Despite antiretroviral therapy (ART) rollout, most cases of tuberculosis among people with HIV in Adama, Ethiopia, occur before ART initiation.

INTRODUCTION: Although antiretroviral therapy (ART) leads to reduced tuberculosis (TB) incidence in people with HIV (PWH), ART recipients remain at higher risk of TB compared to HIV-seronegative people. With accelerated ART rollout in sub-Saharan Africa, increasing proportions of TB cases among PWH in people receiving long-term ART have been reported. OBJECTIVE: To determine TB notifications among PWH by ART status in a mainly urban uptake area in Ethiopia during an 8-year period in connection to the introduction of the 'test-and-treat' strategy for HIV. METHODS: PWH were identified from registers at health facilities providing ART in Adama and surrounding areas, Ethiopia 2015-2022. Annual TB notifications were compared over time. PWH within TB were categorized by ART status at the time of TB diagnosis (pre-ART TB: TB diagnosed before or ≤6 months after starting ART; ART-associated TB: TB diagnosed >6 months after starting ART). RESULTS: Among a total of 8,926 PWH, 993 had been diagnosed with TB (11.1%); mean age 40.0 years [SD 11.8], 53.5% were men). Throughout the study period, most TB cases had been notified before ART initiation (617/993; 62.1%). ART-associated TB cases constituted a mean of 37.4% (range 23.8%-44.2%) of all TB cases among PWH annually. Median time from ART initiation to TB diagnosis among ART-associated TB was 6.0 years. CONCLUSION: TB notifications among PWH in this area did not decrease 2015-2022, implying persistently high risk of TB among PWH in this setting. Most TB cases occurred in ART-naïve persons, illustrating late HIV diagnosis in this population.

Main findings: Annual numbers of TB notifications among PWH in Central Ethiopia were persistently high 2015­2022 and most cases of TB were diagnosed before or within 6 months after ART initiation, implying late diagnosis of HIV in these individuals.Added knowledge: Epidemiology of HIV-associated TB by ART status has not been studied in Ethiopia since the implementation of the 'test-and-treat' strategy and this study shows that, despite ART rollout, most TB cases among PWH still occur before (or in connection to) ART initiation.Global health impact for policy and action: This study provides new and useful information to the readers of Global Health Action and the Ministry of Health in Ethiopia and other countries affected by TB and HIV for current and future management of HIV-associated TB.