Journal of Pregnancy 13. HIV and TB Coinfection in Pregnancy HIV and TB are inextricably linked. Their eﬀect is even more deadly in pregnancy, when they may contribute signiﬁcantly to maternal morbidity and mortality. Over 50% of the mater- nal mortality occurring in mothers with TB in pregnancy is due to coinfection with HIV [64]. Moreover, treatment is complicated by the challenges of adherence, polypharmacy and the overlapping side eﬀect proﬁles of antituberculosis and antiretroviral drugs [65–67]. The key concern is about the interactions between the rifamycins and antituberculous drugs. The suboptimal out- comes of therapeutic trials without a rifamycin has made the use of the drug mandatory, even in the face of drug inter- actions [68, 69]. The spectrum of antiretroviral drugs available for use in pregnancy is limited. Efavirenz is contraindicated before the thirteenth week of gestation, while the risk of toxicity from the use of didanosine and stavudine is signiﬁcantly increased in pregnancy. Rifampicin may cause a reduction in the serum concentration of efavirenz, though, increasing the dose of efavirenz does not result in any signiﬁcant outcome [70]. Nevirapine, which is an alternative to the use of efavirenz, also exhibits some drug interaction with rifampicin. Rifam- picin may lead to the reduction of serum concentration of nevirapine by as much as 50%. To circumvent this problem, rifabutin, another rifamycin that is as eﬀective as rifampicin in the treatment of tuberculosis may be used, as the drug has less eﬀect on the CYP3A system that metabolizes nevirapine [71]. Generally, there is a dearth of studies and data on how pregnancy may aﬀect the aforementioned interactions. Cau- tion is, therefore, of great importance when managing preg- nant women with this cruel duo. 14. Prevention of Tuberculosis The BCG vaccine has been incorporated into the National immunization policy of many countries, especially the high burden countries, thereby conferring active immunity from childhood. Nonimmune women travelling to tuberculosis endemic countries should also be vaccinated. It must, how- ever, be noted that the vaccine is contraindicated in preg- nancy [72]. The prevention, however, goes beyond this as it is es- sentially a disease of poverty. Improved living condition is, therefore, encouraged with good ventilation, while over- crowding should be avoided. Improvement in nutritional sta- tus is another important aspect of the prevention. Pregnant women living with HIV are at higher risk for TB, which can adversely inﬂuence maternal and perinatal outcomes [73]. As much as 1.1 million people were diag- nosed with the co-infection in 2009 alone [2]. Primary pre- vention of HIV/AIDS is, therefore, another major step in the prevention of tuberculosis in pregnancy. Screening of all pregnant women living with HIV for active tuberculosis is recommended even in the absence of overt clinical signs of the disease. 5 Isoniazid preventive therapy (IPT) is another innovation of the World Health Organisation that is aimed at reducing the infection in HIV positive pregnant women based on ev- idence and experience and it has been concluded that preg- nancy should not be a contraindication to receiving IPT. However, patient’s individualisation and rational clinical judgement is required for decisions such as the best time to provide IPT to pregnant women [73]. Most importantly, governments commitments are highly encouraged so that the World Health Organisation and all other international bodies involved in ﬁghting tuberculosis may succeed in chasing this monster out of all communities. References [1] “Facts about health in African Subregion,” Fact sheet N◦314 World Health Organisation, 2011. 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