Adults aged 18 and older with tuberculous meningitis who also have HIV co-infection represent a distinct clinical population in which treatment decisions require careful, case-by-case consideration. The presence of HIV co-infection directly influences how the standard evidence base is applied.
This protocol addresses hospitalised adults with confirmed tuberculous meningitis and concurrent HIV infection. Current evidence supports a specific recommendation posture for this group: guidance that applies with a strong recommendation in HIV-negative individuals carries only a weak recommendation for people living with HIV, reflecting higher uncertainty. Each treatment decision must therefore be individualised.
When a paradoxical reaction or immune reconstitution inflammatory syndrome (IRIS) arises in this setting, the structured protocol addresses corticosteroid management as a central intervention. The approach involves specific guidance on when and how to escalate or extend corticosteroid therapy, along with consideration of additional immunomodulating options in refractory cases.
Conditions: Population: adults in hospital requiring treatment for tuberculous meningitis. Is there HIV co-infection? High certainty of evidence, strong recommendation for use in individuals without HIV; high certainty of evidence, weak recommendation for use in people living with HIV so the decision to use should be made on a case-by-case basis.
Treatment: Increase or prolong corticosteroids; in refractory cases consider other immunomodulating agents (eg, anti-TNF, thalidomide, or anakinra). Expert opinion recommends using high-dose corticosteroids initially, tapering slowly according to symptom resolution.
DOI: 10.1016/S1473-3099(25)00364-0