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Learn more: PMC Disclaimer | PMC Copyright Notice PLOS Glob Public Health . 2026 Apr 10;6(4):e0005970. doi: 10.1371/journal.pgph.0005970 Search in PMC Search in PubMed View in NLM Catalog Add to search Time to incidence of tuberculosis and its predictors among adult HIV/AIDS patients who initiated ART by the Universal Test and Treat approach in Silte Zone, Ethiopia, 2023 Abdulbasit Sherfa Abdulbasit Sherfa 1 Department of Public Health, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing Find articles by Abdulbasit Sherfa 1, * , Kemal Lemnuro Kemal Lemnuro 2 Department of Medicine, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia Data curation, Funding acquisition, Investigation, Project administration, Resources, Software, Supervision, Validation, Visualization Find articles by Kemal Lemnuro 2 , Mohammed Muze Mohammed Muze 3 Department of Nursing, College of Medicine and Health Sciences, Werabe University, Werabe, Central Ethiopia Region, Ethiopia Data curation, Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Visualization Find articles by Mohammed Muze 3 , Abdulkerim Badegba Isa Abdulkerim Badegba Isa 1 Department of Public Health, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia Formal analysis, Investigation, Methodology, Software, Supervision, Validation, Visualization Find articles by Abdulkerim Badegba Isa 1 , Abdulmejid Mustefa Shemsu Abdulmejid Mustefa Shemsu 1 Department of Public Health, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization Find articles by Abdulmejid Mustefa Shemsu 1 , Musa Jemal Musa Jemal 1 Department of Public Health, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Find articles by Musa Jemal 1 , Abas Ali Hassen Abas Ali Hassen 4 Department of Anesthesia, College of Medicine and Health Sciences, Werabe University, Werabe, Central Ethiopia Region, Ethiopia Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Find articles by Abas Ali Hassen 4 , Dawit Tafesse Darsema Dawit Tafesse Darsema 4 Department of Anesthesia, College of Medicine and Health Sciences, Werabe University, Werabe, Central Ethiopia Region, Ethiopia Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Find articles by Dawit Tafesse Darsema 4 , Belete Birhan Belete Birhan 5 Department of Psychiatry, College of Medicine and Health Sciences, Wolayita Sodo University, Wolayita Sodo, Ethiopia Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Find articles by Belete Birhan 5 , Wolyu Korma Wolyu Korma 1 Department of Public Health, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia Data curation, Funding acquisition, Investigation, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – review & editing Find articles by Wolyu Korma 1 Editor: Damen Haile Mariam 6 Author information Article notes Copyright and License information 1 Department of Public Health, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia 2 Department of Medicine, College of Medicine and Health Sciences, Werabe University, Werabe, Ethiopia 3 Department of Nursing, College of Medicine and Health Sciences, Werabe University, Werabe, Central Ethiopia Region, Ethiopia 4 Department of Anesthesia, College of Medicine and Health Sciences, Werabe University, Werabe, Central Ethiopia Region, Ethiopia 5 Department of Psychiatry, College of Medicine and Health Sciences, Wolayita Sodo University, Wolayita Sodo, Ethiopia 6 School of Public Health, College of Health Science, Addis Ababa University, ETHIOPIA The authors have declared that no competing interests exist. ✉ * E-mail: [email protected] Roles Abdulbasit Sherfa : Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing Kemal Lemnuro : Data curation, Funding acquisition, Investigation, Project administration, Resources, Software, Supervision, Validation, Visualization Mohammed Muze : Data curation, Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Visualization Abdulkerim Badegba Isa : Formal analysis, Investigation, Methodology, Software, Supervision, Validation, Visualization Abdulmejid Mustefa Shemsu : Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization Musa Jemal : Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Abas Ali Hassen : Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Dawit Tafesse Darsema : Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Belete Birhan : Data curation, Investigation, Project administration, Software, Supervision, Validation, Visualization, Writing – review & editing Wolyu Korma : Data curation, Funding acquisition, Investigation, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – review & editing Damen Haile Mariam : Editor Received 2025 Oct 5; Accepted 2026 Mar 11; Collection date 2026. © 2026 Sherfa et al This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PMCID: PMC13068246 PMID: 41961813 Abstract Tuberculosis (TB) remains a leading cause of morbidity and mortality among people living with HIV. TB/HIV co-infection continues to challenge global TB control efforts. This study aimed to estimate the incidence and identify predictors of TB among adult HIV-infected patients who initiated antiretroviral therapy (ART) under the Universal Test and Treat (UTT) approach in Silte Zone, Ethiopia. An institution-based retrospective cohort study was conducted among 404 adult HIV patients enrolled in ART. Participants were selected using simple random sampling. Data were extracted using a structured checklist via Kobo Toolbox and analyzed using STATA version 14. Cox proportional hazards regression models were applied to identify predictors of TB. Statistical significance was declared at p < 0.05 with 95% confidence intervals. The proportional hazards assumption was assessed using statistical tests and graphical methods. The median age was 36 years, with near-equal sex distribution. Most participants initiated ART at WHO clinical stages I–II. Approximately 70% had good adherence, and over 80% disclosed their HIV status. The predominant regimen was TDF-3TC-EFV. The overall TB incidence density rate was 5.33 per 1000 person-months (95% CI: 3.68–7.77). The incidence of new TB was 4.0 per 1000 person-months (95% CI: 2.60–6.13), while reinfection was 1.3 per 1000 person-months (95% CI: 0.63–2.70). TB-free survival probabilities at 6, 12, and 18 months were 0.99, 0.93, and 0.90, respectively. Male sex (AHR: 5.05), non-disclosure of HIV status (AHR: 6.29), underweight status (AHR: 3.07), CD4 count <200 cells/μL (AHR: 5.63), and poor ART adherence (AHR: 7.05) were significant predictors. Although TB incidence declined under the UTT approach, risk remained elevated during the first year of ART. Targeted interventions promoting early diagnosis, adherence support, nutritional care, and safe disclosure are essential to reduce TB burden among people living with HIV. Introduction Tuberculosis (TB) is the leading opportunistic infection and a major cause of death among people living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) [ 1 ]. Individuals with HIV are 20–30 times more likely to develop active TB, which accounts for about one-third of HIV-related deaths [ 2 ]. In 2022, 8% of all TB cases occurred in people with HIV [ 3 ]. TB hastens the progression of HIV, while HIV increases TB severity, raises the likelihood of recurrence and [ 4 – 6 ]; and also increases the chance of acquiring resistant TB [ 7 ]. Consequently, early diagnosis and prompt initiation of HIV treatment through the Universal Test and Treat (UTT) strategy are critical components of effective global TB control efforts [ 8 ]. Individuals with recurrent TB have a higher risk of death than those with first-time TB episodes, partly due to advanced immunosuppression and complications from repeated lung damage [ 9 ]. Recurrent TB also carries an increased likelihood of multidrug-resistant TB (MDR-TB), especially in cases where initial treatment was incomplete or poorly adhered to [ 10 ]. Furthermore, each episode can result in cumulative pulmonary impairment, reduced lung capacity, and diminished quality of life (QoL) [ 11 ]. At the public health level, recurrent TB sustains community transmission and complicates TB elimination efforts [ 12 ]. Among HIV-positive patients, recurrent TB can accelerate HIV disease progression through chronic immune activation and systemic inflammation, even in those receiving ART [ 13 ]. Tuberculosis (TB) remains a critical public health challenge among individuals living with HIV, significantly impeding the attainment of global TB prevention targets [ 14 , 15 ]. AIDS-related illnesses, notably TB and bacterial infections, are most common cause of hospital admission among adults with HIV across diverse geographic regions and are the leading cause of in-hospital mortality [ 16 , 17 ]. Evidence revealed that low adherence to antiretroviral treatment (ART) are correlated with significantly higher rates of AIDS-defining Opportunistic Infections (OIs), thereby compromising treatment effectiveness and imposing substantial economic burdens on health systems [ 18 ]. Moreover, post-mortem studies from Sub-Saharan Africa reveal a substantial prevalence of undiagnosed disseminated TB among HIV/AIDS patients, suggesting that TB-related mortality in this population is likely considerably underestimated [ 19 , 20 ]. In Ethiopia, pooled estimates from multiple studies indicate that the prevalence of TB/HIV co-infection is approximately 25.59% [ 21 ], markedly higher than the national average of 9% [ 22 ]. TB is the most frequently detected OI in both pre-ART and on-ART patients [ 23 ], and it is also the leading recurrent OIs, comprising 17.5% of cases among HIV patients [ 24 ]. Evidence suggests that several factors contribute to new or recurrent TB disease among people living with HIV/AIDS (PLHIV/AIDS), including Cell Differentiation 4 (CD4)lymphocyte count [ 25 – 28 ], Body Mass Index (BMI) [ 27 , 29 ], behavioral factors such as smoking and alcohol use, as well as sputum smear test results [ 30 – 32 ], and poor adherence to ART and advanced HIV disease [ 33 , 34 ]. These variables have been commonly identified as predictors of new and recurrent TB. infection. To improve clinical outcomes, increase access to antiretroviral (ARV) drugs for treating and preventing HIV, and ultimately achieve the “goal of ending the HIV epidemic as a major public health threat by 2030,” the World Health Organization (WHO) released a recommendation in 2016 urging the provision of UTT services for people living with HIV (PLHIV), irrespective of their CD4 cell count or WHO clinical stage [ 35 ]. The UTT initiative, the immediate or rapid initiation of ART within 1 week of HIV diagnosis, was introduced in Ethiopia in August 2016 [ 36 ]. Millions of people still get TB every year despite WHO efforts to reduce the incidence of TB diseases through the implementation of the Directly Observed Treatment strategy. The problem is that OIs linked to HIV can cause recurrence in patients who have already received treatment and been cured [ 24 , 37 , 38 ]. Tuberculosis is the leading cause of morbidity and mortality among people living with HIV (PLHIV) [ 39 , 40 ]. Since the beginning of the UTT program, PLHIV have been treated with a variety of intervention modalities to reduce the risk of TB/HIV co-infection as well as TB-related morbidity and mortality. The burden and factors that contribute to tuberculosis occurrence and recurrence have an impact on the health system and the population, making it difficult to meet the 2030 Sustainable Development Goals (SDGs). Evidence on the magnitude of TB in Ethiopia among PLHIV following UTT treatment is scarce. The purpose of this study is to assess the incidence and risk factors for tuberculosis among adult HIV patients in the Silte Zone who began receiving ART following the implementation of the UTT program. Methods Ethics statement Ethical clearance for this study was obtained from the Institutional Ethical Review Board (IRB) of Werabe University prior to data collection (Reference: WRU/CMHS/09/2022; Protocol: GOV/WRU/CMHS/PH/2022–1415; dated May 2, 2022). The clearance letter was subsequently submitted to the Zonal Health Bureau, Silte Zone Health Facilities, and other relevant authorities for official permission to conduct the research. Formal approval was granted by the respective health facilities. To ensure compliance with ethical standards, confidentiality and anonymity of patient information were strictly maintained throughout the study. Data were extracted from medical records without any direct face to face patient contact, and no personally identifiable information was disclosed or recorded. For patients, the study’s purpose and data protection measures were explained in detail, and verbal informed consent was formally obtained via phone calls, in accordance with the Declaration of Helsinki. Furthermore, all data collectors were trained on the importance of maintaining privacy and confidentiality. The study adhered to the principles outlined in the Declaration of Helsinki and relevant national ethical guidelines governing research involving human subjects. Study setting, design and participants The study was conducted in the Silte Zone, Central Ethiopian Region, located at 7.8322° N latitude and 38.2687° E longitude, with an elevation of 1,967 meters above sea level. The zone comprises one government comprehensive specialty hospital, three primary hospitals, and 35 health centers, 14 of which provide ART services. An institution-based retrospective follow-up study was carried out in these public health facilities from January 2017 to December 30, 2022. The source population included all HIV/AIDS patients who initiated ART under the UTT approach, while the study population consisted of randomly selected adult patients from this group. Sample size determination and sampling procedure The sample size for tuberculosis recurrence was calculated using a maximum incidence rate of 50%, due to the absence of prior studies conducted in the country or in regions with comparable socio-demographic and economic conditions. n = ( Z α / 2 ) 2 p ( 1 − p ) / d 2 = ( 1 . 96 ) 2 ( . 5 ) ( . 5 ) / ( . 05 ) 2 n = 384 n = final sample size, Z = coefficient of reliability, p = incidence of reoccurrence, d = margin of error Then, after considering non response rate 15%, final sample size should be n = 442. Sampling procedure Data collectors used a list of PLHIV patients receiving ART at public health facilities in the Silte Zone to locate the records of study participants who satisfied the inclusion criteria in the patients’ follow-up registration book. HIV patients who started ART during the universal test and treat approach between January 1, 2017, and December 30, 2022 were included in the study population using the ART log book as supporting documentation. Then, we created a sample frame utilizing this data. Patients who satisfied the inclusion criteria were coded and compiled, and a using simple random sampling with computer-generated random number approach was used to select the study subject. And in the way shown in Fig A in S1 Text , the final sample was drawn using a proportional allocation. Study variables Dependent variables. Tuberculosis disease Independent variable. Socio demographic (age, sex, residence, catchment area, occupation, educational status, marital status, religion); Clinical (Functional status, BMI, CD4 count, WHO clinical stage, viral load, hemoglobin level, OIs, Non AIDS related chronic disease); Behavioral (ART and anti TB adherence, prophylaxis adherence, substance use); Medication (ART regimen, Cotrimoxazole Preventive Therapy (CPT), Isoniazid Preventive Therapy (IPT), Fluconazole Preventive Therapy (FPT)) Operational definition Censored : During the follow-up period and at the end of the study, there were no reported cases of tuberculosis infection. Event : diagnosis of TB after initiation of HAART Time to incidence of TB: this is the time from initiation of HAART up to the diagnosis of tuberculosis disease. New TB infection: A TB diagnosis occurring during follow‑up in a patient with no prior history of active TB disease at baseline. Re‑infection of Tuberculosis: A new episode of TB occurring after completion of previous TB treatment (relapse or reinfection), consistent with national TB guidelines defining relapse categories. Recurrence : Recurrent tuberculosis (TB) refers to a new episode of TB diagnosed after a patient has been declared cured or has completed treatment, with cure defined by WHO as negative sputum smear and culture results in the final month of therapy and on at least one previous occasion [ 41 ]. Loss to follow-up: defined as an ART patient who has not attended any clinic visit in the past three months and is not recorded as deceased or transferred to another HIV care facility. Transfer out: This occurs when a person living with HIV (PLHIV) receiving care at the selected hospitals transfers their treatment to another health facility. ART Adherence Good Adherence (if adherence greater than 95%, meaning the patient missed fewer than 2 doses out of 30 or fewer than 3 doses out of 60, as documented by ART health personnel); Fair Adherence (if adherence between 85% and 94%, corresponding to 3–5 missed doses out of 30 or 3–9 missed doses out of 60, as recorded by ART staff); Poor Adherence (if adherence below 85%, meaning more than 6 missed doses out of 30 or more than 9 missed doses out of 60, according to ART health personnel documentation) [ 42 ]. Functional status Working: Able to perform usual work in or out of the home; Ambulatory: Able to perform daily activities but not work; Bedridden: Not able to perform daily activities, in line with WHO functional status categories. [ 42 ]. Substance use: Self‑reported current or historical use of substances including alcohol, khat, and cigarettes, as recorded in medical records [ 43 ]. Catchment area: The geographic area or population served by the hospital where the patient receives care. Anemia: Defined based on WHO criteria as hemoglobin < 12 g/dL for females and < 13 g/dL for males, as recorded on the medical records [ 44 ]. Isoniazid Preventive Therapy (IPT): Use of daily isoniazid to prevent active TB disease among people living with HIV who do not have active TB symptoms [ 22 ]. Cotrimoxazole Preventive Therapy (CPT): Use of cotrimoxazole to prevent opportunistic infections among people living with HIV [ 22 ]. Fluconazole Preventive Therapy (FPT): Use of fluconazole to prevent fungal opportunistic infections in HIV‑positive patients at risk [ 22 ]. Data collection procedure and instrument Patient medical record numbers were obtained from the chronic care follow-up clinic, and corresponding folders were retrieved from the card room. Data on ART cohorts were extracted using a structured checklist developed from previous literature and HIV care/ART intake and follow-up forms. The extraction tools, prepared in English, were adapted to capture all variables necessary for the study objectives. Data were collected via the Kobo Toolbox platform by healthcare providers from public health facilities in the Silte Zone, under continuous supervision by principal investigators and supervisors, between January 10 and February 10 2023. Data analysis The completeness and consistency of the data were carefully checked before exporting to STATA version 14 for analysis. Descriptive and summary statistics were conducted as appropriate, and results were organized and presented using tables and graphs. The normality of continuous variables was assessed and summarized using either the mean and standard deviation (SD) or the median and interquartile range (IQR), depending on the distribution. Additional coding, categorization, and re-categorization were performed through data transformation for continuous variables and selected categorical variables, respectively. Survival analysis was conducted since the time from ART initiation to tuberculosis (TB) outcome varied across participants. Patients were censored if they died, transferred out, lost from follow up or did not develop TB disease by the end of follow-up. Kaplan–Meier curves and log-rank tests were used to compare survival across covariate categories, while life tables estimated survival and hazard functions. Bi-variable Cox regression identified candidate predictors (p < 0.25) for inclusion in multivariable Cox proportional hazards models. Statistical significance in the multivariable model was set at p < 0.05, with associations expressed as adjusted hazard ratios (AHR) and 95% confidence intervals (CI). Model selection relied on log-likelihood and Akaike Information Criterion (AIC), and model adequacy was evaluated using Cox-Snell residuals. The proportional hazards assumption was assessed through graphical diagnostics, goodness-of-fit tests, and time-dependent covariates. Results were presented in tables, figures, and graphical summaries. Results Baseline characteristics Socio-demographic characteristic. For this study, 442 HIV-positive adult medical records from all Silte Zone ART clinics were examined, with 404 (91.4%) of them being eligible. At the start of ART, the patients median and interquartile range ages were 36 and 15 years, respectively. The sex ratio was about equal. Approximately 60% of the client was an urban resident, and 80% of the client lived in a facility catchment area. In terms of education, roughly one-quarter are either secondary or postsecondary, while the remainder are either primary or have no formal schooling ( Table 1 ). Table 1. Socio-demographic characteristics of patients enrolled on HAART with the UTT approach, 2023. Variables Category Frequency Percentage Age at initiation ART <25 45 11.14 25-34 118 29.21 35-44 122 30.20 ≥45 119 29.46 Sex Male 206 50.99 Female 198 49.01 Marital status Never married 60 14.85 Married 280 69.31 Separated or Divorced 24 5.94 Widowed 40 9.9 Educational status No formal education 161 39.85 Primary 147 36.39 Secondary 46 11.39 Tertiary 50 12.38 Occupation Governmental employee 44 10.89 Non-Governmental employee 22 5.45 Farmer 65 16.09 Merchant 129 31.93 Daily laborer 32 7.92 House wife 96 23.76 Student 16 3.96 Residence Urban 240 40.59 Rural 164 59.41 Catchment area Reside in facilities catchment area 322 79.7 Not reside in facilities catchment area 82 20.3 Religion Muslim 312 77.23 Orthodox 58 14.36 Protestant 32 7.94 Open in a new tab Behavioral characteristic. Of the total number of patients whose medical records were reviewed, 70.3% exhibited good adherence to ART, and more than 80% declared their HIV status. In terms of substance use, around 30% of patients use one or more of khat, alcohol, or cigarettes ( Table 2 ). Table 2. Behavioral, Clinical, Immunological, and Medication-Related Characteristics of Patients Enrolled in HAART under the UTT Approach, 2023. Variables Categories Frequency Percentage Adherence Good 248 70.30 Fair 50 12.38 Poor 70 17.33 Disclosure status Yes 338 83.66 No 66 16.34 Substance use No 275 68.07 Yes 129 31.93 Khat No 248 70.30 Yes 120 29.70 Alcohol use No 376 93.07 Yes 28 6.93 Tobacco use No 373 92.33 Yes 31 7.67 Baseline WHO clinical stag Non advanced (Stage 1 &2) 286 70.79 Advanced (Stage 3 & 4) 118 29.21 Anemia No 85 21.04 Yes 319 78.96 CD4 count at initiation of ART <200 cells/μl 87 21.53 200-499 cells/μl 243 60.14 ≥ 500 cells/μl 74 18.31 Hemoglobin level Normal 319 78.96 Below normal 85 21.04 Functional status at initiation of ART Working 303 75.00 Ambulatory 74 18.32 Bedridden 27 6.68 BMI >30 47 11.63 18.5-29.9 247 61.14 <18.5 110 27.23 OIs at initiation of ART No 243 57.92 Yes 170 42.08 Other non AIDS related comorbidities No 240 59.41 Yes 164 40.59 ART regimen 1e, TDF-3TC-EFV 397 93.81 1f, TDF-3TC-NVP 25 6.19 IPT Yes 282 69.8 No 122 30.2 CPT Yes 217 53.71 No 187 46.29 FPT Yes 127 31.44 No 299 68.56 Open in a new tab Clinical and immunological characteristics. When they enrolled in ART, more than 70% of patients were in WHO categories I and II, and more than a quarter were in advanced clinical stages (Stage III and IV). The distribution of CD4 counts among research participants has been shifted to the right, with the median and interquartile range for the patients being 324 and 220, respectively, with the majority of the individuals having CD4 counts ranging from 200 to 499 cells/l. Subjects’ BMI and haemoglobin levels were symmetrically distributed, with mean and standard deviations of 20.43 ± 3.21 and 11.08 ± 1.38, respectively. Approximately 40%, on the other hand, were afflicted with opportunistic infections other than tuberculosis and non-AIDS-related chronic illnesses ( Table 2 ). ART and other medication related characteristics. In this investigation, TDF-3TC-EFV was used in more than 90% of the patients’ HAART regimens at the start. More than half (53.71%) of patients had received Cotrimoxazole; roughly 70% were on IPT and 30% were on FPT ( Table 2 ). Incidence of new and recurrent tuberculosis During the four-year retrospective follow-up, 28 patients (6.94%; 5.2% new and 1.73% reinfection) developed tuberculosis, 21 (5.2%) died, 44 (10.89%) were transferred out to other health facilities, 25 (6.19%) were lost to follow-up, and 286 (7.79%) were on follow-up and had not experienced the event until the last visit. Patients were seen for a minimum of 3 months and a maximum of 44 months, for a total of 5,253 person months. The median observation duration was 9 months, with an IQR of 12 months. The overall incidence density rate was 5.33/1000, CI: 3.68, 7.77/1000 person-months of observation (4.01/1000 PM among females and 6.76/1000 PM among males); incidence of new infection was 4/1000 PM (CI: 2.6, 6.13/1000 PM); incidence of reinfection was 1.3/1000 PM (0.63, 2.7/1000 PM). Three-forth (75%) of these occurrences occurred within the first year of monitoring. Survival probability was 0.99, 0.93, 0.90, and 0.87 on the sixth, 12th, and 18th months of the observation, respectively ( Table 3 ). Table 3. Life table for tuberculosis survival among HIV patients on HAART with the UTT approach, 2023. Interval in months Number Entering Interval Number Withdrawing during Interval Number Exposed to Risk Number of Terminal Events Proportion Terminating Probability of Surviving Cumulative Probability Surviving at end of Interval 95% CI 0-6 403 64 371.000 5 0.01 0.99 0.99 0.97, 0.99 6-12 334 131 268.500 16 0.06 0.94 0.93 0.89, 0.95 12-18 187 80 147.000 5 0.03 0.97 0.90 0.84, 0.92 18-24 102 37 83.500 2 0.02 0.98 0.87 0.81, 0.91 24-30 63 26 50.000 0 0.00 1.00 0.87 0.81, 0.91 30-36 37 21 26.500 0 0.00 1.00 0.87 0.81, 0.91 36-42 16 14 9.000 0 0.00 1.00 0.87 0.81, 0.91 42-48 2 2 1.000 0 0.00 1.00 0.87 0.81, 0.91 Open in a new tab The overall Kaplan-Meier survival estimate curve showed that incident of tuberculosis was highest in the first year of ART initiation and reduced over the time Incidence of TB was very high among those patients whose CD4 level less than 200 The incidence of Tuberculosis was higher among those patients whose age is > 45 compared to other ( Figs 1 – 3 ). Fig 1. The overall Kaplan-Meier survival estimate curve of adult HIV patients on HAART with UTT, 2023. Open in a new tab Fig 3. Tuberculosis distribution by age among adult HIV patients on HAART with the UTT, 2023. Open in a new tab Fig 2. Tuberculosis distribution by CD4 level among adult HIV patients on HAART with UTT, 2023. Open in a new tab To test equality of survival curves of different categorical explanatory variables, Cochran-Mantel Haenszel Log rank test was performed. The test statistics showed that there was a significant difference in survival function for different categorical variables (Table A in S1 Text ). In these study males, study participant who did not disclose their HIV status, underweight and patients with poor ART adherence were had lower survival time as compared to their counterparts and the survival time difference between the groups was found statistically significant ( Fig 4 ). Fig 4. Kaplan-Meier survival estimates for Sex, Nutritional status, CD4 count and ART adherence among adult HIV patients on HAART with UTT, 2023. Open in a new tab Predictors of tuberculosis Covariates such as gender, age, educational status, client catchment area, disclosure status, functional status, WHO clinical stage, nutritional status, opportunistic infections other than TB, non-HIV/AIDS-related chronic disease CD4 count, IPT, and adherence to ART were found to be eligible for multiple variables regression to identify an independent predictors of tuberculosis infection at a p-value of 0.25 on the bi-variable Cox regression, see Table 4 . Marital status, residence, religion, general substance use, khat, alcohol, and tobacco use, haemoglobin level, ART regimen, CPT, and FPT, on the other hand, were determined to be ineligible for tuberculosis prediction (p-value ≥ 0.25) ( Table 4 ). Table 4. Bi-variable Cox regression for predictors of TB among HIV patients enrolled on HAART with UTT approach, 2023. Variables Category Survival status CHR (95% CI) P-value Censored Event Sex Female 195(94.7) 11(5.3) 1 Male 181(91.4) 17(8.6) 1.61(0.75, 3.44) 0.217* Age 15-25 43(95.6) 2(4.4) 1 25-34 109(92.4) 9(7.6) 1.68(0.36, 7.77) 0.507 35-44 118(96.7) 4(3.3) 0.74(0.13, 4.07) 0.735 ≥45 106(89) 13(11) 2.70(0.61, 12.01) 0.190* Marital status Never married 55(91.7) 5(8.3) 1 Married 262(95.6) 18(6.4) 1.28(0.30, 2.10) 0.806 Separated /divorced 23(95.8) 1(4.2) 1.65(0.07, 5.18) 0.647 Widowed 36(90) 4(10) 2.73(0.44, 6.20) 0.369 Education No education 146(90.7) 15(9.3) 1 Primary 140(95.2) 7(4.8) 0.46(0.18, 1.13) 0.090* Secondary 43(93.5) 3(6.5) 0.68(0.19, 2.35) 0.545 Tertiary 47(94) 3(6) 0.61(0.17, 2.10) 0.431 Occupation Government employee 41(93.2) 3(6.8) 0.95(0.26, 3.54) 0.948 Farmer 61(94) 4(6) 0.87(0.27, 2.84) 0.825 Merchant 120(93) 9(7) 1 Daily laborer 28(87.5) 4(12.5) 1.85(0.57 6.03) 0.303 House wife 90(93.8) 6(6.2) 0.94(0.33, 2.66) 0.917 Student 15(93.8) 1(6.2) 0.85(0.11, 6.76) 0.883 Non-government employee 21(95.5) 1(4.5) 0.67(0.08, 5.30) 0.706 Residence Rural 155(94.5) 9(5.5) 1 Urban 221(92) 19(8) 1.57(0.71, 3.46) 0.267 Catchment area Yes 304(94.4) 18(5.6) 1 No 72(87.8) 10(12.2) 2.11(0.97, 4.56) 0.059* Adherence Good 278(97.9) 6(2.1) 1 Fair 48(96) 2(4) 1.87(0.37, 9.28) 0.442 Poor 50(71.5) 20(28.5) 18.8(7.45, 47.50) 0.000* Disclosure Disclosed 322(95.3) 16(4.7) 1 Not disclosed 54(81.8) 12(18.2) 4.07(1.92, 8.63) 0.000* Substance use No 258(93.8) 17(6.2) 1 Yes 118(91.5) 11(8.5) 1.43(0.67, 3.06) 0.350 Alcohol use No 265(93.3) 19(6.7) 1 Yes 111(92.5) 9(7.5) 1.79(0.54, 5.95) 0.338 Khat use No 351(93.35) 25(6.65) 1 Yes 25(89.3) 3(10.7) 1.14(0.51, 2.51) 0.747 Cigarette No 348(93.3) 25(6.7) 1 Yes 28(90.3) 3(9.7) 1.85(0.55, 6.20) 0.315 Functional status Working 292(96.4) 11(3.6) 1 Ambulatory 66(89.2) 8(10.8) 3.40(1.36, 8.49) 0.009* Bedridden 18(66.7) 9(33.3) 14.14(5.76,34.68) 0.000* WHO clinical stage I and II 280(96.8) 6(3.2) 1 III and IV 96(81.4) 22(18.6) 10.82(4.35,26.88) 0.000* BMI Underweight 93(84.6) 17(15.4) 3.84(1.76, 8.40) 0.547 Normal 237(96) 10(4) 1 Overweight 46(98) 1(2) 0.53(0.07, 4.15) 0.001* OIs other than TB No 223(95.3) 11(4.7) 1 Yes 153(90) 17(10) 2.28(1.07, 4.89) 0.033* Non-AIDS related chronic disease No 228(95) 12(5) 1 Yes 148(90.3) 16(9.7) 2.12(1.00, 4.49) 0.049* CD4 count <200 cells/μl 68(78.2) 19(21.8) 14(5.17, 37.89) 0.000 200-499 cells/μl 238(97.95) 5(2.05) 1 ≥ 500 cells/μl 70(94.6) 4(5.4) 2.20(0.59, 8.20) 0.240 Hemoglobin Level Normal 78(91.8) 7(8.2) 1 Below normal 298(93.4) 21(6.6) 0.88(0.38 2.10) 0.786 ART regimen 1e, TDF-3TC-EFV 352(93) 27(7) 1 1f, TDF-3TC-NVP 24(96) 1(4) 0.47(0.06, 3.45) 0.458 IPT Yes 259(92) 23(8) 1 No 117(96) 5(4) 0.46(0.17, 1.22) 0.121* CPT No 171(91.5) 16(8.5) 1 Yes 205(94.5) 12(5.5) 0.67(0.31, 1.41) 0.296 FPT No 258(93.2) 19(6.8) 1 Yes 118(93) 9(7) 1.04(0.473, 2.32) 0.907 Open in a new tab Sex, disclosure status, nutritional status, CD4 count, and ART drug adherence were revealed as independent predictors of ART-related incidence and recurrence of tuberculosis during multiple-variable Cox regression. Males were five times more likely than females to get tuberculosis at any particular moment [AHR for male: 5.05 (1.79, 14.28)]. In terms of disclosure status, those who did not disclose their HIV status were nearly six times more likely to contract tuberculosis than those who did [AHR for Not disclosed: 6.29 (1.96, 20.19)]. At any given time, those who are underweight have a higher risk of tuberculosis than those who are normal or overweight [AHR for underweight: 3.07 (1.23, 7.65)]. Immunologic findings suggest that the risk of tuberculosis was more than five times higher in individuals with a CD4 count less than 200 compared to those at any given period [AHR for CD4 200 cells/l: 5.63 (1.72, 18.38)]. Furthermore, when compared to their peers, those with poor ART adherence exhibited a sevenfold increase in tuberculosis risk [poor adherence: AHR: 7.05 (1.99-25.01)] ( Table 5 ). Table 5. Multiple-variable Cox regression for predictors of TB among HIV patients enrolled on HAART with the UTT approach, 2023. Variables Survival status CHR(95%CI) AHR (95% CI) P-value Censored Event Sex Female 195(94.7) 11(5.3) 1 1 Male 181(91.4) 17(8.6) 1.61(0.75, 3.44) 5.05 (1.79,14.28) 0.002 Age <25 43(95.6) 2(4.4) 1 1 25-34 109(92.4) 9(7.6) 1.68(0.36, 7.77) 4.93(0.54,44.83) 0.156 35-44 118(96.7) 4(3.3) 0.74(0.13, 4.07) 1.17(0.91,15.14) 0.902 ≥45 106(89) 13(11) 2.70(0.61, 12.01) 2.24(0.19,26.22) 0.518 Client reside within the Catchment Area Yes 304(94.4) 18(5.6) 1 1 No 72(87.8) 10(12.2) 2.11(0.97, 4.56) 1.88(0.64, 5.55) 0.247 Educational Level No education 146(90.7) 15(9.3) 1 1 Primary 140(95.2) 7(4.8) 0.46(0.18, 1.13) 0.28 (0.08,1.01) 0.053 Secondary 43(93.5) 3(6.5) 0.68(0.19, 2.35) 0.22(0.03,1.62) 0.139 Tertiary 47(94) 3(6) 0.61(0.17, 2.10) 0.25 (0.04, 1.47) 0.125 Disclosure Status Disclosed 322(95.3) 16(4.7) 1 1 Not disclosed 54(81.8) 12(18.2) 4.07(1.92, 8.63) 6.29(1.96, 20.19) 0.002 Functional Status Working 292(96.4) 11(3.6) 1 1 Ambulatory 66(89.2) 8(10.8) 3.40(1.36, 8.49) 0.77(0.22, 2.69) 0.692 Bedridden 18(66.7) 9(33.3) 14.14(5.76,34.68) 0.66(0.18, 2.35) 0.526 WHO clinical stage I and II 280(96.8) 6(3.2) 1 1 III and IV 96(81.4) 22(18.6) 10.82(4.35,26.88) 3.47(0.91,13.20) 0.068 Nutritional Status Underweight 93(84.6) 17(15.4) 3.84(1.76, 8.40) 3.07(1.23, 7.65) 0.016 Normal 237(96) 10(4) 1 1 Overweight 46(98) 1(2) 0.53(0.07, 4.15) 0.68(0.07, 6.22) 0.733 Opportunistic Infection other than Tuberculosis No 223(95.3) 11(4.7) 1 1 Yes 153(90) 17(10) 2.23(1.07, 4.89) 0.78(0.29, 2.09) 0.630 Non-AIDS related chronic disease No 228(95) 12(5) 1 1 Yes 148(90.3) 16(9.7) 2.12(1.00, 4.49) 1.08(0.31, 3.81) 0.899 CD4 count <200 cells/μl 68(78.2) 19(21.8) 14(5.17, 37.89) 5.63(1.72, 18.38) 0.004 200-499 cells/μl 238(97.95) 5(2.05) 1 1 ≥ 500 cells/μl 70(94.6) 4(5.4) 2.20(0.59, 8.20) 3.63(0.77, 16.94) 0.100 Isoniazid Preventive Therapy Yes 259(92) 23(8) 1 1 No 117(95.9) 5(4.1) 0.46(0.17, 1.22) 1.05(0.34, 3.19) 0.931 ART drug adherence Good 278(97.9) 6(2.1) 1 1 Fair 48(96) 2(4) 1.87(0.37, 9.28) 1.25(0.19, 9.14) 0.823 Poor 50(71.5) 20(28.5) 18.8(7.45, 47.50) 7.05(1.99, 25.01) 0.002 Open in a new tab Note: 1 indicates reference group; CI indicates confidence intervals, CHR: Crude Hazard Ratio; AHR: Adjusted Hazard Ratio. The goodness of fit of the model was assessed by Cox-Snell residuals with the Nelson Aalen cumulative hazard function graph. The graph shows that that the Cox-Snell residuals line is following the Nelson Aalen cumulative hazard function graph which means the model is fit ( Fig 5 ). Fig 5. Cox-Snell residuals with the Nelson Aalen cumulative hazard function graph Goodness of fit of the model. Open in a new tab Discussion A total of 404 patients were retrospectively followed for 5,253 person-months (PM) of observation or 437.75 person-years observation. Patients were followed for a minimum of 3 month and maximum of 44 months and the median observation time was 9 months with IQR 12 months. The overall incidence density rate (IDR) of Tuberculosis in the cohort was 5.33 per-1000-PM (95%CI: 3.68, 7.72/1000), which is equal to 6.39 (95%CI: 4.32, 9.24) per 100PY. Incidence of new infection was 4/1000 PM (CI: 2.6, 6.13/1000 PM); incidence of reinfection was 1.3/1000 PM (0.63, 2.7/1000PM). The IDR of tuberculosis in this study is consistent with similar study done in Addis Ababa in which the overall IDR among HIV patients enrolled to ART by universal test and treat approach was 4.84 cases(95%CI: 3.83–6.11) per 100 PY over 1529 PY of observation [ 45 ]. The current finding is higher than a study conducted at Gurage zone in which IDR of tuberculosis among HIV patient enrolled on UTT was 2.10/100 over 9,766 PM of follow up [ 46 ]. This disparity could be attributed to the two research’ vastly different follow-up periods. The current study's total PY of observation is nearly one-third that of the Addis Ababa study, and evidence, including this study, indicates that the bulk of occurrences occur in the first year after ART beginning. However, the incidence in this is lower than other studies conducted in selected ART clinics in Addis Ababa (6.82/100PY during 2140.08 person-years) [ 47 ], Debre Markos (6.19/100PY during 1000.22 Person Years follow up) [ 48 ] and Afar (8.6/100PY 1377.41 during PY of observation). Study from Tanzania also shows a match more incidence of tuberculosis infection compared to the current study [ 49 ]. Regarding the timing of event occurrence, the current finding reveals the risk of tuberculosis infection was higher in the first years of ART initiation (7.33 with 95% CI: 4.99, 10.76/1000 PM) compared to the incidence in the latter years of ART (1.17 with 95% CI: 0.29, 4.68/1000 PM). Of all the events that happened in our study, three-forth (75%) of the cases occurred in the first year of observation. The cumulative survival probability at the 6 th , 12 th, 18th, and by the end of the study was 0.99, 0.93, 0.90, and 0.87, respectively. This finding is supported by studies done in Addis Ababa and Debre Markos, in which the highest incidence was observed within the first year of follow-up [ 47 , 48 ]. During multiple variable cox regression the result revealed that sex (being male), disclosure of HIV status (not disclosed HIV status), nutritional status (being underweight), CD4 count (<200 cells) and ART drug adherence (poor ART drug adherence) were statistically significant independent predictors of tuberculosis among HIV patients who initiated ART under the Universal Test and Treat approach. This study found that, at any given time, the risk of developing tuberculosis among male was 5 times that of their counterpart [AHR: 5.05 (1.79, 14.28)]. This finding is supported by a study done in Tanzania and Ghana; where the risk of Tuberculosis was reduced among female [ 49 , 50 ]. This finding is in line with a study conducted in Nepal in which the prevalence of tuberculosis infection was significantly higher among male PLHIVs than female PLHIVs (AOR: 2.62 (1.176–5.865)) [ 51 ]. In addition this finding is also favored by a systematic review and Meta-analysis finding in Sub Saharan Africa, in which being male was a significant factor for an increased incidence of tuberculosis among HIV patients on ART [ 52 ]. The higher risk of tuberculosis among male PLHIVs may be due to biological, behavioral, and health-system factors. Men may have weaker immune responses and are more likely to engage in risk behaviors, such as smoking, alcohol use, and high-risk occupational exposure. Delayed health-seeking and poorer adherence to HIV care may further increase their susceptibility.[ 53 ]. In terms of disclosure status, the risk of tuberculosis was nearly six times greater among those who did not disclose their HIV status at any given moment [AHR: 6.29 (1.96, 20.19)]. This may be due to patients’ fear of disclosing their HIV status, which may have an indirect negative impact on their adherence to their ART because they are unable to take their medication freely in public, and they may also forget to take the medication and no one reminds them to do so because they did not disclose their HIV status, which is one of the factors contributing to the increased risk of opportunistic infection and failure to suppress viral load [ 54 ]. This study indicate that at any given time, those who are underweight have a threefold risk of developing tuberculosis than those who are normal or overweight [AHR: 3.07 (1.23, 7.65)]. This finding is consistent with a study conducted with the same approach in Addis Ababa at St. Peter Hospital and Zewditu Memorial Hospital, which discovered that the risk of tuberculosis is 2.42 times higher among underweight individuals than in normal patients [ 45 ]. Studies done under condition, without considering the UTT approach, also have comparable evidence with this study. Such as two studies conducted at Zewditu Memorial Hospital and seven selected ART clinics in Addis Ababa found that the risk of having tuberculosis infection was approximately doubled among underweight patients (AHR = 2.29) [ 55 ] and (AHR = 1.91) [ 47 ] respectively compared to patients with a normal BMI. Furthermore, the current finding are comparable with a studies conducted in public health institutions in north-east Ethiopia (Afar) [ 56 ], north-west Ethiopia (east and west Gojjam) [ 43 ], Arba Minch [ 27 ] and Sub-Saharan Africa [ 52 ]. Underweight HIV patients may have increased catabolic activity, infection, loss of appetite, and decreased intake, which increases the risk of developing TB when compared to persons with a normal BMI. Malnutrition, which reduces immunity and promotes tuberculosis reactivation, could increase susceptibility to tuberculosis in HIV patients who are underweight [ 57 , 58 ]. Immunologic findings suggest that the risk of tuberculosis was more than five times greater in patients with a CD4 count less than 200 at any one time [AHR: 5.63 (1.72, 18.38)]. This finding is consistent with a previous similar study done on HIV patient started ART with UTT approach conducted in Addis Ababa at St. Peter Hospital and Zewditu Memorial Hospital, which found that the risk of tuberculosis infection was three times higher among individuals with a CD4 level of less than 200 cells at any given moment [ 45 ]. Evidence from different studies conducted in Ethiopia; Addis Ababa [ 45 ], Gondar [ 28 ], Debre Markos [ 34 ] and Arba Minch [ 27 ] found positive evidence for the current conclusion that patients with a CD4 level of 200 cells or less are more likely to get tuberculosis. Furthermore, the findings shown above is confirmed by a meta-regression that found CD4 < 200 cells/mm3 to be a significant positive predictor of TB among HIV patients following the start of ART [ 59 ]. This is due to the fact that HIV infection is an immunosuppressive disease that impairs cellular immune responses and raises the risk of opportunistic infections by diverting CD4 + T cells, which is linked to an increased risk of TB development. Low CD4 + cell counts are also linked to recurrence and relapse [ 60 , 61 ]. Moreover, when compared to their counterparts, those with poor ART adherence had a sevenfold greater risk of tuberculosis [AHR: 7.05 (1.99-25.01)]; see Table 5 . This finding is confirmed by a study conducted in Addis Ababa at St. Peter Hospital and Zewditu Memorial Hospital, which found that individuals with poor ART adherence were twice as likely to develop tuberculosis [ 45 ]. This finding has been verified by a study conducted at Debre Markos referral hospital, which discovered that having fair or poor ART adherence increased the likelihood of contracting tuberculosis [ 48 ]. This is due to the fact that treatment adherence is widely viewed as a key element in obtaining optimal outcomes across a wide range of disease states; in the treatment of HIV, poor adherence to treatment has the potential to affect outcomes on numerous levels. Poor adherence to antiretroviral medication (ART) is linked to less efficient viral suppression, which increases the risk of opportunistic infections, most notably tuberculosis [ 62 ]. There are a number of limitations to this study. Its retrospective design depended on routinely gathered clinical records, which could be misclassified and had inadequate documentation. Discrepancies with current treatment guidelines may be explained by the fact that ART regimens were recorded at the time of ART initiation and did not capture later regimen switches, such as transitions to tenofovir/lamivudine/dolutegravir during national scale-up. Medical records and self-report were used to document behavioral factors and tuberculosis preventive therapy, which may have resulted in an overestimation or underestimation. Furthermore, the results may not be entirely applicable to patients starting therapy under more recent national guidelines because many participants started ART during the early stages of Universal Test and Treat implementation, and the observational design prevents causal inference. Conclusion Incidence rate of tuberculosis was reduced among HIV patients who enrolled ART with the Universal Test and Treat approach compared to previous studies. The incidence is high during first year of ART initiation, particularly the first six months. Being male, underweight, not disclosing HIV status, having low CD4 count (<200 cells/μl) and poor ART adherence were an independent predictor for an increased incidence of new or re-infection tuberculosis among HIV patients on ART under the universal test and treat approach. To reduce tuberculosis risk in HIV patients, early detection through risk-group screening and rapid ART initiation are critical, with close monitoring during the early ART stages when TB prevalence is highest. Patients should be encouraged to disclose their HIV status to close contacts, and ART adherence should be monitored and supported on a frequent basis. Nutritional counseling and weight management should be focused for underweight patients to boost immunity. Furthermore, prospective studies are required to properly quantify the condition and investigate other measurable characteristics using primary patient data. Supporting information S1 Text. Additional methods and results. 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[ PubMed ] [ Google Scholar ] PLOS Glob Public Health. 2026 Apr 10;6(4):e0005970. doi: 10.1371/journal.pgph.0005970.r001 Author response to Decision Letter 0 Article notes Copyright and License information Collection date 2026. PMC Copyright notice Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. 5 Oct 2025 PLOS Glob Public Health. doi: 10.1371/journal.pgph.0005970.r002 Decision Letter 0 Damen Haile Mariam Damen Haile Mariam Academic Editor Find articles by Damen Haile Mariam Author information Copyright and License information Roles Damen Haile Mariam : Academic Editor © 2026 Damen Haile Mariam This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 3 Dec 2025 PGPH-D-25-01412 Time to incidence of tuberculosis and its predictors among adult HIV/AIDS patients who initiated ART by the Universal Taste and Treat approach in Silte Zone, Ethiopia, 2023. PLOS Global Public Health Dear Dr. Sherfa, Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 17 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at [email protected]. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. We look forward to receiving your revised manuscript. Kind regards, Damen Haile Mariam, MD, MPH, PhD Academic Editor PLOS Global Public Health Journal Requirements: 1. Please ensure that your Ethics Statement is available in its entirety at the beginning of your Methods section, under a subheading 'Ethics Statement'. 2. Please upload separate figure files in .tif or .eps format. Also, remove the figures from your manuscript file but keep the legends. For more information about figure files please see our guidelines: https://journals.plos.org/globalpublichealth/s/figures https://journals.plos.org/globalpublichealth/s/figures#loc-file-requirements 3. We have noticed that you have cited Tables 1 to 8 in the manuscript file but there are no corresponding tables in the manuscript. Please amend your manuscript to include this table, noting that tables should not be uploaded as individual files. 4. We have noticed that you have uploaded Supporting Information files, but you have not included a list of legends. Please add a full list of legends for your Supporting Information files after the references list. 5. In the online submission form, you indicated that “All relevant materials and data are within the manuscript and its supporting files and if any additional data or clarification needed, will be available from the corresponding author upon reasonable request.”. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons by return email and your exemption request will be escalated to the editor for approval. Your exemption request will be handled independently and will not hold up the peer review process, but will need to be resolved should your manuscript be accepted for publication. One of the Editorial team will then be in touch if there are any issues. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments (if provided): Reviewer 1: - General Comments - - The document requires serious editorial revisions. For instance, the word "taste" is used in the place of "test" in the title of the manuscript. - The authors have not made distinction between TB disease and TB infection (Refer to the WHO criteria). - There are also a lot of redundancies. - Abstract - - The results should start with describing the cohort characteristics. - Methods - - What is the power of the study? - Results - - What proportion of patients were given TB preventive therapy? This is part of the care bundle. Most received tenofovir, lamivudine and efavirenz, but nationally it is tenofovir, lamivudine and dolutegravir? Is the reason known? - Discussion - - - What are the study limitations? Reviewer 2: - Geneal Comments - - To enhance the manuscript’s contribution and clarity, the reviewer recommends the authors address the following points: - General Editorial suggestions - • While the manuscript reads well overall, it would benefit from additional editing and formatting. Specific areas for improvement include: o Ensure all acronyms are defined at first mention and used consistently thereafter. For example, the “Universal Test and Treat (UTT)” approach is inconsistently referenced with and without the acronym. Other acronyms such as DOT and SGDs appear without explanation (e.g., on page 3 and page 9). o Correct typographical errors, such as “aer” instead of “are” and “reveled” instead of “revealed” (page 3, last paragraph). o Clarify sentence structure. For instance, the sentence ending with “…were considered as common predictors associated with new and re-infection of TB” (page 4, first paragraph) does not logically follow the preceding list of factors. - Methods - - The rationale for calculating the sample size based on “tuberculosis recurrence” is unclear. Why was recurrence used instead of the primary outcome of interest—TB incidence? - The justification for using a 50% maximum incidence rate due to the “absence of prior studies” seems inconsistent with the literature cited in the discussion, including previous meta-analyses. Please clarify. - Provide clear operational definitions for key study variables, including how TB infection was determined and how independent variables were measured. - Results - - On page 8, the manuscript notes the exclusion of 38 patients due to ineligibility. Please specify the eligibility criteria used. - Table numbering is inconsistent. The results section refers to Tables 1–8, but the attached tables are labeled Tables 9–16. This may be a formatting issue, but the tables should be renumbered accordingly. - There is a discrepancy in the adherence data: the narrative on page 9 reports 770.3% adherence, which is likely a typographical error. Please verify and correct (likely intended to be 70.3%). - Avoid using the term “substance abuse” if the data only reflect self-reported use. Additionally, clarify which substances were included beyond alcohol, khat, and cigarettes. - Consider reducing the number of tables and figures. Presenting only the most critical results in the main text and moving others to supplementary materials may improve readability. - Discussion - - Broad claims in the discussion should be supported by references. For example, on page 14, explanations for gender differences in TB incidence (e.g., social behaviors, hormonal differences) are not cited. Similar unsupported statements appear on pages 15–16. - On page 15, the statement “Malnutrition, which reduces immunity and promotes tuberculosis activation, could be the source of tuberculosis in HIV patients who are underweight” is misleading. Malnutrition may increase susceptibility but is not a source of TB. Please revise for accuracy. - References - - Review reference 20, which includes conflict of interest disclosures for each author. This may not be necessary in the reference list. - Check all references for broken links. - Ensure acronyms are expanded where appropriate. For example, in reference 22, clarify “FMOH” and specify if it refers to the Ethiopian Federal Ministry of Health. - Tables - - Renumber tables sequentially from Table 1 to Table 8. - Include appropriate footnotes for all tables. For instance, Table 15 (likely intended as Table 2) includes asterisks next to p-values, but no explanation is provided. Also, define all acronyms used in the tables. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Does this manuscript meet PLOS Global Public Health’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.-->?> Reviewer #1: Yes Reviewer #2: Yes ********** 2. Has the statistical analysis been performed appropriately and rigorously?-->?> Reviewer #1: Yes Reviewer #2: Yes ********** 3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)??> The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ********** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ********** Reviewer #1: The article entitled " Time to incidence of tuberculosis and its predictors among adult HIV/AIDS patients who initiated ART by the Universal Taste and Treat approach in Silte Zone, Ethiopia" addresses an important public health issue. There are few comments. I see lots of editorial mistakes. One is see above which says "taste". The right word is test. The authors have not made distinction between TB disease and TB infection (Refer to the WHO criteria). There is lot of redundancy; thus it requires diligent editorial work. In the abstract section, the result should start with describing the cohort characteristics. What proportion of patients were given TB preventive therapy? This is part of the care bundle. Most received tenofovir, lamivudine and efavirenz, but nationally it is tenofovir, lamivudine and dolutegravir? Is the reason known? What are the study limitations? What is the power of the study? Reviewer #2: GENERAL COMMENTS This is an interesting and well-written manuscript with the potential to make a valuable contribution to scientific literature on the incidence and predictors of tuberculosis (TB) infection among adults living with HIV/AIDS in a developing country context. The authors confirm findings from prior studies that report high levels of incident TB and identify a set of associated risk factors among Ethiopian HIV/AIDS patients. Based on these findings, the authors offer public health and clinical recommendations that, if implemented, could support progress toward TB control targets in Ethiopia and similar settings. To enhance the manuscript’s contribution and clarity, the reviewer recommends the authors address the following points: GENERAL EDITORIAL SUGGESTIONS • While the manuscript reads well overall, it would benefit from additional editing and formatting. Specific areas for improvement include: o Ensure all acronyms are defined at first mention and used consistently thereafter. For example, the “Universal Test and Treat (UTT)” approach is inconsistently referenced with and without the acronym. Other acronyms such as DOT and SGDs appear without explanation (e.g., on page 3 and page 9). o Correct typographical errors, such as “aer” instead of “are” and “reveled” instead of “revealed” (page 3, last paragraph). o Clarify sentence structure. For instance, the sentence ending with “…were considered as common predictors associated with new and re-infection of TB” (page 4, first paragraph) does not logically follow the preceding list of factors. METHODS • The rationale for calculating the sample size based on “tuberculosis recurrence” is unclear. Why was recurrence used instead of the primary outcome of interest—TB incidence? • The justification for using a 50% maximum incidence rate due to the “absence of prior studies” seems inconsistent with the literature cited in the discussion, including previous meta-analyses. Please clarify. • Provide clear operational definitions for key study variables, including how TB infection was determined and how independent variables were measured. RESULTS • On page 8, the manuscript notes the exclusion of 38 patients due to ineligibility. Please specify the eligibility criteria used. • Table numbering is inconsistent. The results section refers to Tables 1–8, but the attached tables are labeled Tables 9–16. This may be a formatting issue, but the tables should be renumbered accordingly. • There is a discrepancy in the adherence data: the narrative on page 9 reports 770.3% adherence, which is likely a typographical error. Please verify and correct (likely intended to be 70.3%). • Avoid using the term “substance abuse” if the data only reflect self-reported use. Additionally, clarify which substances were included beyond alcohol, khat, and cigarettes. • Consider reducing the number of tables and figures. Presenting only the most critical results in the main text and moving others to supplementary materials may improve readability. DISCUSSION • Broad claims in the discussion should be supported by references. For example, on page 14, explanations for gender differences in TB incidence (e.g., social behaviors, hormonal differences) are not cited. Similar unsupported statements appear on pages 15–16. • On page 15, the statement “Malnutrition, which reduces immunity and promotes tuberculosis activation, could be the source of tuberculosis in HIV patients who are underweight” is misleading. Malnutrition may increase susceptibility but is not a source of TB. Please revise for accuracy. REFERENCES • Review reference 20, which includes conflict of interest disclosures for each author. This may not be necessary in the reference list. • Check all references for broken links. • Ensure acronyms are expanded where appropriate. For example, in reference 22, clarify “FMOH” and specify if it refers to the Ethiopian Federal Ministry of Health. TABLES • Renumber tables sequentially from Table 1 to Table 8. • Include appropriate footnotes for all tables. For instance, Table 15 (likely intended as Table 2) includes asterisks next to p-values, but no explanation is provided. Also, define all acronyms used in the tables. ********** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.If you choose “no”, your identity will remain anonymous but your review may still be made public.If you choose “no”, your identity will remain anonymous but your review may still be made public.If you choose “no”, your identity will remain anonymous but your review may still be made public. For information about this choice, including consent withdrawal, please see our Privacy Policy ..--> Reviewer #1: Yes: Wondwossen Amogne DeguWondwossen Amogne DeguWondwossen Amogne DeguWondwossen Amogne Degu Reviewer #2: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] PLOS Glob Public Health. 2026 Apr 10;6(4):e0005970. doi: 10.1371/journal.pgph.0005970.r003 Author response to Decision Letter 1 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 27 Feb 2026 Attachment Submitted filename: Response to Reviewers.docx pgph.0005970.s004.docx (63.2KB, docx) PLOS Glob Public Health. doi: 10.1371/journal.pgph.0005970.r004 Decision Letter 1 Damen Haile Mariam Damen Haile Mariam Academic Editor Find articles by Damen Haile Mariam Author information Copyright and License information Roles Damen Haile Mariam : Academic Editor © 2026 Damen Haile Mariam This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 12 Mar 2026 Time to incidence of tuberculosis and its predictors among adult HIV/AIDS patients who initiated ART by the Universal Test and Treat approach in Silte Zone, Ethiopia, 2023. PGPH-D-25-01412R1 Dear Mr Sherfa, We are pleased to inform you that your manuscript 'Time to incidence of tuberculosis and its predictors among adult HIV/AIDS patients who initiated ART by the Universal Test and Treat approach in Silte Zone, Ethiopia, 2023.' has been provisionally accepted for publication in PLOS Global Public Health. Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests. Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated. IMPORTANT: The editorial review process is now complete. 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Best regards, Damen Haile Mariam, MD, MPH, PhD Academic Editor PLOS Global Public Health *********************************************************** Reviewer Comments (if any, and for reference): Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials S1 Text. Additional methods and results. (DOCX) pgph.0005970.s001.docx (62KB, docx) S1 Data. Dataset used for analysis. (DTA) pgph.0005970.s002.dta (246.9KB, dta) Attachment Submitted filename: Response to Reviewers.docx pgph.0005970.s004.docx (63.2KB, docx) Data Availability Statement All relevant materials and data are within the paper and its Supporting Information files, and if any additional data or clarification is needed, it will be available from the corresponding author upon reasonable request. 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