Tuberculosis Prevention Key to HIV Care in Mozambique

Tuberculosis (TB) remains a leading cause of illness and death among people living with HIV (PLHIV) globally and in Mozambique. However, significant progress has been made in reducing TB incidence through the widespread implementation of tuberculosis preventive therapy (TPT) alongside antiretroviral therapy (ART). Recent data from Mozambique demonstrate the effectiveness of TPT in averting TB disease, even among those who don’t complete the full course of treatment, though certain populations remain at elevated risk.

Global and National TB Burden

In 2024, an estimated 40.8 million people worldwide were living with HIV, with approximately 620,000 recent TB cases and 150,000 TB-related deaths occurring among this population . In Mozambique, there were approximately 2.5 million PLHIV in 2024, with 86% receiving ART. Despite this, the country saw around 29,000 new TB cases and 5,600 TB-related deaths .

Expanding TPT Coverage in Mozambique

Since 2007, Mozambique has significantly expanded access to TPT for PLHIV, achieving 89% coverage by March 2024 . The standard TPT regimen historically consisted of a 6-month course of isoniazid (INH). In May 2023, a shorter 3-month course of isoniazid and rifapentine (3HP) was introduced in the southern region of the country.

Study Findings: TPT Effectiveness

A recent study analyzing data from Mozambique’s national ART data warehouse, MozART, examined the impact of TPT on TB incidence among PLHIV newly initiating ART during 2021-2022. The analysis included 341,844 individuals. Results showed a clear association between TPT completion and reduced TB incidence.

• Individuals who did not start TPT had a 6.9 times higher risk of TB diagnosis compared to those who completed TPT.
• Those with incomplete TPT had a 3.5 times higher risk compared to those who completed TPT.
• The overall incidence of diagnosed TB was 5.0 per 1,000 person-years.

Risk Factors for TB Despite TPT

Even among those who completed TPT, certain groups experienced a higher risk of developing TB:

• Sex: Men had a 1.5 times higher risk.
• Age: Younger (<15 years) and older (>50 years) PLHIV had a 1.5 and 1.7 times higher risk, respectively.
• Region: Individuals in the Southern Region had a 1.6 times higher risk.
• Clinical Status: PLHIV with unsuppressed HIV viral load, low CD4 counts (<200 cells/mm3), and advanced WHO clinical staging (II-IV) were also at increased risk.

Implications for TB Control

The findings underscore the importance of TPT as a critical component of HIV care in Mozambique. While TPT significantly reduces TB incidence, targeted interventions are needed to address the elevated risk among specific populations. Further research is needed to determine the potential benefit of a second course of TPT for those who complete an initial course without experiencing new TB exposures, though recent trials have not shown additional benefit .

Strengths and Limitations

This study benefits from its large sample size, drawing data from 85% of PLHIV on ART in Mozambique. However, as with any study relying on routine data, potential limitations include data quality concerns and the lack of information on certain factors influencing TB risk.

Conclusion

TPT remains a highly effective strategy for preventing TB among PLHIV in Mozambique. Continued efforts to improve TPT initiation and completion rates, coupled with targeted interventions for high-risk groups, are essential to further reduce the burden of TB and save lives. The U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Agency for International Development (USAID) continue to support Mozambique’s National Tuberculosis Control Program (PNCT) and the National Institute of Health (INS) network of TB reference laboratories in these efforts .