Tuberculosis disease among people with HIV: therapeutic advances

Over the past 80 years, tuberculosis treatment has evolved with the development of all-oral treatments, which are now given for 4-6 months for drug-sensitive tuberculosis and 6-9 months for drug-resistant tuberculosis. Treatment success is often reduced among people with HIV due to an interplay of factors, including immune dysregulation, lower drug concentrations, complexities of cotreatment (eg, high pill burden and overlapping toxicities), and social factors. Recent clinical trials have shown that among adults and adolescents, treatment duration can be decreased to 4 months with repurposed therapeutics for drug-sensitive tuberculosis, and a four-drug regimen of isoniazid, rifapentine, moxifloxacin, and pyrazinamide has become part of WHO recommendations. Among children with drug-sensitive, non-severe tuberculosis disease, a 4-month regimen of standard tuberculosis drugs (eg, isoniazid, rifampicin, pyrazinamide, and ethambutol) is non-inferior to a 6-month regimen. Following recent research advances for drug-resistant tuberculosis, a 6-month regimen containing a potent combination of bedaquiline, pretomanid, linezolid, and moxifloxacin is a new standard for people with and without HIV. The tuberculosis drug development pipeline contains promising new therapeutics in various stages of development. To accelerate tuberculosis elimination, future research should focus on shortened treatment duration, and safer and effective therapeutics for tuberculosis-affected populations globally, including people with HIV, children, and pregnant people, and should assess newer modalities of treatment delivery.