Figure 2

Algorithm for the diagnosis of tuberculosis in seriously ill HIV-positive patients using Xpert.¹Seriously ill refers to the presence of danger signs, including: respiratory rate >30/min, temperature >39°C, heart rate >120/min and unable to walk unaided. ²Among adults and adolescents living with HIV, a TB suspect is defined as a person who reports any one of current cough, fever, weight loss or night sweats. Among children living with HIV, a TB suspect is defined as a person who reports one of poor weight gain, fever, current cough, or history of contact with a TB case. ³In all persons with unknown HIV status, HIV testing should be performed according to national guidelines. In high HIV prevalent settings, seriously ill patients should be tested using Xpert MTB/RIF as the primary diagnostic test regardless of HIV status. ⁴The highest priority should be to provide the patient with life-sustaining supportive therapy, such as oxygen and parenteral antibiotics. If life-sustaining therapy is not available at the initial point of care, the patient should be transferred immediately to a higher level facility before further diagnostic testing. ⁵Antibiotics (except fluoroquinolones) to cover both typical and atypical bacteria should be considered. ⁶PCP= Pneumocystis jirovecii pneumonia. ⁷CPT = cotrimoxazole preventive therapy. ⁸ART = antiretroviral therapy. All TB patients living with HIV are eligible for ART irrespective of CD4 count. Start TB treatment first, followed by ART as soon as possible within the first 8 weeks of TB treatment. See ART guidelines. ⁹In low MDR-TB prevalence setting, a confirmatory test for Rifampicin resistance should be performed. See MDR-TB algorithm. ¹⁰An HIV treatment assessment includes WHO clinical staging and/or CD4 count to assess eligibility for antiretroviral therapy. See ART guidelines. ¹¹Additional investigations for TB may include chest x-ray, liquid culture of sputum, lymph node aspiration for acid-fast bacilli microscopy and culture, abdominal ultrasound. Non-tuberculosis mycobacterial infection should be considered in the differential diagnosis of patients who have a negative Xpert but a sputum or extra-pulmonary specimen with acid-fast bacilli.