From Tuberculosis › Chapter 12: Tuberculosis and HIV co-infection · Médecins Sans Frontières, Current online edition, 2026
MSF guidance on recognition and management of TB-IRIS in patients receiving antiretroviral and tuberculosis treatment.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Clinicians managing tuberculosis and HIV
- Evidence
- Expert consensus with cited evidence
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This section from the MSF Tuberculosis guideline addresses TB-associated immune reconstitution inflammatory syndrome (TB-IRIS), which occurs when patients on antiretroviral therapy (ART) and/or TB treatment develop new or worsening TB symptoms due to immune system restoration. TB-IRIS presents in two forms: paradoxical TB-IRIS (worsening after starting treatment) and unmasking TB-IRIS (new TB manifestations after starting ART). It typically occurs within 3 months of ART initiation, most commonly in the first month, and is more frequent in patients with low CD4 counts.
The guideline distinguishes between severe TB-IRIS (with neurological signs, respiratory distress, or requiring hospitalisation) and non-severe forms. Before diagnosing TB-IRIS, clinicians must exclude new opportunistic infections, other infections unmasked by immune reconstitution, and TB treatment failure due to drug resistance. Management depends on severity: severe cases require corticosteroids (prednisolone 1.5 mg/kg daily for 2 weeks, then 0.75 mg/kg for 2 weeks), whilst non-severe cases are treated with NSAIDs. Crucially, ART should not be interrupted except in life-threatening situations.
Key points
For clinicians — doses and thresholds as stated in the guideline
- TB-IRIS typically occurs within 3 months of starting ART, most often within the first month, and is more common in patients with low CD4 counts
- Paradoxical TB-IRIS: patient starts TB treatment followed by ART, then TB symptoms worsen; Unmasking TB-IRIS: patient starts ART then develops new TB symptoms
- Most common signs include fever, lymphadenopathy, pulmonary infiltrates, pleural effusion, respiratory distress, and neurological signs
- Severe TB-IRIS (neurological signs, respiratory distress, or requiring hospitalisation) is treated with prednisolone 1.5 mg/kg once daily for 2 weeks, then 0.75 mg/kg once daily for 2 weeks
- Non-severe TB-IRIS is treated with ibuprofen: children over 3 months 5–10 mg/kg 3–4 times daily (max. 30 mg/kg daily); children ≥12 years and adults 200–400 mg 3–4 times daily (max. 1200 mg daily)
- Corticosteroids are contraindicated in Kaposi's sarcoma or cryptococcal meningitis; patients on corticosteroids require monitoring for opportunistic infections
- In unmasking TB-IRIS, TB treatment should be started immediately
- ART should not be interrupted except in life-threatening IRIS; exclude new opportunistic infections, drug-resistant TB, and other infections before diagnosing TB-IRIS
Symptomatic treatment of TB-IRIS
Table extracted from the guideline
| TB-IRIS severity | Treatment |
|---|---|
| Severe | prednisolone PO: Child and adult 1.5 mg/kg once daily (2 weeks) then 0.75 mg/kg once daily (2 weeks) |
| Non-severe | ibuprofen PO for shortest possible duration: Child over 3 months 5–10 mg/kg 3–4 times daily (max. 30 mg/kg daily); Child 12 years and over and adult 200–400 mg 3–4 times daily (max. 1200 mg daily) |
Source: Médecins Sans Frontières, Immune Reconstitution Inflammatory Syndrome in TB-HIV Co-infection — MSF Tuberculosis. Reproduced in summary form.
From the guideline
Verbatim
“ART should not be interrupted, except in case of life-threatening IRIS.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As we work to scale up integrated TB-HIV services across Georgia and the South Caucasus, recognising and managing immune reconstitution inflammatory syndrome becomes critical for treatment success. I would emphasise to Georgian clinicians that TB-IRIS is a paradoxical sign of immune recovery, not treatment failure, and the key principle is to continue both ART and TB treatment whilst managing inflammation. The specific prednisolone dosing schedules provided here (1.5 mg/kg then 0.75 mg/kg for 2 weeks each) offer practical guidance that should be incorporated into our national protocols. The main implementation challenge will be ensuring that frontline clinicians, particularly in rural areas where TB-HIV co-infection services are being expanded, can confidently distinguish TB-IRIS from treatment failure or new opportunistic infections, which requires accessible laboratory support and specialist consultation pathways.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is highly relevant for Georgia and the South Caucasus, where TB-HIV co-infection remains a significant clinical challenge, particularly in regions with high TB burden and growing HIV prevalence. Georgian national TB and HIV programmes should ensure that clinicians managing co-infected patients are trained to recognise TB-IRIS early, especially given the emphasis on rapid ART initiation in current HIV treatment protocols. Healthcare facilities managing TB-HIV patients need access to prednisolone and capacity for close monitoring during the critical first 3 months after ART initiation. Integration of TB and HIV services, as recommended by WHO and increasingly implemented in the region, is essential for timely recognition and management of this complication.
Questions this guideline answers
Quick answers
When should I suspect TB-IRIS in my patient?
Suspect TB-IRIS if a patient develops new or worsening TB symptoms (fever, lymphadenopathy, respiratory symptoms, neurological signs) within 3 months of starting ART, especially in the first month, particularly in those with low CD4 counts. First exclude new opportunistic infections, other unmasked infections, and drug-resistant TB.
What is the difference between paradoxical and unmasking TB-IRIS?
Paradoxical TB-IRIS occurs when a patient on TB treatment starts ART and then worsens. Unmasking TB-IRIS occurs when TB was not initially detected, the patient starts ART, and then develops TB symptoms for the first time.
Should I stop ART if my patient develops TB-IRIS?
No, ART should not be interrupted except in life-threatening IRIS. Continue both ART and TB treatment whilst managing the inflammatory response with corticosteroids (severe cases) or NSAIDs (non-severe cases).
When are corticosteroids contraindicated in TB-IRIS?
Corticosteroids are contraindicated in patients with Kaposi's sarcoma or cryptococcal meningitis. If corticosteroids are used, patients must be monitored closely to detect any opportunistic infections that may emerge during immunosuppressive therapy.
Related on GMJ
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Conditions A–Z
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Same guideline
- Concomitant treatment of tuberculosis and HIV co-infection — MSF TuberculosisChapter 12: Tuberculosis and HIV co-infection
- Standard treatment regimen for isoniazid-resistant tuberculosis — MSF TuberculosisChapter 11: Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis
- Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis — Introduction — MSF TuberculosisChapter 11: Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis
- Surgery in Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
- Treatment interruptions — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
- Treatment adaptation and change of treatment — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
Other guidelines on this topic
- Concomitant treatment of tuberculosis and HIV co-infection — MSF Tuberculosis
- Standard treatment regimen for isoniazid-resistant tuberculosis — MSF Tuberculosis
- Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis — Introduction — MSF Tuberculosis
- Surgery in Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis
- Treatment interruptions — MSF Tuberculosis
- Issuer
- Médecins Sans Frontières
- Guideline
- Tuberculosis
- Chapter
- Chapter 12: Tuberculosis and HIV co-infection
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- TB-HIV co-infection
- Audience
- Clinicians managing tuberculosis and HIV
- Evidence
- Expert consensus with cited evidence
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Tuberculosis. Section 12.5: Immune reconstitution inflammatory syndrome. Paris: MSF; 2026 Oct 14.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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