Predictors of Treatment Response Among HIV Positive Individuals with XDR- and MDR-Pulmonary Tuberculosis in Rural Eastern Cape, South Africa

Background: Drug-resistant tuberculosis (DR-TB) remains a major public health challenge in South Africa, particularly in rural settings with high HIV co-infection rates. Under-standing predictors of treatment response among people living with HIV is essential for improving clinical management and programmatic outcomes. This study aimed to iden-tify socio-demographic and clinical predictors of treatment outcomes among HIV-positive individuals diagnosed with multidrug-resistant (MDR) and extensively drug-resistant tuberculosis (XDR-TB) in the rural Eastern Cape Province, South Africa. Methods: A ret-rospective cohort study was conducted using routinely collected clinical records of DR-TB patients initiated on treatment between January 2020 and December 2024 at two public healthcare facilities. A total of 239 patients with complete treatment outcome data were included. Treatment outcomes were classified as favorable (cured or treatment completed) or unfavorable (death, treatment failure, or loss to follow-up). Descriptive statistics were used to summaries patient characteristics, while univariate and multivariable logistic re-gression analyses were performed to identify factors associated with treatment outcomes. Results: Most participants were aged ≤39 years (58%), male (60%), unemployed (90%), and without income (80%). MDR-TB accounted for 40% of cases, rifampicin-resistant TB (RR-TB) for 53%, and XDR-TB for 7.1%. Multivariable analysis showed that XDR-TB was the strongest independent predictor of unfavorable treatment outcome (AOR = 0.18; 95% CI: 0.06–0.58; p = 0.004). Income status was also significantly associated with outcome, with participants reporting some income having lower odds of favorable outcomes (AOR = 0.46; 95% CI: 0.23–0.92; p = 0.036). The model demonstrated modest predictive perfor-mance (AUC = 0.67). Conclusion: These findings highlight the dominant influence of re-sistance phenotype particularly XDR-TB on treatment prognosis among HIV-positive DR-TB patients in rural Eastern Cape. Integrating early resistance profiling, intensified clinical management of XDR-TB, and socioeconomic support mechanisms may improve treatment outcomes in high-burden rural settings.