THE TUBERCULOSIS-HIV PARTNERSHIP

Eight million people contract tuberculosis every year, 95% of them in developing countries, and one-third of the world's population is infec ted with Mycobacterium tuberculosis. Annually, tuberculosis causes thr ee million deaths (in Africa 26% of the avoidable deaths). The main ca use of dissemination is the absence of early diagnosis and insufficien t treatment. Today, 3% of the new cases of tuberculosis are related to infection with the human immunodeficiency virus (HIV), a proportion w hich is rising rapidly. HIV infection does not change the classic rule s of treatment: rifampicine, isoniazid, ethambutol and pyrazinamide fo r 2 months followed by at least 4 more months with a two-drug regimen (rifampicine and isoniazid). No-compliance is the major cause of recur rence, together with the risk of infection with another strain of M. t uberculosis. Certain authors suggest that in Africa, due to poor compl iance and the lack of a sufficient provision of major antituberculous agents, treatment should be continued for life in HIV positive patient s. Others propose chemotherapy for an HIV infected patients who are he althy carriers of M. tuberculosis. The risk of selecting mutant strain s could be avoided by limiting prophylaxis to non-febrile patients. Ne vertheless, the long-term effect of generalized chemoprophylaxis on th e epidemiology of resistant strains is unknown. The only method of scr eening for healthy carriers is the tuberculin skin test but interpreta tion is complicated by prior BCG vaccination and now by HIV infection. There are tvo crucial steps required to control tuberculosis in this era of the tuberculosis-HIV partnership. First, patients should have e asy and cost-free access to antituberculous drugs and second, complian ce must be improved. Certain barriers have been lifted, including the requirement of patient identification to obtain free drugs. Hospital s taffs must renew their efforts and attempt to follow-up their patients to assure compliance after discharge. All these measures will be diff icult to implement but are the price we must pay to eradicate a new ri se in the incidence of tuberculosis and the risk of multidrug-resistan t strains. The only alternative may well be a return to pre-antibiotic days.