title: HIV infection and multidrug-resistant tuberculosis: the perfect storm.
abstract: BACKGROUND
  Multidrug-resistant (MDR) tuberculosis (TB) has emerged as a global epidemic, with ~425,000 new cases estimated to occur annually. The global human immunodeficiency virus (HIV) infection epidemic has caused explosive increases in TB incidence and may be contributing to increases in MDR-TB prevalence.
  
  
  METHODS
  We reviewed published studies and available surveillance data evaluating links between HIV infection and MDR-TB to quantify convergence of these 2 epidemics, evaluate the consequences, and determine essential steps to address these epidemics.
  
  
  RESULTS
  Institutional outbreaks of MDR-TB have primarily affected HIV-infected persons. Delayed diagnosis, inadequate initial treatment, and prolonged infectiousness led to extraordinary attack rates and case-fatality rates among HIV-infected persons. Whether this sequence occurs in communities is less clear. MDR-TB appears not to cause infection or disease more readily than drug-susceptible TB in HIV-infected persons. HIV infection may lead to malabsorption of anti-TB drugs and acquired rifamycin resistance. HIV-infected patients with MDR-TB have unacceptably high mortality; both antiretroviral and antimycobacterial treatment are necessary. Simultaneous treatment requires 6-10 different drugs. In HIV-prevalent countries, TB programs struggle with increased caseloads, which increase the risk of acquired MDR-TB. Surveillance data suggest that HIV infection and MDR-TB may converge in several countries.
  
  
  CONCLUSIONS
  Institutional outbreaks, overwhelmed public health programs, and complex clinical management issues may contribute to the convergence of the MDR-TB and HIV infection epidemics. To forestall disastrous consequences, infection control, rapid case detection, effective treatment, and expanded program capacity are needed urgently.
authors.affiliation: Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. cdwells6@bellsouth.net
authors.forename: Charles D
authors.initials: CD
authors.lastname: Wells
authors.forename: J Peter
authors.initials: JP
authors.lastname: Cegielski
authors.forename: Lisa J
authors.initials: LJ
authors.lastname: Nelson
authors.forename: Kayla F
authors.initials: KF
authors.lastname: Laserson
authors.forename: Timothy H
authors.initials: TH
authors.lastname: Holtz
authors.forename: Alyssa
authors.initials: A
authors.lastname: Finlay
authors.forename: Kenneth G
authors.initials: KG
authors.lastname: Castro
authors.forename: Karin
authors.initials: K
authors.lastname: Weyer
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000378:metabolism / Q000494:pharmacology* / Q000627:therapeutic use; D004196:Disease Outbreaks; D024901:Drug Resistance, Multiple, Bacterial; D004359:Drug Therapy, Combination; D014943:Global Health; D006678:HIV; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology* / Q000401:mortality; D006801:Humans; D008286:Malabsorption Syndromes; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000187:drug effects*; D015995:Prevalence; D012294:Rifamycins / Q000494:pharmacology; D012307:Risk Factors; D018571:Sentinel Surveillance; D016896:Treatment Outcome; D014376:Tuberculosis / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology* / Q000401:mortality
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents; D012294:Rifamycins