Tuberculosis Prevention in Pregnant Women Living with HIV: A Review of the Current Management Strategies and Guidance

Introduction: Tuberculosis (TB) is a leading cause of maternal mortality globally, especially for women living with HIV. TB preventive therapy (TPT) regimens treat TB infection and prevent progression to TB disease, but the components of these regimens, including isoniazid and rifamycins, often interact with HIV antiretroviral therapy (ART). There are limited data on drug-drug interactions, adverse pregnancy outcomes, and treatment success specifically in pregnant women living with HIV on ART but several new trials in pregnancy have recently been conducted. Objective: To perform a comprehensive narrative review of the literature outlining the available updated guidance and pregnancy considerations for implementing TPT in pregnant women living with HIV. Methods: We performed a narrative review to explore an in-depth yet flexible overview of TPT in pregnancy. Keywords related to pregnant women living with HIV on ART and TPT were used to identify manuscripts in PubMed from 1980 to 2026. All primary literature including various study designs was included; review manuscripts were excluded. Results: Three hundred and sixty-nine initial results were screened for relevance. Two hundred and seventy-seven abstracts were then chosen, and ultimately 111 manuscripts were extracted. These manuscripts and their reference lists were reviewed, and ultimately 78 references published from 1980 to 2026 were included for our review. We included six randomized controlled trials, 17 references related to clinical guidance, and 54 studies of various designs. Conclusion: Isoniazid and rifamycin-based TPT regimens appear safe and effective in pregnancy, but each with limitations. Newer short course combinations of these medications for TPT appear safe in pregnancy, although no clear guidelines exist. Lack of definitive trial data for pregnant women living with HIV results in conflicting national and international guidelines. Inclusion of this population in TPT trials is critical, especially countries with a high burden of HIV and TB.