[Association of tuberculosis and HIV infection]

Eight million people contract tuberculosis every year, 95% of them in developing countries, and one-third of the world's population is infected with Mycobacterium tuberculosis. Annually, tuberculosis causes three million deaths (in Africa 26% of the avoidable deaths). The main cause of dissemination is the absence of early diagnosis and insufficient treatment. Today, 3% of the new cases of tuberculosis are related to infection with the human immunodeficiency virus (HIV), a proportion which is rising rapidly. HIV infection does not change the classic rules of treatment; rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months followed by at least 4 more months with a two-drug regimen (rifampicin and isoniazid). No-compliance is the major cause of recurrence, together with the risk of infection with another strain of M. tuberculosis. Certain authors suggest that in Africa, due to poor compliance and the lack of a sufficient provision of major antituberculous agents, treatment should be continued for life in HIV positive patients. Others propose chemotherapy for an HIV infected patients who are healthy carriers of M. tuberculosis. The risk of selecting mutant strains could be avoided by limiting prophylaxis to non-febrile patients. Nevertheless, the long-term effect of generalized chemoprophylaxis on the epidemiology of resistant strains is unknown. The only method of screening for healthy carriers is the tuberculin skin test but interpretation is complicated by prior BCG vaccination and now by HIV infection. There are two crucial steps required to control tuberculosis in this era of the tuberculosis-HIV partnership. First, patients should have easy and cost-free access to antituberculous drugs and second, compliance must be improved. Certain barriers have been lifted, including the requirement of patient identification to obtain free drugs. Hospital staffs must renew their efforts and attempt to follow-up their patients to assure compliance after discharge. All these measures will be difficult to implement but are the price we must pay to eradicate a new rise in the incidence of tuberculosis and the risk of multidrug-resistant strains. The only alternative may well be a return to pre-antibiotic days.