Tuberculosis and HIV coinfection: Progress and challenges towards reducing incidence and mortality

HIV-associated tuberculosis (HIV-TB) is associated with disproportionate mortality: approximately 24% of the 660,000 individuals with TB and HIV died, compared to 11% of those without HIV dying from TB in 2023. HIV is a key driver of ongoing high TB incidence in many countries, particularly in the World Health Organization Africa region, and TB is the leading cause of hospitalization in people with HIV (PWH) globally. Significant developments have occurred recently concerning the prevention, screening, diagnosis, and management of HIV-TB. Antiretroviral therapy and novel regimens for TB preventive therapy are now known to decrease TB incidence and improve survival. The use of Xpert Ultra (Cepheid, USA) and urine Determine^TM TB LAM Antigen (Abbott, USA) as diagnostics are associated with improved survival for HIV-TB. However, there are ongoing gaps in our knowledge: regarding the natural history of TB disease in PWH; optimal approaches to diagnosis of TB and TB drug resistance including in non-sputum samples; and post-TB disease in PWH. We discuss recent progress, together with ongoing challenges towards reducing incidence, morbidity, and mortality. We highlight ongoing research that will advance our understanding and management of HIV-TB: including vaccine research, novel treatment strategies, and expanded options for the diagnosis of TB and drug resistance in PWH.