Tuberculosis and HIV--Needed: A New Paradigm for the Control and Management of Linked Epidemics

Simon J. Tsiouris, MD, MPH (corresponding author); Neel R. Gandhi, MD; Wafaa M. El-Sadr, MD, MPH; Gerald Friedland, MD

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In This Article

Diagnostic and Clinical Challenges for Resource-limited Settings

The rising number of TB/HIV coinfected patients in sub-Saharan Africa, as well as in other resource-limited areas, has brought with it and intensified the need to identify solutions for diagnostic, therapeutic, and management issues at the interface of both diseases. The recent documentation of multidrug resistant (MDR) and extensively drug resistant (XDR) TB among persons coinfected with HIV and its association with extremely high mortality in South Africa[4] calls for heightened attention to these issues and the urgent need for their solutions. Knowledge and experience in the separate diagnosis and management of TB and HIV is extensive in resource-rich settings and in some resource limited settings. However, knowledge and experience in the diagnosis and management of TB/HIV co-infection is available in resource-rich settings but severely limited in resource-poor settings.

HIV co-infection can complicate the clinical presentation and diagnosis of active TB and limit the sensitivity of the acid-fast bacilli sputum smear, the most widely (and often the only) available TB diagnostic method in resource-limited settings.[5,6] How to overcome this diagnostic obstacle in resource-limited settings is neither known nor well studied. New TB-specific interferon gamma release assays are beginning to be studied in TB-HIV co-infected individuals in resource-limited settings[7,8] as are new rapid mycobacterial culture and drug susceptibility methods that have been developed;[9,10] how and if these tests can be used, and whether their associated cost will be prohibitive in these settings is yet to be determined.

Likewise, the treatment of HIV in the setting of active TB may be complicated by several factors, including additive toxicities of antiretroviral and anti-tuberculous medications, drug interactions, risk of immune reconstitution events, and difficulty in adherence with multiple medications.[11] Successfully overcoming these hurdles in resource limited-settings that often have a dearth of diagnostic testing capabilities and narrow choices of antiretrovirals and anti-tuberculous medications requires creative and inventive solutions. While the coexistence of TB and HIV epidemics creates added challenges, caring for coinfected patients offers opportunities for developing new paradigms to address the co-epidemics. Through innovative operational research, collaborative training, and integrated treatment efforts, these may improve the management and outcome of both diseases.

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