Treatment of Tuberculous Meningitis with HIV Co-infection in Children and Adolescents (Age ≤19)
This protocol covers the management of tuberculous meningitis in children and adolescents aged 19 years or younger who have concurrent HIV co-infection — a clinical combination that directly influences both anti-tuberculosis regimen selection and the timing of adjunctive interventions.
In this population, WHO guidance supports regimen options specifically adapted for children and adolescents with drug-susceptible tuberculous meningitis, including a shorter alternative to the standard course. The presence of HIV co-infection introduces additional considerations around adjunctive therapy and antiretroviral management that must be addressed alongside the anti-tuberculosis regimen.
Anti-tuberculosis therapy is initiated promptly, with a choice between the standard multi-drug regimen and the Cape Town regimen — a shorter option developed for this age group. In patients with HIV co-infection, the timing of antiretroviral therapy initiation is a key decision point, informed by clinical status. Adjunctive corticosteroids may be considered on an individual basis in the HIV co-infected population, with the decision weighing benefits against risks.
The complete regimen, sequencing, supportive care measures, and the specific clinical criteria guiding each decision are set out in the full protocol.
DOI: 10.1016/S1473-3099(25)00364-0
- For children and adolescents aged 19 years or younger with drug-susceptible tuberculous meningitis, WHO recently recommended that a 6-month regimen (isoniazid 15–20 mg/kg per day, rifampicin 22·5–30 mg/kg per day, and pyrazinamide 35–45 mg/kg per day, and the substitution of ethambutol with ethionamide at 17·5–22·5 mg/kg per day) can be used instead of the 12-month standard regimen.
- 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
- Adults: RHZE with quinolone if at high risk of isoniazid resistance; children: RHZE or Cape Town regimen
- In the absence of an effective alternative adjunctive therapy for HIV-associated tuberculous meningitis, and the safety and potential effectiveness of corticosteroids, we recommend their use on a case-by-case basis in people living with HIV.
- If not already on ART initiate at week 4–8 unless there is a clinical need for earlier initiation (eg, other opportunistic illness); if CD4 count less than 50 then consider ART at 2 weeks, if there is an urgent clinical need and close monitoring and optimal tuberculosis treatment can be ensured