients where TB prevalence >10%
• Added package of interventions for advanced HIV disease including screening/prophylaxis for opportunistic infections beyond TB and cryptococcal disease
• Expanded HIV testing recommendations to include partner services for people with HIV-associated TB

From the guideline

Verbatim

“ART should be started as soon as possible within two weeks of initiating TB treatment, regardless of CD4 cell count, among people living with HIV.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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