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

Abstract

Background

While 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.

Methods

In 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.

Results

The 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.

Conclusions

The 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.

Keywords:

• HIV prevalence
• tuberculosis incidence
• trends
• epidemiology
• coinfection

Acknowledgement

We thank Dr. Wen Ye for her helpful review of the statistical analysis plan of the study and for her useful suggestions for data presentation.

Author contribution

CP and MH contributed to the study design, data collection, data analysis, interpretation of results, and drafting of the manuscript. ZY contributed to the study design, directed the conduction of the study and the development of the manuscript. All the authors contributed to the revision of the manuscript and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Publicly available data from WHO and UNAIDS was used for this study and can be freely accessed using the following links.

https://www.who.int/teams/global-tuberculosis-programme/data

https://www.unaids.org/en/resources/documents/2021/HIV_estimates_with_uncertainty_bounds_1990-present