Incident tuberculosis in people with HIV across Europe from 2012 to 2022: incidence rates, risk factors, and regional differences in a multicentre cohort study

BACKGROUND: Tuberculosis (TB) remains the leading cause of death among people with HIV. The aim of this study was to describe the incidence of TB, to explore risk factors and to calculate their population attributable fractions (PAFs) in people with HIV across Europe, stratified by region.

METHODS: This was a longitudinal study of people with HIV aged ≥18 years with follow-up from either 1 January 2012 or cohort enrolment until date of a TB diagnosis, date of last visit, death or 31 December 2022. Factors associated with TB, in particular antiretroviral therapy status and smoking, were analysed using multivariable Poisson regression.

RESULTS: A total of 38 837 participants with HIV had a median (interquartile range) follow-up of 7.7 (4.3-10.4) years. Overall, 306 TB cases were diagnosed during 275 811 person-years of follow-up (PYFU) (incidence rate 1.03 (95% CI 0.91-1.11) per 1000 PYFU). 3.3% (81/2428) of participants had incident TB in Eastern Europe (incidence rate 6.13 (95% CI 4.93-7.62) per 1000 PYFU). Overall, the incidence rate decreased from 2.03 (95% CI 1.53-2.68) per 1000 PYFU in 2012 to 0.44 (95% CI 0.20-0.97) per 1000 PYFU in 2022. Modifiable risk factors were smoking (adjusted incidence rate ratio (aIRR) 2.94, 95% CI 1.62-5.34) and not receiving antiretroviral therapy (versus on; aIRR 3.29, 95% CI 2.36-4.58). A history of TB pre-baseline increased the risk of recurrence (aIRR 7.77, 95% CI 4.09-14.74). The PAF for not receiving antiretroviral therapy was 34.6% in non-Eastern Europe and 31.2% in Eastern Europe.

CONCLUSIONS: TB incidence has been decreasing among people with HIV, but remains more frequent in Eastern Europe. Improvement of antiretroviral therapy coverage and adherence and a focus on non-communicable disease risk factors such as smoking could reduce the incidence of TB.