HIV infection and multidrug-resistant tuberculosis: the perfect storm

J Infect Dis. 2007 Aug 15;196 Suppl 1:S86-107. doi: 10.1086/518665.

Abstract

Background: Multidrug-resistant (MDR) tuberculosis (TB) has emerged as a global epidemic, with ~425,000 new cases estimated to occur annually. The global human immunodeficiency virus (HIV) infection epidemic has caused explosive increases in TB incidence and may be contributing to increases in MDR-TB prevalence.

Methods: We reviewed published studies and available surveillance data evaluating links between HIV infection and MDR-TB to quantify convergence of these 2 epidemics, evaluate the consequences, and determine essential steps to address these epidemics.

Results: Institutional outbreaks of MDR-TB have primarily affected HIV-infected persons. Delayed diagnosis, inadequate initial treatment, and prolonged infectiousness led to extraordinary attack rates and case-fatality rates among HIV-infected persons. Whether this sequence occurs in communities is less clear. MDR-TB appears not to cause infection or disease more readily than drug-susceptible TB in HIV-infected persons. HIV infection may lead to malabsorption of anti-TB drugs and acquired rifamycin resistance. HIV-infected patients with MDR-TB have unacceptably high mortality; both antiretroviral and antimycobacterial treatment are necessary. Simultaneous treatment requires 6-10 different drugs. In HIV-prevalent countries, TB programs struggle with increased caseloads, which increase the risk of acquired MDR-TB. Surveillance data suggest that HIV infection and MDR-TB may converge in several countries.

Conclusions: Institutional outbreaks, overwhelmed public health programs, and complex clinical management issues may contribute to the convergence of the MDR-TB and HIV infection epidemics. To forestall disastrous consequences, infection control, rapid case detection, effective treatment, and expanded program capacity are needed urgently.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.
  • Review

MeSH terms

  • Adolescent
  • Adult
  • Anti-HIV Agents / therapeutic use
  • Antitubercular Agents / metabolism
  • Antitubercular Agents / pharmacology*
  • Antitubercular Agents / therapeutic use
  • Disease Outbreaks*
  • Drug Resistance, Multiple, Bacterial
  • Drug Therapy, Combination
  • Global Health
  • HIV Infections / complications*
  • HIV Infections / drug therapy
  • HIV Infections / epidemiology*
  • HIV Infections / mortality
  • HIV*
  • Humans
  • Malabsorption Syndromes
  • Middle Aged
  • Mycobacterium tuberculosis / drug effects*
  • Prevalence
  • Rifamycins / pharmacology
  • Risk Factors
  • Sentinel Surveillance
  • Treatment Outcome
  • Tuberculosis / complications*
  • Tuberculosis / drug therapy
  • Tuberculosis / epidemiology
  • Tuberculosis / microbiology*
  • Tuberculosis / mortality

Substances

  • Anti-HIV Agents
  • Antitubercular Agents
  • Rifamycins