The co-epidemic of tuberculosis (TB) and human immunodeficiency virus (HIV) is one of the major global health challenges in the present time.
[2] This condition becomes more severe in case of multi-drug (MDRTB) and extensively drug resistant TB (XDRTB), which are difficult to treat and contribute to increased mortality (see Multi-drug-resistant tuberculosis).
In those with HIV and immunosuppression, lower lobe, non-cavitary nodular consolidations may be seen, with hilar or mediastinal lymph node swelling.
Normally CD4+ helper T-cells secrete the cytokine IFN-γ which recruits macrophages and stimulates them to destroy tuberculosis bacteria and surround them, forming a granuloma to prevent spread of infection.
[2] During HIV infection, IFN-γ production is decreased dramatically which leads to an increased risk of developing reactivation or reinfection by M. tuberculosis in these HIV/TB patients.
[2] The experimental M72/AS01E tuberculosis vaccine has shown to reduce the incidence of TB in adults by 50% and its immunogenicity has been demonstrated in those with HIV.
The classic cavitary lung lesions are not usually present and the mycobacterial load in the sputum is low making diagnosis difficult.
[2] The GeneXpert MTB/RIF is a PCR based test can simultaneously detect TB as well as resistance to rifampine with a 2 hour waiting time.
[2] The test is recommended by the WHO in places where TB and HIV are endemic, and when used as part of the diagnostic process has been shown in multiple studies to reduce mortality rates.
[2][14][15] The LAM can be combined with XPert MTB/RIF to increase diagnostic yield, however if both tests are negative and clinical suspicion of TB in those with HIV remains high, empiric treatment may need to be started.
[2] It is currently recommended that HIV-infected individuals with TB receive combined treatment for both diseases, irrespective of CD4+ cell count.
[2] It may present as recurrent pulmonary TB, inflammatory lymph node swelling and has a death rate of 2%, with an incidence of 18% in those with HIV who start ART.
[16] A systematic review investigated the optimal timing of starting antiretroviral therapy in adults with newly diagnosed pulmonary tuberculosis.
[17] The review suggested that early provision of antiretroviral therapy in HIV-infected adults with newly diagnosed tuberculosis improved survival in patients who had a low CD4 count (less than 0.050 x 109 cells/L).
Regarding patients with higher CD4 counts (more than 0.050 x 109 cells/L), the evidence is not sufficient to make a conclusion about benefits or risks of early antiretroviral therapy.