{"doi":"10.1002/jia2.25481","title":"TB prevention strategies and unanswered questions for pregnant and postpartum women living with HIV: the need for improved evidence","abstract":"To end the tuberculosis (TB) epidemic, the World Health Organization (WHO) recommends improving access to testing and treatment of latent TB infection (LTBI) [1]. Despite recent epidemiologic studies demonstrating an approximately twofold increased risk of active TB in peripartum women [2], and poor outcomes associated with TB during pregnancy for mothers and their infants [3, 4], lack of data has prevented comprehensive inclusion of pregnant and postpartum women in guidelines and remains a critical gap in our efforts to address TB globally. Because few TB studies include pregnant and lactating women, many questions remain, from TB epidemiology in pregnancy to optimal testing and treatment. In this viewpoint, we highlight knowledge gaps for TB prevention in pregnant and postpartum women living with HIV (PWLHIV) and opportunities to address them. Of 10 million new TB diagnoses each year, 3 million occur in women, the majority of whom are of childbearing age [5]. Pregnancy status is not routinely collected and therefore not included in national or WHO global TB estimates, hampering our ability to understand the burden of disease in peripartum women. A recent model estimates there are 150,000 pregnant and 50,000 postpartum women globally with incident TB each year [6]. In studies based on high-burden settings, TB prevalence among pregnant women with HIV ranged from 0.8 to 11% [3]. Many of these studies are small, vary in design and quality of screening; therefore, the true burden of TB in pregnancy is not known. Furthermore, studies suggest pregnant women with TB may be asymptomatic, leading to further diagnostic delays. A major challenge in TB prevention for pregnant women is identifying those at highest risk of progressing to active TB. WHO recommends the TB-symptom screen to rule-out active TB [1]. While early data from India suggested high negative predictive value in postpartum women [7], newer prospective data from multiple sub-Sahara African countries suggests performance may be lower during pregnancy. Once active TB is excluded, WHO recommends providing isoniazid preventive therapy (IPT) for people living with HIV, including pregnant women to prevent TB disease [1]. This recommendation has been called into question since the recently published TB-APPRISE study found IPT initiation during pregnancy among PWLHIV increased the risk of adverse pregnancy outcomes [8]. (see details in “Treatment” section below). While some national programmes opt to first screen for LTBI, the optimal diagnostic test and timing remain unclear. The two most commonly used LTBI tests, tuberculin skin test (TST) and interferon gamma-release assays (IGRA), demonstrate moderate agreement in non-pregnant populations. Conversely, in studies among pregnant women in India and Kenya tested with both IGRA and TST, LTBI prevalence varied considerably (13-49%) depending on the test (Figure 1) [3, 9, 10]. Moreover longitudinal analyses suggest performance of these tests differ throughout pregnancy and the early postpartum period, with the number of positive results lowest during delivery and early postpartum, but increasing by 3 months postpartum [9, 10]. Pregnancy-related decreases in CD4+ T cells that produce interferon-gamma may impact testing results. Ongoing longitudinal cohorts in India and Kenya aim to evaluate whether immune changes of pregnancy impact host response to TB. Among pregnant women in Ethiopia, the new IGRA, fourth generation QuantiFERON®-TB GoldPlus, which measures interferon-gamma production by CD4+ and CD8+ cells, had lower indeterminate results compared to the third generation Quantiferon Gold-in-tube® IGRA test, with most pregnant women (89%) having adequate CD4+ and CD8+ interferon-gamma responses with the fourth generation assay [11]. Regardless of LTBI test used, positive predictive value remains low in both pregnant and non-pregnant populations, and new tests that diagnosis LTBI and better predict progression to active TB are urgen","journal":"Journal of the International AIDS Society","year":2020,"id":84494,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":9,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9608,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2020-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":323079,"name":"Sylvia M. LaCourse","orcid":"0000-0002-9809-5997","position":1,"is_corresponding":false},{"id":326405,"name":"Amita Gupta","orcid":"0000-0001-7036-2718","position":2,"is_corresponding":false},{"id":366696,"name":"Jyoti S. Mathad","orcid":"0000-0001-9487-7775","position":0,"is_corresponding":true}],"reference_count":16,"raw_metadata":null,"created_at":"2026-07-18T21:55:38.506333Z","pmid":"32202066","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}