Gaps in HIV testing among people with presumptive TB in Mozambique: a 3-year retrospective cohort study

HIV testing among people with presumptive tuberculosis (PP-TB) represents a critical entry point for HIV diagnosis and care, especially in high-burden settings like Mozambique. However, systematic testing in this population remains suboptimal. This study assessed gaps in HIV testing across the TB care cascade. We conducted a retrospective cohort study using programmatic data from clients screened for TB through community-based TB interventions in four high TB burden provinces from 2021 to 2023. Data was extracted from the registry books and triangulated with an electronic reporting system used by the national TB program. Descriptive analysis was conducted to identify drop-offs in HIV testing among PP-TB, particularly at three key stages: community screening, facility-based TB evaluation, and among confirmed TB clients. Among the 4,607,257 clients screened, 52% were female, and 62% were aged 15 years and older. Of those screened, 9% (415,654) were identified as PP-TB from whom 85% (351,255) were referred to health facilities, 97% (341,049) successfully completed referrals, and 96% (326,664) were further evaluated for TB. Of those evaluated, 24% (77,584) were diagnosed with TB and 85% were notified and initiated anti-TB treatment. Three levels of gaps in HIV testing were identified: (i) HIV testing omission, no evidence of concurrent HIV testing was documented at community level – community TB lay staff not allowed to perform HIV testing; (ii) HIV testing gap among TB-negative clients, 76% were not tested for HIV, despite their presumptive TB status; (iii) HIV testing deficiency among confirmed TB clients, 14% of these confirmed TB remained with unknown HIV status. Combining these sequential testing failures, the estimated overall gap in HIV testing among PP-TB reached 84%. HIV testing integration into TB care cascade remains limited in Mozambique, with substantial missed opportunities at the community level, among TB-negative clients, and even among confirmed TB clients. Strengthening HIV testing as a systematic component of TB screening, especially in outreach context, could enhance early diagnosis, linkage to care, and co-infection management. These findings call for urgent policy and operational adjustments to close the gaps in HIV testing, particularly within the community-based TB services.