Hierarchical analysis of unsuccessful tuberculosis treatment among people living with HIV in Brazil using nationwide surveillance data

Introduction People with tuberculosis-HIV coinfection face multiple barriers to effective treatment, including social vulnerability, stigma and limited access to healthcare. This study examined factors associated with loss to follow-up and death among individuals with tuberculosis-HIV in Brazil. Methods We conducted a longitudinal study using a nationally linked database from surveillance systems. Poisson regression models with robust variance were applied to identify factors associated with unfavourable outcomes, guided by a theoretical-conceptual hierarchical framework. Results We analysed data from 54 516 individuals. The median time to loss to treatment follow-up was 115 days, with a cumulative proportion of 29.56%. Among the most consistent predictors of loss to follow-up were homelessness (relative risk, RR 1.18; 95% confidence interval, 95% CI 1.16-1.19), tuberculosis retreatment (RR 1.16; 95% CI 1.15-1.17) and drug use (RR 1.15; 95% CI 1.14-1.16), whereas antiretroviral therapy use (RR 0.95; 95% CI 0.95-0.96) showed a negative association. The median time to death during tuberculosis treatment was 27 days, with a cumulative proportion of 27.54%. Higher risk of death was observed among individuals with CD4 counts 3 (RR 1.09; 95% CI 1.08-1.10), those experiencing homelessness (RR 1.08; 95% CI 1.06-1.10) and those with rifampicin resistance (RR 1.11; 95% CI 1.07-1.15). Conclusion Key social, clinical and programmatic factors were associated with loss to follow-up and death during tuberculosis treatment among people with HIV. Addressing these vulnerabilities is essential to improving treatment outcomes and advancing progress towards the 2030 targets.