High Incidence of Tuberculosis in Young Children Living With HIV in the Western Cape, South Africa

Background: Data on tuberculosis (TB) incidence and risk factors among children living with HIV (CLHIV) in the universal ART era are limited. Methods: We analyzed routinely collected data on TB diagnoses for CLHIV age <= 5 years, born 2018-2022, in the Westen Cape, South Africa. We examined factors associated with TB diagnosis, with death and loss to follow-up as competing events. Results: Among 2219 CLHIV, 30% were diagnosed with HIV at birth. Median follow-up from birth was 38 months [interquartile range (IQR: 24-50); 90% started antiretroviral therapy (ART). TB was diagnosed in 28% of CLHIV (n = 626/2219); 62% were first diagnosed before/within 3 months of ART start ("TB before ART") and 38% >3 months after ART start ("TB after ART"). Of those with "TB before ART" (n = 390), median age at HIV diagnosis was 13 months (IQR: 6-22); median time between HIV and TB diagnoses was 5 days (IQR: 0-31). "TB before ART" was associated with older age at HIV diagnosis and advanced/severe immunodeficiency. Of those with "TB after ART" (n = 258), median age at HIV diagnosis was 2 months (IQR: 0-8) and median time from ART start to TB diagnosis was 12 months (IQR: 7-21). "TB after ART" was associated with increased viral load and advanced/severe immunosuppression (time updated). Overall, 5% (n = 112/2219) of CLHIV died, 36% of whom were diagnosed with TB (median time from TB diagnosis to death: 58 days; IQR: 17-191). Conclusions: Young CLHIV in this setting have high TB-associated morbidity and mortality. Efforts to improve early HIV and TB diagnosis, viral suppression, and TB preventive therapy are needed.