Clinical management of tuberculosis and HIV-1 co-infection

Abstract

In many parts of the world the commonest serious opportunistic infection that occurs in HIV-1 infected persons is tuberculosis (TB). HIV-1 co-infection modifies the natural history and clinical presentation, and adversely affects the outcome of TB. Severe disseminated disease is well-recognised but it is increasingly appreciated that early disease characterised by very few or no symptoms is also common. Immunodiagnostic methods to ascertain latent TB in HIV-1 infected persons are compromised in sensitivity.Chemoprevention of HIV-1-associated TB is effective, its benefits are restricted to those which have evidence of immune sensitisation and appear short-lived in areas of high TB burden. Although promising advances in the microbiological diagnosis of TB have recently occurred, the diagnosis of HIV-1-associated TB remains difficult because of more frequent presentation as sputum negative or extrapulmonary disease.Management of co-infected patients can be complex because of overlapping drug toxicities and interactions. Nevertheless consensus is developing that antiretroviral therapy should be provided as soon as practicable after starting TB treatment in HIV-1 co-infected persons. This has the consequence of increasing the frequency of immune reconstitution inflammatory syndrome, the pathogenesis and management of which is poorly defined.

Short- and long-term mortality and causes of death in HIV/tuberculosis patients in Europe

“…Initiation of TB-treatment with a RHZ-based regimen was associated with a 55% reduced risk of TB-related death, thus highlighting the importance of starting empiric rifamycin-based TB therapy, even in settings with high rates of MDR-TB [25,26]. Initial RHZ-based treatment was used as a reference group, thus other anti-TB drugs could have been added to the empirical regimen (either ethambutol or streptomycin, or second-line drugs if MDR-TB was suspected).…”

Clinical Aspects of Adult Tuberculosis

“…However, treatment is not without its complications. This is most evident in the management of HIV-associated TB (Khan et al 2010;Schutz et al 2010), in which there are considerable drug -drug interactions between antiretrovirals and anti-TB medication, and an increased risk of the intense inflammatory response provoked by concurrent use of these drugs (IRIS) (Meintjes et al 2008). This means that in practice, the relative timing of introduction of these agents also needs to be factored (Blanc et al 2011;Török et al 2011).…”

Indicator condition-guided HIV testing in Europe: a step forward to HIV control

“…The ERS recognised early the importance of the synergistic relationship between tuberculosis and HIV and the European Respiratory Journal is on the frontline of the scientific production in this area as certified by recent pivotal publications [2][3][4][5]. Now it is time to go beyond.…”