Implementation considerations Where it is feasible, TB infection testing is desirable to identify individuals at highest risk for developing active TB. However, it is not required in PLHIV or in household contacts aged under 5 years. In HIV-negative household contacts aged 5 years and older, and in other risk groups, TB infection tests are recommended, but their unavailability should not be a barrier to treating people who are judged to be at higher risk. The GDG noted that the availability and affordability of the tests could determine which TB infection test is used. Other considerations include the structure of the health system, feasibility of implementation and infrastructure requirements. Operational difficulties should be considered in deciding which test to use. For example, IGRAs requires phlebotomy, which can be difficult, particularly in young children; they also require laboratory infrastructure, technical expertise and expensive equipment, and their sensitivity is reduced in children aged under 2 years and PLHIV. However, only a single visit is required to do an IGRA test (although patients may have to make a second visit to receive the result). The TST requires a cold chain, two health care visits and training in intradermal injection, reading and interpretation. One other practical advantage of IGRAs over the TST is that IGRAs are not susceptible to a “booster response”, which makes a two-step approach necessary for the TST in situations where reactivity to the TST has waned since infection. BCG vaccination plays a decisive role in reducing the specificity of the TST, although the GDG noted that the impact of BCG vaccination on the specificity of the TST depends on the strain of vaccine used, the age at which the vaccine is given and the number of doses administered. When BCG is given at birth, as is the case in most parts of the world, it has a variable, limited impact on TST specificity (19). The GDG agreed that a history of BCG vaccination has a limited effect on interpretation of TST results later in life; hence, BCG vaccination should not be a determining factor in selecting a test. Neither the TST nor IGRAs are to be used to diagnose active TB disease; also, they are not to be used for diagnostic work-up of adults suspected of having active TB.