An Update on the Clinical Management of HIV and Tuberculosis Co-Infection in Pregnancy: TB Preventative Therapy, Long-Acting ARVs, and Bedaquiline-Based Regimens.

Purpose: This update addresses HIV/TB co-infection management in pregnancy, focusing on new treatment options.

Recent findings: Pregnancy with HIV increases TB risk and worsens treatment outcomes. While long-acting antiretroviral therapies (LA-ART) like cabotegravir/rilpivirine and lenacapavir exist, data on their safety and efficacy in pregnant individuals are limited. Treating both HIV and TB is crucial, but pregnancy's physiological changes complicate drug management. Standard ART and TB preventive therapy (TPT) with isoniazid are recommended after excluding active TB, despite some concerns about adverse outcomes when combined with ARV treatment. For active drug-resistant TB, the new 6-month BPaLM regimen (bedaquiline, pretomanid, linezolid, moxifloxacin) is not recommended in pregnancy due to limited safety data on pretomanid. Instead, a 9-month regimen is preferred, though bedaquiline and pretomanid are likely safe. More research on these new therapies in pregnant populations is needed. While standard ART remains the recommended approach for HIV/TB co-infection in pregnancy, further research is crucial to establish the safety and efficacy of newer LA-ART and bedaquiline-based TB regimens in this high-risk population. Concerns around the safety of TPT in pregnancy remain unanswered and further prospective research is urgently needed.