Recurrent Tuberculosis Among People Living with HIV in a High-Burden Setting of Andhra Pradesh, India, 2017–2023: Findings from a Cohort Study

Abstract Introduction Tuberculosis (TB) remains the leading cause of mortality among people living with HIV (PLWH). Recurrent TB after successful treatment completion is associated with poor outcomes. Limited data exist on long-term post-TB treatment outcomes among PLWH in India. Methods We conducted a retrospective cohort study of 3,357 PLWH aged ≥15 years who completed antituberculosis treatment (ATT) between 2017–2021 across 14 ART centers in Andhra Pradesh, India. Participants were followed for two years post-treatment for the primary outcomes: recurrent TB and all-cause mortality. Incidence rates (IR) per 100 person-years were calculated. Multivariable Fine–Gray competing-risk and Cox proportional hazards models estimated adjusted subdistribution hazard ratios (aSHRs) and adjusted hazard ratios (aHRs) for predictors of recurrent TB and mortality, respectively. Results Over 5,333 PY of observation, 270 (8.0%) participants developed recurrent TB (Incidence Rate: 5.1 per 100 person-years) and 510 died (IR: 9.1 per 100 person-years). The median time to recurrent TB was 7 months (IQR: 3–14), and the median time to death was 8 months (IQR: 5–12) following completion of TB treatment. Nearly two-thirds of recurrent TB cases occurred within 12 months of ATT completion. Predictors of recurrent TB included male sex (aSHR, 1.60), delayed TPT initiation (aSHR, 1.63), no TPT (aSHR, 1.45), no dolutegravir exposure (aSHR, 2.62), and viral non-suppression (aSHR, 3.36). Mortality was associated with viral non-suppression (aHR, 3.71), no documented viral load (aHR, 8.93), lack of dolutegravir exposure (aHR, 2.77), and no TPT (aHR, 2.35). Conclusion Recurrent TB and mortality remained high after completion of antituberculosis treatment, particularly during the first year. Strengthened post-treatment follow-up, sustained HIV care, routine viral load monitoring, and timely TB preventive therapy during this high-risk period may help reduce adverse outcomes.