Low Cholesterol associated with TB in people living with HIV in an Asia-Pacific cohort

Background: Tuberculosis (TB) remains the leading cause of illness and death among people living with HIV (PLHIV), particularly in high-burden areas. This study examined associations between TB and routine clinical markers: serum cholesterol, platelet count, and CD4 cell count. Setting: The analysis included data from the TREAT Asia HIV Observational Database (TAHOD), a multicenter cohort of adult PLHIV receiving care across the Asia-Pacific region. Methods: We conducted a cross-sectional matched case–control study of prospective and retrospective TB cases, comparing clinical and laboratory data within ±3 months of TB diagnosis. Conditional logistic regression assessed associations between TB and covariates. Results: The analysis included 4,244 PLHIV from 20 sites: 1,427 TB cases and 2,817 matched controls. TB cases were predominantly male (75.3%) and 45.7% aged 31–40. Multivariable analysis showed greater odds of TB diagnosis among males, those with low BMI, prior AIDS diagnosis, high HIV viral load, low CD4+ counts, or low total cholesterol. CD4+ counts <200 cells/μL had higher TB odds (adjusted OR [aOR] 12.90, 95% CI 8.84–18.82) compared to CD4+ >500 cells/μL. Cholesterol <3.9 mmol/L had higher TB odds (aOR 3.11, 95% CI 1.94–4.98) compared to cholesterol >5.5 mmol/L. Conclusion: In this Asia-Pacific cohort of adults living with HIV, low CD4+ cell count and low total serum cholesterol were associated with increased TB odds. Cholesterol may represent a low-cost adjunct marker to support TB risk stratification in PLHIV in endemic settings, but requires validation and evaluation of feasibility and cost-effectiveness.