In April, 2003 the World Bank approved a long-awaited $150 million loan to the Russian Federation to support tuberculosis (TB) and AIDS control. Although the Russian Federation accounts for a relatively small fraction of the global TB case-load the proportion of cases which are drug-resistant and particularly multidrug-resistant is very high in some regions. HIV incidence, principally associated with intravenous drug abuse, has also increased dramatically and this will impact upon TB control efforts. Federation-wide data are limited but a focus on one region shows something of the confluence of the epidemics of HIV and TB. Approaching 200 cases of HIV-associated TB have occurred in the past two years, and the age structure of the HIV-infected population and that with high rates of TB shows sizeable overlap. The region has high rates of multidrug-resistant TB which are likely to impact considerably on efforts to meet this emerging and complex public health challenge. Insights gained through the examination of this one region can tell us something of the magnitude of the challenge now faced by both the international community and Russia.