TPT in Pregnant and Breastfeeding Women with TB Exposure or Living with HIV
TPT should be offered to all pregnant and breastfeeding women (regardless of their HIV status) with significant TB exposure TPT should be deferred or not offered if the pregnant woman Management of TPT amongst HIV-negative and HIV-positive pregnant and breastfeeding women with TB exposure TPT should be offered to all pregnant and breastfeeding women (regardless of their HIV status) with significa
TPT should be deferred or not offered if the pregnant woman
TPT should be offered to all pregnant and breastfeeding women (regardless of their HIV status) with significant TB exposure
All pregnant and breastfeeding women with significant exposure to TB require TPT once TB disease has been excluded through careful evaluation, including TB testing for all, regardless of symptoms.
TPT should not be deferred in a pregnant or breastfeeding woman with significant TB exposure, defined as sharing the same enclosed space with a person (adult or adolescent) known to have had pulmonary TB during the three months before this index patient starting his/her TB treatment. Sharing enclosed space includes one or more nights (e.g., a home, correctional facility or similar) or for frequent and extended periods. The prior completion of either TB treatment or TPT does not exclude a new course of TPT, if there has been a new source of TB exposure.
TPT should be offered to pregnant women with significant TB exposure, regardless of HIV status. Conversely, TPT should also be offered to all pregnant or breastfeeding women living with HIV, regardless of TB exposure.
TPT should be deferred or not offered if the pregnant woman:
- is diagnosed with TB disease
- has active liver disease (acute or chronic)
- has symptoms and signs of severe peripheral neuropathy (could consider rifampicin only regimen)
- has a history of adverse reactions to any medications used for TPT
- makes excessive use of alcohol (and is unwilling or unable to scale down), defined as four or more standard drinks on a day or eight or more per week
For individuals with abnormal baseline liver function test results, sound clinical judgement is required to ensure that the benefit of TB preventive treatment outweighs the risks, and they should be tested routinely at subsequent visits.
TPT should not be deferred to the postpartum period in pregnant women living with HIV.
Breastfeeding is NOT a contraindication to TPT.
Management of TPT amongst HIV-negative and HIV-positive pregnant and breastfeeding women with TB exposure
When an adult or adolescent patient is diagnosed with pulmonary TB disease, thorough contact investigation is essential to establish who may have had a significant exposure to this index patient.
For subsequent TB exposures, TB evaluation is again required followed by either TPT or TB treatment, as appropriate, i.e., TB test and treat approach (see also Section 4 - Adult, Adolescent and Older Child Contact).
Evaluation for TB disease amongst pregnant and breastfeeding women
Evaluation for TB disease in pregnant women includes symptom screening, physical examination, and diagnostic testing. TB can either be bacteriologically confirmed or clinically diagnosed. A minimum of symptom screening and a sputum test (regardless of the presence of symptoms) are required prior to initiating either TPT in a pregnant or breastfeeding woman.
Evaluation for TB disease is required at the first antenatal care (ANC) booking or visit and each subsequent ANC and postpartum follow-up visit. Sputum should always be collected from those who are symptomatic during follow-up visits.
Symptom screening for TB disease amongst pregnant or breastfeeding women include the presence of any one or more of the following:
- current cough
- weight loss or poor weight gain
- fever
- night sweats
- haemoptysis
Diagnostic tests for TB disease amongst pregnant or breastfeeding women:
- a sputum sample should be obtained and tested using GeneXpert
- tests of TB infection (TST/IGRA) are not a requirement to initiating TPT
- if CXR is needed (e.g., sputum not obtained), precautions are required to protect the foetus from radiation exposure
Pregnant or breastfeeding women declining TPT (despite counselling), should be followed up and screened for TB symptoms at every antenatal and postpartum visit, and offered TPT again after TB disease was excluded.
Considerations for TPT initiation in pregnant and breastfeeding women living with HIV:
- TPT should not be deferred in pregnant and breastfeeding women living with HIV
- newly pregnant women living with HIV and already on TPT should continue TPT
TPT treatment options for pregnant and breastfeeding women
For HIV-negative pregnant and breastfeeding women there are two regimen options: 3RH or 6H.
For HIV-positive pregnant and breastfeeding women there is one option: 12H.
For ALL pregnant and breastfeeding women pyridoxine (vitamin B6) 25mg is added for the duration of TPT – irrespective of HIV status.
Recommended daily dosages for the 6H regimen amongst HIV-negative pregnant and breastfeeding women
| Drug | Isoniazid (H)* |
| Dose | 5mg/kg |
| Maximum Dose/day | 300mg |
| Duration | 6 months |
| Interval | Daily |
* If 300mg tablets are not available, use 100mg
Recommended daily dosages for the 3RH regimen amongst HIV-negative pregnant and breastfeeding women: Please refer to Section 4 - Adult, Adolescent and Older Child Contacts.
Recommended daily dosages for the 12H regimen amongst HIV-positive pregnant and breastfeeding women. All HIV-positive women initiated on DTG should receive 12H.
| Drug | Isoniazid (H)* |
| Dose | 5mg/kg |
| Maximum Dose/day | 300mg |
| Duration | 12 months |
| Interval | Daily |
* If 300mg tablets are not available, use 100mg
National Guidelines on the Treatment of Tuberculosis Infection, February 2023
TPT in Pregnant and Breastfeeding Women with TB Exposure or Living with HIV