Role of oral candidiasis in TB and HIV co-infection: AIDS Clinical Trial Group Protocol A5253.

THE IDENTIFICATION of human immunodeficiency virus (HIV) infected persons with low CD4+cell count is important in areas of high tuberculosis (TB) prevalence, as this group is at highest risk of having TB disease concomitantly with HIV infection. Several studies have shown that oral candidiasis and TB disease were the most common comorbidities among populations with advanced HIV disease: one study among 356 hospitalized Cambodian patients with the acquired immunedeficiency syndrome (AIDS) revealed that oral candidiasis (51%) and pulmonary and extra-pulmonary TB (44%) were the most frequent opportunistic infections.1 Another study among 205 HIV-infected adults in Malaysia showed that oral candidiasis was the most common mucocutaneous disease, and significant co-existence was found with the major opportunistic systemic diseases such as TB.2 Early in the HIV epidemic, oral candidiasis was found to be among the strongest clinical predictors of progression to AIDS in various HIV-infected populations.3,4 Oral candidiasis has also been shown to be the most common oral manifestation of HIV infection in different parts of the world,5–14 and to be closely associated with low CD4+ cell count.5,7,8,15–20 A diagnosis of oral candidiasis is usually made by visual examination of the mouth, and non-dental health care providers can be readily trained to perform such an examination.19 The strong positive association between oral candidiasis and a low CD4+cell count is thus a useful finding with respect to the need for inexpensive surrogate markers of HIV disease progression and related comorbidities in resource-limited countries where measurement of CD4+cell counts is not widely available. A visual inspection of the soft tissues of the mouth is quick (<5 min), non-invasive, and inexpensive. It could be used as initial screening to identify patients with oral candidiasis who are most likely to have CD4+cell count <200 cells/mm3, and thus at higher risk for TB disease that may or may not yet be symptomatic. The objective of the present study was to evaluate the value of oral candidiasis as a predictor of TB disease among HIV-infected men and women in resource-limited settings with high TB prevalence.