Sex differences in risk factors for unsuccessful tuberculosis treatment outcomes in Eastern Europe from 2020 to 2022: a multi-country retrospective cohort study

Abstract

Background Addressing the disproportionate representation between sexes is essential for achieving universal health coverage. Studies on the association between sex and unsuccessful tuberculosis treatment outcomes have shown conflicting results. This study examines this association and analyses sex-stratified risk factors associated with unsuccessful outcomes. Methods This retrospective, observational cohort study analysed prospectively collected data from six Eastern Eu ropean countries from 2020 to 2022. Treatment outcomes were defined using World Health Organization criteria. Uni- and multivariable logistic regression models were used to assess the association between sex and unsuccessful outcomes (‘treatment failure’, ‘lost to follow-up’, ‘died’, or any of these). After propensity score matching females and males, the multivariable analysis was repeated. Risk factors were analysed separately for each sex and compared using interaction terms. Findings Among females, 19⋅5% (n = 290/1490) (95% confidence interval [CI]: 18, 22) achieved an unsuccessful treatment outcome, compared with 30% (n = 1363/4553) (95% CI: 29, 31) among males. In the multivariable an alyses, female sex was associated with 32% lower odds of any unsuccessful outcome (adjusted odds ratio [aOR] 0⋅68, 95% CI: 0⋅58, 0⋅80), 36% lower odds of dying (aOR 0⋅64, 95% CI: 0⋅51, 0⋅80), and 37% lower odds of treatment failure (aOR 0⋅63, 95% CI: 0⋅47, 0⋅85). The association between sex and being ‘lost to follow-up’ was not significant. In the propensity score-matched cohort, sex was not associated with unsuccessful outcomes. Risk factors for unsuccessful outcomes were similar for females and males, except that in females aged >65 years, the odds of death were 2⋅2 times higher (95% CI: 1⋅1, 4⋅4). Interpretation Male sex was associated with unsuccessful outcomes, including death and treatment failure, but adjusting for socio-demographic and clinical factors, and matching males to females, attenuated the association, suggesting that sex disparities in tuberculosis outcomes may be driven more by behavioural than biological factors. Longitudinal studies are needed to confirm these findings.