Impact of human immunodeficiency virus on transmission and severity of tuberculosis

It is now clear that tuberculosis is one of the major diseases associated with human immunodeficiency virus (HIV) infection and the acquired immune deficiency syndrome both in developing countries and in disadvantaged groups in the northern hemisphere. In the USA, and probably several other countries, the annual incidence of tuberculosis is rising as a result of the HIV epidemic. This is probably a result of an increase in both pulmonary and, especially, extrapulmonary tuberculosis, due to reactivation of latent infections, but a secondary increase in the infection rate is also possible. The hard-won gains in tuberculosis control of the last 30 years are thus in jeopardy. This article focuses on the effect HIV is likely to have on the known risk factors for infection with Mycobacterium tuberculosis and for reactivation. Whilst HIV-associated tuberculosis may be indistinguishable from HIV-negative disease, it is likely in other cases to present diagnostic difficulties, to respond poorly to treatment with more adverse effects, and to result in high early mortality, although this may not be due directly to tuberculosis. HIV-associated tuberculosis thus represents a major challenge to physicians, especially in developing countries, but like other forms of tuberculosis it is (i) treatable and (ii) preventable.