Varied trends of tuberculosis and HIV dual epidemics among different countries during 2000-2020: lessons from an ecological time-trend study of 9 countries

BackgroundWhile Human Immunodeficiency Virus (HIV) infection is a well-established risk factor for tuberculosis (TB), the effect of HIV infection on TB incidence varies across countries given differences in local epidemiological factors and disparate progress with respect to TB elimination goals.MethodsIn this descriptive epidemiological study, we explored the country-specific associations between HIV prevalence and TB incidence in nine countries representing four WHO regions using data between 2000 and 2020. For each of these countries, we (1) described the trends of TB incidence and HIV prevalence, and (2) examined country-level associations between TB incidence and HIV prevalence, using negative binomial regression.ResultsThe trends of TB incidence and HIV prevalence, and the country-level associations, varied across the study countries. Angola, Thailand and Zimbabwe showed parallel TB incidence and HIV prevalence trends while the two trends diverged in Brazil, Liberia and Indonesia during the study period. Additionally, the strength of association between HIV prevalence and TB incidence varied widely between countries, with the risk ratio ranging from 0.42 (95% CI: 0.36, 0.49) in Indonesia to 2.78 (95% CI: 2.57, 3.02) in Thailand.ConclusionsThe association of HIV infection with TB incidence varied across high burden settings, suggesting that HIV is not a ubiquitous driver of TB incidence. Without acknowledging the local drivers of TB epidemics across countries, the END TB Strategy cannot be adapted at the country level. The findings from this analysis can inform the design of future studies to identify country-specific drivers of TB using individual-level data.