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The incidence of active tuberculosis is high in regions of the world in which HIV is
prevalent. The risk of developing tuberculosis (TB) is estimated to be between 20–37
times greater in people infected with HIV than among those without HIV infection. In
2011, 430 000 people are estimated to have died of TB and HIV co-infection. This is
due to the immunosuppression by HIV affecting the very cells required to contain M.
tuberculosis, namely CD4+ cells, as well as the high concordance of both conditions.
Tuberculosis is treatable with triple antituberculous therapy but with the increase in
multiresistant strains, there are now concerted efforts by international agencies to
tackle this combined problem; not least as the only vaccine against tuberculosis,
Bacillus Calmette–Guerin (BCG) is not only contraindicated in HIV as a live vaccine
but is not effective against pulmonary tuberculosis even if given prior to HIV infection.
Two other mycobacterial species are prominent human pathogens. Mycobacterium
leprae is currently responsible for 5.5 million cases of leprosy worldwide, causing
considerable morbidity in the developing world. The severity and extent of disease in
leprosy are closely related to the host immune response. Robust cellular immunity leads
to localized tuberculoid leprosy affecting skin and nerves with few bacilli and vigorous
granuloma formation. In contrast, patients with poor cellular immunity develop
disseminated, bacteraemic lepromatous disease. Mycobacterium avium-intracellulare
(MAC) is an ubiquitous environmental mycobacterium which is handled satisfactorily
by immunocompetent individuals, but causes disseminated disease in patients with
advanced HIV infection (CD4 T cell count <50/mm3). MAC is estimated to affect 50%
of patients with HIV disease and its increasing prominence is a direct result of the HIV
epidemic.
a. Mycobacteria and the normal immune response
d. Prevention of tuberculosis
BCG has been available since the 1920s and it reduced disseminated TB and
TB meningitis in children and infants. It is protective against multiresistant TB
(those bacteria resistant to antituberculous drugs) which is rapidly increasing
worldwide, as well as to non-tuberculous atypical mycobacteria (such as MAC)
because of BCG cross-reactivity. Nevertheless, there are considerable problems
associated with BCG. As a live vaccine it is not suitable for immunosuppressed
individuals such as HIV+ persons, those taking immunosuppressive drugs for
autoimmunity or after transplantation or infants with severe combined immune
deficiencies (SCID). In these individuals, BCG immunization results in
disseminated BCG disease which is difficult to treat and can be fatal. Attempts to
make new, more effective, safer vaccines are under intense investigation.
Prevention of tuberculosis with drugs, known as chemoprophylaxis, can reduce
the risk of a first episode of active disease in those exposed to infection or with
latent TB. The World Health Organization recommends isoniazid should be taken
daily for at least 6 months and preferably 9 months in those at particular risk
following exposure (HIV+ patients, infants and children aged less than 4 years old,
those on immunosuppression or those with diabetes or chronic renal failure). This
policy has been difficult to implement due to failure of compliance by those already
taking considerable amounts of medication for their underlying disease