Tuberculosis remains one of the most consequential threats facing people living with HIV, despite the availability of preventive medicines and effective treatments for both infections. In 2024, tuberculosis was the leading cause of death among people with HIV and accounted for roughly one quarter of all AIDS-related deaths. A new analysis of routine health-program data from six countries now shows that tuberculosis preventive treatment can reduce the risk of tuberculosis disease and death in real-world settings, particularly when it is introduced soon after a person enters HIV care.
The study, led by researchers from the Centers for Disease Control and Prevention’s Division of Global HIV and Tuberculosis and Emory University’s Rollins School of Public Health, examined outcomes in Haiti, Kenya, Nigeria, Uganda, Ukraine, and Zimbabwe. These countries represent diverse health systems and populations with substantial burdens of both HIV and tuberculosis. The investigators combined evidence from a prospective cohort study with a meta-analysis, allowing them to assess the effectiveness of preventive treatment across different program environments rather than under the tightly controlled conditions of a clinical trial.
Tuberculosis is caused by Mycobacterium tuberculosis, a bacterium that is usually transmitted through the air when a person with active pulmonary disease coughs, speaks, or breathes. After inhalation, the bacteria may be contained by the immune system in organized cellular structures known as granulomas. This state, commonly called latent tuberculosis infection, can persist for years without symptoms. HIV changes that balance. As the virus progressively damages immune function, particularly by reducing populations of CD4 T cells, previously contained bacteria may begin multiplying and spread beyond the lungs. People with HIV are therefore substantially more likely to develop active tuberculosis than people with intact immune systems.
The analysis found that preventive treatment was associated with lower rates of tuberculosis and death among people living with HIV who received it. Most participants were treated with six months of isoniazid, a drug that interferes with the production of mycolic acids, essential components of the tuberculosis bacterium’s cell wall. By suppressing or eliminating bacteria that remain dormant in the body, isoniazid can prevent latent infection from progressing to active disease. The protective effect was observed across a broad range of national settings, health conditions, and risk groups, suggesting that preventive treatment retains its value even when delivered through ordinary public-health services with varying resources and clinical capacity.
Timing emerged as an important feature of the findings. Preventive treatment was most effective when started early in HIV care, ideally within the first two weeks after a person entered an HIV program. Treatment initiated within eight weeks was also associated with benefit. The result is biologically plausible: HIV diagnosis and enrollment in care can represent a critical window in which clinicians evaluate tuberculosis symptoms, begin antiretroviral therapy, and address infections that may otherwise advance unnoticed. Starting preventive treatment during this period may reduce the time in which latent or subclinical tuberculosis is allowed to progress while the patient’s immune system remains compromised.
The researchers’ conclusions support integrating tuberculosis prevention into the standard architecture of HIV services rather than treating it as a separate intervention. HIV testing, rapid linkage to care, antiretroviral treatment, viral-load monitoring, and tuberculosis screening operate most effectively when they are connected. Antiretroviral therapy can suppress HIV replication and allow partial immune recovery, but it does not eliminate tuberculosis bacteria already present in the body. Preventive treatment addresses that separate biological risk. Before it begins, health workers must assess patients for symptoms and signs of active tuberculosis, because preventive regimens alone are not sufficient for treating established disease and could contribute to missed diagnoses or drug resistance if used incorrectly.
The findings are especially significant because they come from programmatic data rather than a conventional randomized clinical trial. Controlled trials establish whether an intervention can work under defined conditions, while routine-care studies reveal what happens when medicines must be prescribed, monitored, and completed across diverse communities. In practice, patients may face transportation barriers, drug shortages, competing medical needs, stigma, or difficulty returning for follow-up. The study therefore provides evidence that tuberculosis preventive treatment can remain effective when embedded in large HIV programs and delivered at scale. Anand Date, chief of the CDC’s Global TB Branch, described the results as evidence of what happens when countries implement prevention through routine services.
The global stakes extend beyond the six countries included in the analysis. In 2024, an estimated 10.7 million people developed tuberculosis worldwide and approximately 1.2 million died from the disease. Tuberculosis occurs in every country, including all 50 states of the United States. An estimated 13 million people in the United States are living with latent tuberculosis infection, creating a reservoir from which future active disease can arise. Preventive treatment can interrupt that progression when it is taken correctly. In the United States, newer regimens have shortened treatment from six or more months to three months or, in selected circumstances, one month, including for people living with HIV. Shorter regimens may improve completion by reducing the duration of medication exposure and the number of opportunities for treatment to be interrupted.
The new evidence arrives during a period of increasing uncertainty for international HIV and tuberculosis programs. Freezes in US foreign aid, the dissolution of the US Agency for International Development, and disruptions to funding associated with the President’s Emergency Plan for AIDS Relief have threatened services that have expanded over the past two decades. Since a major PEPFAR commitment in 2018, more than 13 million people living with HIV worldwide have received tuberculosis preventive treatment. Researchers and public-health leaders warn that interruptions to this infrastructure could reverse those gains. Modeling studies have projected that reductions in tuberculosis funding could produce more than half a million additional deaths and increase the catastrophic costs borne by affected families.
The study ultimately presents tuberculosis preventive treatment as a central component of HIV medicine, not an optional add-on. The biological relationship between the two infections means that progress against HIV cannot be sustained while tuberculosis remains untreated or preventable disease is allowed to emerge. Early initiation of preventive therapy, combined with timely HIV diagnosis, antiretroviral treatment, symptom screening, and reliable long-term care, offers a practical strategy for reducing mortality. Sarita Shah of Emory University said the findings reinforce the role of tuberculosis prevention in HIV programs at a time when reduced global-health funding threatens hard-won progress. The results indicate that protecting people with HIV from tuberculosis depends not only on scientific discovery, but also on preserving the systems capable of delivering proven interventions consistently.
Subject of Research: Tuberculosis preventive treatment for people living with HIV
Article Title: Programmatic effectiveness of tuberculosis preventive treatment for people with HIV in six high-tuberculosis-burden countries (PROTECT): a prospective cohort study and meta-analysis
News Publication Date: 17 August 2026
Web References:
https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(26)00140-2/fulltext
https://www.cdc.gov/tb/risk-factors/index.html
https://www.cdc.gov/tb-data/aboutprovisionaldata/2025-provisional-data.html
References:
DOI: 10.1016/S2352-3018(26)00140-2
Keywords: Tuberculosis; HIV; AIDS; tuberculosis preventive treatment; isoniazid; latent tuberculosis infection; infectious diseases; public health; disease prevention; global health; HIV care; antimicrobial therapy
