Global Stakeholders Warm to Long-Acting TB Injectables, but Experience Shapes Acceptance
Long-acting injectables for tuberculosis treatment and prevention drew broad interest across a multi-regional stakeholder sample, yet the enthusiasm was not uniform. In a mixed-methods study spanning survey responses and focus group discussions, 83% of 310 participants favored long-acting injectable approaches over standard oral therapy. The appeal was strongest when injectable regimens were designed to reduce the burden of daily pills, clinic visits, and the friction that often erodes adherence in TB care.
The practical attraction is easy to see. Tuberculosis treatment has long relied on prolonged oral regimens that demand sustained behavior change from patients, families, and health systems. A formulation that can compress part of that burden into scheduled injections could improve convenience, reduce missed doses, and make treatment more durable in real-world settings where medication fatigue is common.
Preference Rose as Oral Burden Fell
Participants did not simply prefer any injectable format; regimen design clearly mattered. Compared with six months of daily oral treatment, 69% preferred a three-month regimen that started with one month of daily oral treatment followed by four injections per monthly visit for two months. Preference rose to 80% when the same schedule used two injections per visit instead of four. For prevention, 79% preferred a single injection over one month of oral treatment.
Those choices suggest that acceptability tracks with simplicity, fewer visits, and a lower perceived burden of swallowing pills over time. In TB care, every extra pill day can compound the risk of missed doses, stigma, side effects, and treatment fatigue. A depot-like approach may therefore feel less like a novelty than a practical workaround for one of the oldest problems in infectious disease management: keeping people on treatment long enough to matter.
The pattern also points to an important implementation reality. Stakeholders appeared to favor regimens that balanced convenience with enough flexibility to preserve clinical oversight. A three-month model that still began with oral therapy may feel more familiar and reassuring than a fully injectable pathway from the outset.
Lived Tuberculosis Experience Lowered Enthusiasm
Interest dropped among participants with lived TB experience. Survey B, which included community members and persons affected by TB, showed variation tied to prior experience, and focus group discussions suggested that earlier negative encounters with injectables may have contributed to hesitancy. The study design does not reduce that finding to a single cause, but the qualitative material points to an obvious bedside reality: prior pain, side effects, and coercive-feeling care can shape how patients judge a new formulation before they ever receive it.
One sentence from the data lands with particular force: past experience changed the shape of preference.
For TB programs, that matters because the people most likely to have concrete views about treatment are often those who have already spent months navigating it. If injectable TB products advance, they will enter a patient population that may already associate injections with discomfort, repeated clinic encounters, or a lack of control over treatment decisions. Product developers and implementers will need to account for those memories rather than assuming that convenience alone will overcome them.
Side Effects, Agency, and Trust Will Decide Real-World Use
The focus group findings make clear that acceptability is inseparable from concerns about injectables themselves. Participants wanted reassurance about side effects and appeared sensitive to the possibility that longer-acting delivery could feel restrictive if patients are not given meaningful choice. That tension is central to TB care, where adherence strategies have often been built around compliance rather than partnership.
A long-acting injectable can reduce daily pill burden, but it also shifts the treatment experience. Once a dose is administered, it cannot be easily taken back if side effects emerge. For some patients, that pharmacologic durability is the point; for others, it may deepen anxiety about losing control over a regimen that already carries stigma and uncertainty. Implementation strategies will therefore need to address how patients are counseled, how adverse effects are explained, and how choice is preserved between oral and injectable options.
The study’s mixed-methods structure strengthens that message. Survey data captured broad preference patterns, while focus group discussions provided the reasons underneath them. Together, they show not just whether stakeholders like the idea of long-acting injectables, but why some do and why others hesitate.
Product Design Will Need to Match Program Reality
Stakeholder preferences were not abstract. They were tied to the number of injections per visit, the duration of oral lead-in therapy, and whether the product was framed for treatment or prevention. Preference for the two-injection monthly visit over the four-injection version suggests a ceiling on procedural burden even when the overall regimen is shorter than six months of oral therapy.
That has direct implications for product development. A successful TB injectable will not only need pharmacologic durability; it will also need a dosing format that clinics can deliver without creating new bottlenecks. More injections per visit may be acceptable to some participants, but the preference data show that fewer injections is better. Manufacturing strategy, formulation concentration, and delivery devices will all influence whether a future product feels workable at scale.
The study was conducted across World Health Organization regions and included 310 participants, split between two survey groups: 102 in Survey A and 208 in Survey B. That breadth gives the findings a useful cross-stakeholder reach, though the work remains a preprint and has not undergone peer review. Its ethical approvals were obtained from the WCG Institutional Review Board and the London School of Hygiene & Tropical Medicine Research Ethics Committee.
Acceptance Is High, but Choice May Be the Real Endpoint
The most actionable signal in the study is not simply that long-acting TB injectables were popular. It is that acceptance depended on preserving patient agency, minimizing procedural burden, and confronting prior negative experiences with injectables head-on. Those features will likely determine whether a future product is welcomed as a relief from daily therapy or rejected as another form of medical inconvenience.
The study leaves one crucial practical challenge unresolved: how to design injectable TB programs that are both acceptable to communities and robust enough for routine use across settings with very different resources, staffing patterns, and patient expectations.