review · International Journal of Infectious Diseases
Tuberculosis remains the primary cause of hospitalisation among people living with HIV, driving substantial mortality globally and especially within the World Health Organisation Africa region. In 2023, roughly 24 percent of individuals coinfected with HIV and tuberculosis died, more than double the mortality rate of tuberculosis patients without HIV. Recent clinical advances have helped reduce incidence and improve patient survival, particularly through the use of antiretroviral therapy and new regimens for preventive treatment. In addition, diagnostic tools such as Xpert Ultra and the urine Determine TB LAM Antigen test are linked to better survival outcomes. Significant challenges persist, however, including knowledge gaps surrounding disease progression, post-tuberculosis health, and the diagnosis of tuberculosis and drug resistance using non-sputum samples. Active investigations into vaccines, expanded diagnostic options, and novel treatment strategies aim to address these ongoing issues.
Tuberculosis is the main reason people living with HIV are admitted to hospital and accounts for disproportionately high death rates. Improving prevention, diagnosis, and care directly affects public health outcomes, especially in high-burden areas like Africa. Addressing coinfection through better diagnostic testing and preventive treatments saves lives and reduces the strain on healthcare systems.
The findings point to opportunities for diagnostic developers and clinical researchers addressing tuberculosis and drug resistance, particularly through non-sputum sampling methods. Commercial tools such as Xpert Ultra and urine-based antigen tests are already deployed in clinical settings, while highlighted areas like novel therapeutics, vaccines, and alternative diagnostics represent active, earlier-stage research and development pathways.
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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<sup>TM</sup> 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.
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DOI: 10.1016/j.ijid.2025.107876
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