Prevalence and Mortality of Tuberculosis at HIV Diagnosis in Spain, 2004–2024

ABSTRACT Background Tuberculosis coinfection at HIV diagnosis drives early morbidity and mortality. We estimated tuberculosis prevalence at HIV diagnosis over two decades in a Spanish cohort and quantified its determinants and outcomes. Methods We analyzed 19,058 ART-naive adults in CoRIS (2004–2024). Prevalent tuberculosis was defined as disease diagnosed from the date of HIV diagnosis up to six months after ART initiation. Predictors were identified using multivariable logistic regression; mortality was assessed using Kaplan–Meier and competing-risk methods Results Prevalence was 2.2% (426/19,058), declining from 4.9% (2004–2008) to 0.8% (2019–2024), an 83% reduction (p<0.001). Despite this decline, affected individuals presented with increasingly advanced immunosuppression. Strong independent predictors included geographical origin (Sub-Saharan Africa OR=4.3; Latin America OR=1.6), positive TB screening (OR=7.5), viral load >1,000,000 copies/mL (OR=2.9), injection drug use (OR=2.9), and age ≥50 years (OR=6.7), whereas university education (OR=0.3) and CD4 ≥500 cells/µL (OR=0.5) were protective. Model discrimination was good (AUC=0.84). Mortality was higher with tuberculosis (15.0% vs 4.1%; RR=3.6; 5-year survival 87% vs 97%). Conclusions Although prevalence has declined substantially, tuberculosis at HIV diagnosis remains concentrated in high-risk groups and confers excess mortality. Targeted screening and prompt ART remain essential, particularly for migrants from high-burden regions.