HIV-Associated TB Syndemic: A Growing Clinical Challenge Worldwide

Abstract

The association of tuberculosis (TB) with human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome over the past several years has become an emerging syndemic. Approximately 10% of people living with HIV (PLHIV) with latent TB infection will develop active TB disease each year. In this review, we highlight that this phenomenon is not limited to high endemic regions, such as Afro-Asian nations, but globalization/migration is causing increased case detection even in developed nations, such as the United States. Active screening should be performed for TB in PLHIV. A high degree of clinical suspicion for TB is warranted in PLHIV presenting with fever, cough, and unintentional weight loss. HIV-Mycobacterium tuberculosis (MTB) coinfection is often paucibacillary, precluding diagnosis by conventional diagnostics and/or smear microscopy/culture. Improved detection of pulmonary and extrapulmonary TB is now possible by incorporation of the GeneXPERT MTB/RIF assay (Cepheid Inc., Sunnyvale, CA, USA). The World Health Organization recommends instituting immediate therapy for MTB, in conjunction with ongoing or newly introduced anti-retroviral therapy. Vigilance is required to detect drug-induced organ injuries, and early-treatment-induced immune reconstitution inflammatory syndrome. Collaborating MTB and HIV activities in concentrated HIV epidemic settings should become a high public health priority.

Keywords: AFB; GeneXpert; HIV; TB; coinfections; diagnosis; extrapulmonary tuberculosis.

Figure 1

Chest radiographic appearances of tuberculosis in HIV. (A) Right hilar lymphadenopathy and bronchial markings in a primary pulmonary tuberculosis-like presentation in a HIV-infected young adult (B) Left lower lobe consolidation due to Streptococcus pneumonia infection in pre-existing tuberculosis and HIV coinfections (Ci,ii) Radiologic appearance of IRIS. Chest X-ray showing radiographic progression of a small left lobar lesion to widespread consolidation of a tuberculosis patient few weeks after initiating anti-retroviral therapy (ART). All CXRs obtained from permission with Chou et al. (38).