Guideline

WHO consolidated guidelines on tuberculosis: module 6: tuberculosis and comorbidities, 2nd ed.

Year of Publication

2025

Issuing Institution

World Health Organization

Links

WHO IRIS

Recommendations

50 included recommendations

People living with HIV should be systematically screened for TB disease at each visit to a health facility

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

Among adults and adolescents living with HIV, systematic screening for TB disease should be conducted using the WHO-recommended four-symptom screen, and those who report any one of the symptoms of current cough, fever, weight loss or night sweats may have TB and should be evaluated for TB and other diseases

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Among adults and adolescents living with HIV, C-reactive protein with a cut-off of > 5 mg/L may be used to screen for TB disease

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Among adults and adolescents living with HIV, chest X-ray may be used to screen for TB disease

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Among individuals aged 15 years and older in populations in which TB screening is recommended, computer-aided detection software programmes may be used in place of human readers for interpreting digital chest X-rays for screening and triage for TB disease

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Among adults and adolescents living with HIV, molecular WHO-recommended rapid diagnostic tests may be used to screen for TB disease

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

Adult and adolescent inpatients with HIV in medical wards where the TB prevalence is > 10% should be tested systematically for TB disease with a molecular WHO-recommended rapid diagnostic test

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

In HIV-positive adults and children with signs and symptoms of disseminated TB, Xpert MTB/RIF may be used in blood, as an initial diagnostic test for disseminated TB.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

In inpatient settings, WHO strongly recommends using LF-LAM to assist in the diagnosis of active TB in HIV-positive adults, adolescents and children: •with signs and symptoms of TB (pulmonary and/or extrapulmonary) (strong recommendation, moderate certainty in the evidence about the intervention effects); or •with advanced HIV disease; or •who are seriously ill (strong recommendation, moderate certainty in the evidence about the intervention effects); or •irrespective of signs and symptoms of TB and with a CD4 cell count <200 (strong recommendation, moderate certainty in the evidence about the intervention effects).

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

In outpatient settings, WHO suggests using LF-LAM to assist in the diagnosis of active TB in HIV-positive adults, adolescents and children: with signs and symptoms of TB (pulmonary and/or extrapulmonary) or seriously ill

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

In outpatient settings, WHO suggests using LF-LAM to assist in the diagnosis of active TB in HIV-positive adults, adolescents and children: irrespective of signs and symptoms of TB and with a CD4 cell count of less than 100 cells/mm3

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

In outpatient settings, WHO recommends against using LF-LAM to assist in the diagnosis of active TB in HIV-positive adults, adolescents and children: without assessing TB symptoms

Status

Maintained

Recommended against

Strong

Certainty of evidence

Very low

In outpatient settings, WHO recommends against using LF-LAM to assist in the diagnosis of active TB in HIV-positive adults, adolescents and children: without TB symptoms and unknown CD4 cell count or without TB symptoms and CD4 cell count greater than or equal to 200 cells/mm3

Status

Maintained

Recommended against

Strong

Certainty of evidence

Very low

In outpatient settings, WHO recommends against using LF-LAM to assist in the diagnosis of active TB in HIV-positive adults, adolescents and children: without TB symptoms and with a CD4 cell count of 100–200 cells/mm3

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

It is recommended that TB patients who are living with HIV should receive at least the same duration of TB treatment as HIV-negative TB patients

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

People living with HIV with TB and histoplasmosis coinfection should receive TB therapy according to WHO treatment guidelines

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

In settings with a high burden of HIV and TB, TB treatment may be provided for people living with HIV in HIV care settings where a TB diagnosis has also been made

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

Adults and adolescents living with HIV who are unlikely to have active TB should receive TB preventive treatment as part of a comprehensive package of HIV care. Treatment should also be given to those receiving ART, to pregnant women and to those who have previously been treated for TB, irrespective of the degree of immunosuppression and even if latent TB infection testing is unavailable

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

Adults and adolescents living with HIV who are screened for TB according to a clinical algorithm and who report any of the symptoms of current cough, fever, weight loss or night sweats may have active TB and should be evaluated for TB and other diseases and offered preventive treatment if active TB is excluded.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Chest radiography may be offered to people living with HIV on ART and preventive treatment be given to those with no abnormal radiographic findings

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Either the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs) can be used to test for TB infection.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

Mycobacterium tuberculosis antigen-based skin tests (TBSTs) may be used to test for TB infection.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

The following options are recommended for the treatment of latent tuberculosis infection (LTBI) regardless of HIV status: 6 or 9 months of daily isoniazid, or a 3-month regimen of weekly rifapentine plus isoniazid, or a 3 month regimen of daily isoniazid plus rifampicin. (Strong recommendation, moderate to high certainty in the estimates of effect). A 1-month regimen of daily rifapentine plus isoniazid or 4 months of daily rifampicin alone may also be offered as alternatives.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

In settings with high TB transmission, adults and adolescents living with HIV who have an unknown or a positive latent TB infection test and are unlikely to have active TB disease should receive at least 36 months of daily isoniazid preventive therapy. Daily isoniazid preventive therapy for 36 months should be given whether or not the person is receiving ART and irrespective of the degree of immunosuppression, history of previous TB treatment and pregnancy in settings considered to have high TB transmission as defined by national authorities

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

Routine HIV testing should be offered to all people with presumptive and diagnosed TB

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

All household contacts of a person with HIV-associated TB should be offered HIV testing services

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

In settings of high HIV burden, all household and close contacts of people with TB should be offered HIV testing services

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

In settings of low HIV burden, all household members and close contacts of people with TB who have symptoms compatible with TB disease may be offered HIV testing services as part of their clinical evaluation

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Partner services should be offered to people with HIV-associated TB

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

A package of interventions including screening, treatment and/or prophylaxis for major opportunistic infections, rapid ART initiation and intensified adherence support interventions should be offered to everyone presenting with advanced HIV disease.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

(Adults and adolescents) ART should be started as soon as possible within two weeks of initiating TB treatment, regardless of CD4 count, among people living with HIV

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

Antiretroviral therapy is recommended for all patients with HIV and drug-resistant TB requiring second-line antituberculosis drugs irrespective of CD4 cell count, as early as possible (within the first 8 weeks) following initiation of antituberculosis treatment

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

Routine co-trimoxazole prophylaxis should be administered to all HIV-infected people with active TB disease regardless of CD4 cell counts.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

High

In settings with a high burden of HIV and TB, ART should be initiated for people living with HIV in TB treatment settings, with linkage to ongoing HIV care and ART

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

At diagnosis and throughout treatment, all individuals with tuberculosis should be offered nutritional assessment and appropriate counselling based on their nutritional status.

Status

Updated

Recommended in favor

Strong

Household contacts of people with tuberculosis should be offered nutritional assessment and counselling as part of contact tracing. If undernutrition is identified, it should be managed according to WHO guidance

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Low

Nutritional interventions should be offered to individuals with tuberculosis (TB) who have severe, moderate or mild undernutrition, as part of a comprehensive package of TB care.

Status

Updated

Recommended in favor

Strong

A package of treatment adherence interventions may be offered to patients on TB treatment in conjunction with the selection of a suitable treatment administration option

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers: tracers and/or digital medication monitor

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Very low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers: tracers and/or digital medication monitor

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers: material support to the patient

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Moderate

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers: material support to the patient

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Moderate

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers: psychological support to the patient

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers: psychological support to the patient

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers:staff education

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health-care providers:staff education

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

In settings of food insecurity, food baskets in combination with multiple micronutrient supplements should be offered to all households of people with tuberculosis

Status

Updated

Recommended in favor

Strong

Certainty of evidence

Moderate

Vitamin D supplementation may be provided to people with tuberculosis in the context of rigorous research

Status

Updated

Recommended in favor

Conditional

Certainty of evidence

Low

In settings where the TB prevalence in the general population is 100/100 000 population or higher, systematic screening for TB disease may be conducted among people with a risk factor for TBa who are either seeking health care or who are already in care

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

Systematic screening for TB disease may be conducted among subpopulations with structural risk factors for TB. These include urban poor communities, homeless communities, communities in remote or isolated areas, indigenous populations, migrants, refugees, internally displaced persons and other vulnerable or marginalized groups with limited access to health care

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low