Mortality and Predictors of Poor Outcomes among Persons with HIV and Tuberculous Meningitis, in Mozambique

Background: Tuberculous meningitis (TBM) is the most severe form of tuberculosis and is associated with high morbidity and mortality, especially in resource-limited settings. In Mozambique, where both tuberculosis and HIV are highly prevalent, TBM poses significant diagnostic and therapeutic challenges. This study aimed to describe the clinical characteristics and outcomes of TBM patients and to identify factors associated with mortality in a rural hospital. Methods: We conducted a retrospective observational study of 372 patients diagnosed with TBM at Carmelo Hospital of Chókwè between 2015 and 2020. Data on demographics, clinical presentation, and laboratory findings were extracted from patient records. TBM diagnosis was based on a hospital-adapted algorithm incorporating clinical features, cerebrospinal fluid (CSF) analysis, TB-LAM, and Xpert MTB/RIF testing. Cox proportional hazards models were used to identify independent predictors of mortality, and Kaplan–Meier survival curves with log-rank tests were used to assess survival differences across clinical subgroups. Results: Among the 372 TBM cases, 140 patients (37.6%) died during follow-up, corresponding to a mortality incidence of 3.76 deaths per 100 person-months. Factors independently associated with increased mortality included male sex (adjusted hazard ratio [aHR]: 1.80; 95% CI: 1.21–2.68), BMI <18.5 kg/m² (aHR: 2.75; 95% CI: 1.41–5.36), HIV-related immunovirological failure (aHR: 2.82; 95% CI: 1.54–5.16), CSF opening pressure >40 cmH₂O (aHR: 3.83; 95% CI: 2.33–6.31), and late-stage neurological signs such as coma or decerebrate posturing (aHR: 2.15; 95% CI: 1.31–3.56). Disseminated TB involving other organs also significantly worsened survival (aHR: 2.07; 95% CI: 1.31–3.29). Conclusions: Tuberculous meningitis remains a major cause of mortality in rural Mozambique, particularly among malnourished individuals, males, and patients with advanced HIV or disseminated TB. Early diagnosis, prompt management of intracranial hypertension, and integrated HIV/TB/nutritional care are critical for improving outcomes. Strengthening diagnostic capacity and tailoring interventions to high-risk subgroups should be prioritized in low-resource settings.