HIV Still Raises Risk of Poor TB Treatment Outcomes in Botswana

Tuberculosis (TB) and HIV often occur together, and researchers led by Sanghyuk S. Shin set out to measure whether people living with HIV still faced worse TB treatment outcomes now that antiretroviral therapy is widely available under the Treat All approach. Using data collected in Botswana from 2017–2023 and comparing it with an earlier Pre-Treat All cohort from 2012–2016 (n = 233, HIV prevalence 60.8%), the team focused on whether HIV infection remained a risk factor for unfavorable TB outcomes. The primary finding reported was that HIV infection was associated with approximately three-fold higher odds of unfavorable outcomes compared with HIV-negative participants [OR: 3.12, 95% CI: (1.65, 5.97)]. That result indicates that, even in the era of universal access to antiretroviral therapy via Treat All, people with HIV in these data had significantly greater odds of experiencing an unfavorable result from TB treatment than those without HIV.

To explore whether the effect of HIV changed after Treat All implementation, the researchers combined the 2017–2023 data with the Pre-Treat All cohort and applied statistical models designed to test an interaction between HIV status and treatment era. Specifically, they fit frequentist logistic regression and Bayesian mixed-effects models that included an interaction term allowing the treatment era (Pre- vs. Post-Treat All) to modify the effect of HIV on TB treatment outcome. The estimated change in the HIV effect within the Botswana data alone was uncertain, reported as a relative OR of 0.41 with a 95% CI of (0.11, 1.55), indicating no clear evidence for a reduction in the HIV-associated risk after Treat All in that set. The analysis was then expanded: combining the two Botswana data sets with 12 Pre- and Post-Treat All studies from neighboring Ethiopia, the pooled analysis found that the effect of HIV infection on unfavorable TB outcome increased in the Post-Treat All period [relative OR: 2.39; 95% BCI: (1.36, 3.34)].

Taken together, these findings suggest that HIV remains an important risk factor for unfavorable TB treatment outcomes even in an era of broad antiretroviral access. In the Botswana data, the roughly three-fold higher odds linked to HIV were clear, while formal tests for change after Treat All were inconclusive within Botswana alone. However, when those data were pooled with studies from Ethiopia, the overall picture was of an increased HIV-associated effect on unfavorable TB outcomes in the Post-Treat All period. For clinicians, program planners, and researchers, this points to a need to look beyond ART access alone when seeking to improve TB outcomes for people with HIV — and to study what additional supports or interventions might reduce the persistent excess risk. The results underline the importance of continuing to monitor TB treatment outcomes by HIV status and to investigate why universal ART has not eliminated this disparity.