How do I screen for tuberculosis and provide tuberculosis preventive treatment in people with HIV?

Tuberculosis infection (TBI) remains a major cause of preventable morbidity and mortality in people with HIV (PWH). Compared with the general population, PWH have a substantially higher risk of progression from TBI to active tuberculosis (TB), especially in the setting of advanced immunosuppression, delayed antiretroviral therapy (ART), social vulnerability, and barriers to continuity of care. Early diagnosis and timely TB preventive treatment (TPT) are therefore essential components of comprehensive HIV care.

To summarize the current approach to the diagnosis and treatment of TBI in PWH, with particular attention to screening strategies, exclusion of active TB, selection of TPT regimens, drug-drug interactions with ART, and follow-up.

This narrative review integrates current international HIV/TB guidelines and recent key studies, together with a representative clinical vignette illustrating common diagnostic and therapeutic challenges.

All PWH should be assessed for TB and TBI at HIV diagnosis. In asymptomatic individuals, screening for TBI relies on tuberculin skin test or interferon-gamma release assay, although both have reduced sensitivity in advanced immunodeficiency. A positive test requires exclusion of active TB through clinical assessment, chest imaging, and microbiological investigations when indicated. Available TPT options include isoniazid- and rifamycin-based regimens, whose choice should be individualized according to tolerability, feasibility, and expected adherence. Special consideration is required for interactions between rifamycin and ART, often necessitating antiretroviral regimen adjustment and close virological monitoring. Follow-up should include assessment of adherence, toxicity, liver function, and maintenance of HIV care linkage.

Optimal management of TBI in PWH requires systematic screening, prompt initiation of effective and individualized TPT, careful integration with ART, and structured follow-up. Strengthening linkage to care and improving access to shorter, safer preventive regimens are critical to reducing TB-related morbidity and mortality in this high-risk population.