Concept
HIV and Co-infection
5 studiesEvidence last moved Sep 24, 2026
HIV rarely acts alone: other infections change how easily it spreads and how it presents, and HIV changes how other infections behave. The evidence here comes from African cohorts on tuberculosis and bacterial vaginosis, a global cohort of adolescents with perinatal HIV, and pharmacology studies of efavirenz given with TB treatment.
Students often treat HIV, TB and genital infections as separate chapters. These studies show how they interact in incidence, transmission, survival and drug treatment, which is why care in high-prevalence settings is integrated.
Studies
5
Findings
5
6 supporting · 0 challenging · 0 qualifying citations
Open tensions
2
Latest change
Concept page published
HIV and Co-infection
Currently
What we know
- HIV multiplies TB risk roughly twentyfold.
- Prevalence surveys under-count HIV's contribution because HIV-TB progresses and is found quickly.
- Treating genital dysbiosis is a plausible, not proven, prevention target.
- Where and when treatment starts shapes survival into adolescence.
- Genotype mattered more than the TB drug for efavirenz exposure.
Largest unresolved question
The TB cohort and the adolescent cohort measure HIV's toll in different ways: incidence and diagnostic delay in adults without routine ART versus survival and retention in children on ART. They are not comparable estimates of the same effect, and both are observational.
Common misconceptions
If an HIV-TB survey finds little HIV-associated TB, HIV is not driving the TB epidemic.
In Harare HIV caused 78% of new TB but only 14% of prevalent TB, because HIV-positive cases are diagnosed within weeks rather than years. Prevalence snapshots miss fast-moving disease.
Rifampicin must be the main reason efavirenz levels vary in co-infected patients.
Two African cohorts found rifampicin had little or transient effect, whereas CYP2B6 genotype strongly predicted exposure.
Related
Claim ledger
What the evidence shows
Drawn from 5 studies in this library. Mix labels say which citation roles are present; they are not a strength score. Supports means evidence for a finding; Challenges means evidence against a stated position; Qualifies marks scope.
HIV multiplies TB risk roughly twentyfold.
HIV sharply raises tuberculosis incidence: among 6,440 Harare workers, culture-positive TB occurred at 25.3 per 1,000 person-years in HIV-positive versus 1.3 in HIV-negative workers, an adjusted rate ratio of about 19.
Prevalence surveys under-count HIV's contribution because HIV-TB progresses and is found quickly.
HIV-positive TB was diagnosed much faster (about 12 versus 108 weeks of culture positivity), so HIV accounted for 78% of incident but only 14% of prevalent culture-positive TB in the same cohort.
Treating genital dysbiosis is a plausible, not proven, prevention target.
A co-infection in one partner can raise HIV transmission: in a prospective cohort of 2,236 serodiscordant African couples, bacterial vaginosis in the HIV-positive woman carried a 3.17-fold adjusted risk of genetically linked transmission to the male partner, only partly explained by a small (~0.2 log) rise in genital HIV RNA.
Where and when treatment starts shapes survival into adolescence.
Among 38,187 adolescents with perinatal HIV in 51 countries, antiretroviral therapy began at a median 0.9 years in North America but 7.9 years in sub-Saharan Africa, and cumulative mortality by age 15 ranged from 0.8% in Europe to 4.4% in South America and the Caribbean.
Genotype mattered more than the TB drug for efavirenz exposure.
TB co-treatment complicates HIV drug therapy less than expected for efavirenz: rifampicin lowered efavirenz levels only in the first week in a Ugandan cohort (symptoms 74% vs 72%), and made no significant difference to clearance in a Zimbabwean population-pharmacokinetic study.
- Why do some HIV patients get side effects from efavirenz?
- Why do people on the same HIV drug dose reach different blood levels?
Study Role Design N Population Outcome Why do some HIV patients get side effects from efavirenz? Supports CohortProspective cohort: treatment-naive HIV patients started efavirenz 600 mg daily (plus zidovudine and lamivudine); TB co-infected patients also took rifampicin-based TB therapy. Mid-dose efavirenz levels were measured from day 3 to week 12, five drug-handling genes were genotyped, and neuropsychiatric symptoms were assessed at baseline, week 2 and week 12. N=197 · 197 patients: 59 with HIV only on efavirenz alone and 138 with HIV-TB co-infection also receiving rifampicin; 89.9% were assessed at week 12. Newly diagnosed, antiretroviral-naive adults with HIV, with or without tuberculosis, at two national referral hospitals in Kampala, Uganda (2008-2009). Incidence and type of neuropsychiatric symptoms (sleep disorders, hallucinations, cognition on an adjusted MMSE) over 12 weeks, and their relation to plasma efavirenz concentration, rifampicin co-treatment and genotype. Why do people on the same HIV drug dose reach different blood levels? Supports Cross-sectionalSingle-timepoint plasma efavirenz measurement (12-15 h post-dose) with TaqMan genotyping, analysed by nonlinear mixed-effects population PK modelling in NONMEM plus Monte Carlo simulations N=185 · 185 patients analysed: 95 recruited on efavirenz-based ART alone and 90 with HIV/TB co-infection also receiving rifampicin-containing TB therapy (60 men, 125 women) Adults with HIV, some co-infected with tuberculosis, attending two hospitals in Zimbabwe while taking efavirenz-based antiretroviral therapy Apparent oral clearance of efavirenz and plasma concentration; secondary outcomes were reported central nervous system adverse effects
Debates
Tensions and limits
Some items are genuine disagreements on the same question. Others mark different assays, populations, or outcomes.
The TB cohort and the adolescent cohort measure HIV's toll in different ways: incidence and diagnostic delay in adults without routine ART versus survival and retention in children on ART. They are not comparable estimates of the same effect, and both are observational.
The TB cohort and the adolescent cohort measure HIV's toll in different ways: incidence and diagnostic delay in adults without routine ART versus survival and retention in children on ART. They are not comparable estimates of the same effect, and both are observational.
- Can easy TB diagnosis keep infectious TB low where HIV is common?
- How do teens born with HIV fare in different parts of the world?
Study Role Design N Population Outcome Can easy TB diagnosis keep infectious TB low where HIV is common? Supports CohortTwo-year prospective workforce cohort (nested in a cluster-randomised HIV testing trial) measuring incident TB, followed by a cross-sectional TB culture screening survey of all remaining employees. N=6440 · 6,440 employees of 22 Harare workplaces in the incidence cohort; 4,668 of them (874 HIV positive) were screened in the end-of-study prevalence survey. Adult employees (mostly male, middle-aged manual and factory workers) of small and medium enterprises in Harare, Zimbabwe, with 19% HIV prevalence and no routine antiretroviral therapy. TB incidence per 1,000 person-years, point prevalence of undiagnosed TB, risk factors for each, and estimated duration of infectious disease before diagnosis by HIV status. How do teens born with HIV fare in different parts of the world? Supports CohortRetrospective analysis of pooled individual data from 12 paediatric HIV cohort networks (CIPHER); competing-risks cumulative incidence and Cox models of mortality from age 10 to 15, with Europe as reference. N=38187 · 38,187 adolescents with perinatally acquired HIV (in care before and after age 10) drawn from 183,119 children in the pooled dataset. Adolescents aged 10-19 with perinatally acquired HIV in 51 countries across Europe, North America, South America and the Caribbean, South and Southeast Asia, and sub-Saharan Africa. Characteristics at first visit, ART start, age 10 and last visit (age, CD4, height-for-age), and mortality, transfer out and loss to follow-up between ages 10 and 15.
PaperFren reads this as a limit on how far one study travels — different assays, populations, or outcomes — not a forced fight between papers.
The bacterial vaginosis result is from women with HSV-2, CD4 ≥250 and not on ART, with only 50 analysable transmissions; it may not apply where partners are virally suppressed.
The bacterial vaginosis result is from women with HSV-2, CD4 ≥250 and not on ART, with only 50 analysable transmissions; it may not apply where partners are virally suppressed.
PaperFren reads this as a limit on how far one study travels — different assays, populations, or outcomes — not a forced fight between papers.
Timeline
How understanding moved
Study years are when the paper was published. Evidence edits are dated changes to this page's claims. Explanations are when PaperFren added a Discovery — not a claim that the science happened that day.
2026
Concept page published
HIV and Co-infection
Change log
What changed
Dated edits to this page's evidence: studies added or removed from a claim, claims added or withdrawn, and new explanations tagged here. Rewordings are not listed.
- Concept page published
Papers
5 studies in this library bear on HIV and Co-infection, ordered by citations.
- Does bacterial vaginosis make HIV easier to pass to men?
Men whose HIV-positive female partners had bacterial vaginosis were about three times more likely to catch HIV from them than men whose partners had normal vaginal bacteria.
- How do teens born with HIV fare in different parts of the world?
Adolescents born with HIV in sub-Saharan Africa, Asia and Latin America started treatment years later and were several times more likely to die in early adolescence than those in Europe.
- Can easy TB diagnosis keep infectious TB low where HIV is common?
HIV made new TB cases about twenty times more common, but because HIV-positive people got sick and were diagnosed quickly, most undiagnosed infectious TB found by screening was in HIV-negative workers.
- Why do some HIV patients get side effects from efavirenz?
Most Ugandan patients starting the HIV drug efavirenz had neuropsychiatric side effects such as vivid dreams, and these were linked to higher blood levels of the drug, which in turn depended on a patient's CYP2B6 gene variant, while taking TB drugs at the same time made no difference.
- Why do people on the same HIV drug dose reach different blood levels?
Two variants of the liver enzyme gene CYP2B6, along with body weight and sex, together explained about 55% of the person-to-person variation in how quickly patients cleared efavirenz.
Compare studies
Select 2–10 studies. Design and N are labels, not a ranking.
Nothing selected yet.
Questions
What is still open
The TB cohort and the adolescent cohort measure HIV's toll in different ways: incidence and diagnostic delay in adults without routine ART versus survival and retention in children on ART. They are not comparable estimates of the same effect, and both are observational.
The bacterial vaginosis result is from women with HSV-2, CD4 ≥250 and not on ART, with only 50 analysable transmissions; it may not apply where partners are virally suppressed.
Ask PaperFren about HIV and Co-infection
Study this conceptflashcards and short-answer questions
Why can incident and prevalent TB give different pictures of HIV's role?
Prevalence equals incidence times duration. In the Harare cohort HIV raised incidence about 19-fold, but HIV-positive TB was diagnosed after about 12 weeks versus 108 weeks, so it contributed 78% of new but only 14% of prevalent cases. A prevalence survey therefore understates HIV's role.
How strong is the evidence that bacterial vaginosis increases female-to-male HIV transmission?
A prospective cohort of 2,236 couples with genetically confirmed transmissions found a 3.17-fold adjusted risk with bacterial vaginosis. Viral linkage and adjustment for behaviour strengthen it, but it is observational, based on 50 events in women not on ART, and the mechanism was not fully explained by genital viral load. It supports a trial of BV treatment rather than proving benefit.
Flashcards
0 of 1 answers reviewed