A child surrounded by medical symbols, representing TB, HIV, and malnutrition in Africa.

TB and Malnutrition: Unmasking the Deadly Duo in HIV-Positive Children

Beau Callahan in Health & Wellness December 2025 • 4 min read.

"A South African study sheds light on the challenges of diagnosing and treating tuberculosis in children with HIV and severe acute malnutrition."

Tuberculosis (TB), human immunodeficiency virus (HIV), and severe acute malnutrition (SAM) form a deadly trio, especially for children in sub-Saharan Africa. While researchers are working hard to understand how these conditions interact, the combined impact has long been recognized. The convergence of TB, HIV, and SAM creates a perfect storm, making diagnosis and treatment incredibly challenging.

A staggering 650,000 cases of pediatric TB occur annually in the 22 highest-burden countries, resulting in an estimated 140,000 deaths each year. Globally, over 2.6 million children are living with HIV, with 90% of these residing in sub-Saharan Africa. In 2014 alone, HIV was responsible for 150,000 childhood deaths. SAM, encompassing conditions like marasmus and kwashiorkor, accounts for up to 10% of all global mortality in children under five, with marasmus responsible for over 500,000 deaths annually. In South Africa, more than 36,000 cases of childhood TB occur yearly, with about a quarter of these cases believed to be HIV-coinfected.

Recognizing the critical challenges posed by the intersection of HIV, SAM, and TB, researchers conducted a study to investigate the diagnostic difficulties and incidence of TB in HIV-infected children with SAM. The study emphasizes the importance of integrating rigorous TB investigations into the programmatic management of HIV and SAM to improve outcomes for these vulnerable children.

Unveiling the Challenges: Diagnosing TB in Malnourished, HIV-Positive Children

A child surrounded by medical symbols, representing TB, HIV, and malnutrition in Africa.

A recent study published in the International Journal of Tuberculosis and Lung Disease explored the incidence and diagnostic challenges of TB in HIV-infected children also suffering from severe acute malnutrition (SAM). This post-hoc analysis was conducted using data from a randomized controlled trial that enrolled antiretroviral therapy-naive, HIV-infected children with SAM in Durban, South Africa.

The study involved reviewing trial records and hospital laboratory results to identify both clinically diagnosed and bacteriologically confirmed cases of TB. Negative binomial regression was used to explore associations with confirmed TB cases, excluding cases where the clinical diagnosis lacked microbiological support. This rigorous approach aimed to provide a clearer picture of TB’s impact on this vulnerable population.

Setting: The research was based at an academic tertiary referral hospital in Durban, South Africa.
Objective: The primary goal was to determine the incidence and challenges in diagnosing TB in children infected with HIV and SAM.
Design: The study analyzed data from a randomized controlled trial involving HIV-infected children with SAM who had not yet started antiretroviral therapy.

Of the 82 children enrolled in the study, 21 (25.6%) were diagnosed with TB. Bacteriological confirmation was achieved in eight of these cases. Interestingly, sputum sampling (as opposed to gastric washings) was associated with a higher risk of TB diagnosis, with an adjusted relative risk (aRR) of 1.134 (95% CI: 1.02–1.26). However, culture-proven bacterial infection during admission was linked to a reduced risk of TB (aRR 0.856, 95% CI: 0.748-0.979), potentially due to false-negative results from broad-spectrum antibiotics.

Moving Forward: Integrating TB Care into HIV and SAM Programs

The study underscores that TB is a common comorbidity in HIV-infected children with SAM. While microbiological confirmation of TB diagnosis is achievable, the high rate of empirical treatment suggests that current diagnostic methods may be insufficient or lead to false negatives. To improve outcomes, rigorous microbiological TB investigations should be integrated into the routine management of HIV and SAM in resource-limited settings. Further research is needed to develop more reliable diagnostic strategies for this vulnerable population, ultimately reducing the burden of this deadly combination of diseases.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.5588/ijtld.16.0753, Alternate LINK

Title: Tuberculosis In Hiv-Infected South African Children With Complicated Severe Acute Malnutrition

Subject: Infectious Diseases

Journal: The International Journal of Tuberculosis and Lung Disease

Publisher: International Union Against Tuberculosis and Lung Disease

Authors: H. Adler, M. Archary, P. Mahabeer, P. Larussa, R. A. Bobat

Published: 2017-04-01

Everything You Need To Know

What are the key health issues explored in this study?

The study identified that Tuberculosis (TB), Human Immunodeficiency Virus (HIV), and Severe Acute Malnutrition (SAM) often occur together, creating major health challenges. The study observed that a notable percentage of the children in the study, specifically 25.6%, were diagnosed with TB, highlighting the significant incidence of TB in this vulnerable group. The overlap of these conditions leads to complex diagnostic difficulties and poor outcomes.

What is the significance of Severe Acute Malnutrition (SAM) in this context?

Severe Acute Malnutrition (SAM) is a condition characterized by severe wasting and nutritional deficiencies, and it affects the health of children globally. SAM accounts for a considerable portion of child deaths worldwide. In the context of HIV and TB, SAM weakens the immune system, making children more susceptible to infections like TB and complicating both diagnosis and treatment. The study focused on the diagnostic challenges for children with HIV and SAM in the presence of TB.

Where was the study conducted, and why is the location important?

The study was conducted in Durban, South Africa, at an academic tertiary referral hospital. This location was chosen to focus on a population with a high prevalence of TB, HIV, and SAM. The location provides a setting where researchers could investigate the interplay between TB, HIV, and SAM, focusing on diagnostic challenges and improving outcomes for vulnerable children. The study aimed to generate evidence for integrating more rigorous TB investigations within HIV and SAM programs in resource-limited areas.

What diagnostic challenges were identified by the study?

The study observed that the current methods used to diagnose TB may be inadequate in children coinfected with HIV and SAM, leading to potential false negative results. The study suggests the need for better diagnostic strategies. The challenges include differentiating TB from other infections in malnourished children and achieving microbiological confirmation. These challenges underscore the necessity of improving and integrating TB care into HIV and SAM programs.

Why is HIV a major concern for children, especially in the context of TB and malnutrition?

HIV poses a major risk to children because it weakens the immune system, making them prone to infections like TB. Children with HIV are at increased risk of malnutrition, and in turn, SAM. The presence of both HIV and SAM significantly complicates the diagnosis and treatment of TB. The study highlights the need for more rigorous TB investigations to be included in the standard care for children with HIV and SAM to improve health outcomes. This integration of care could involve more reliable diagnostic methods tailored to children with weakened immune systems.