Starting HIV treatment early improves outcomes for people with tuberculosis

Tuberculosis and HIV often occur together, and how quickly people living with HIV (PLHIV) begin antiretroviral therapy (ART) after starting tuberculosis treatment can matter for health outcomes. To understand what happened in routine care, Jienchi Dorward and colleagues looked back at anonymized records from 62 clinics in KwaZulu-Natal, South Africa. They studied adults aged 16 and over who were not already on ART and who began tuberculosis treatment between October 2016 and November 2019. In total 5,548 PLHIV were included in the analysis. The goal was simple: find out when people started ART after beginning TB treatment, and whether timing was linked to two important outcomes — successful tuberculosis treatment and control of HIV as measured by HIV viral load (VL) six months after starting ART. By focusing on routinely collected clinic data, the team sought to describe real-world delays and the effects those delays had on treatment success in a high-burden setting.

The researchers used multivariable Poisson regression models with robust standard errors to assess associations between ART timing and outcomes while accounting for other factors. They grouped ART initiation after TB treatment into four categories: within 15 days (labelled “early”), 16–56 days, 57–210 days, and no ART by seven months. Among the 5,548 people studied, 29.8% initiated ART within 15 days, 36.2% between 16–56 days, 8.7% between 57–210 days, and 25.3% had not started ART by seven months. Rates of successful tuberculosis treatment were similar for those who started ART at 16–56 days or 57–210 days compared with early initiators, but people who had not started ART within seven months were less likely to have a successful TB outcome (adjusted risk ratio aRR 0.81, 95% CI 0.77–0.86, p<0.001). Looking at HIV control, among the 2,658 people with a known HIV viral load six months after ART initiation, starting ART in the 57–210 day window was associated with a lower likelihood of viral suppression to VL <50 copies/mL (aRR 0.90, 95% CI 0.82–0.99, p<0.03). Overall, fewer than 30% of PLHIV with tuberculosis began ART within 15 days, and early initiation was associated with better TB outcomes and viral suppression.

These findings point to an important message for care systems: many people with HIV who begin tuberculosis treatment do not start ART quickly, and those who delay or never start ART within seven months face worse outcomes. While the analysis describes associations rather than proving cause, the patterns observed suggest that helping people start ART sooner — ideally within the first two weeks after beginning TB treatment — could support both successful tuberculosis treatment and stronger HIV viral suppression. For clinics and programs working in KwaZulu-Natal and similar settings, the study highlights gaps in linkage to ART and the potential value of systems that prioritize early initiation, follow-up, and viral load monitoring. The retrospective, routine-data approach used by Jienchi Dorward’s team reflects day-to-day practice and suggests where interventions and resources might have the biggest impact on health outcomes for people living with both HIV and tuberculosis.