Impact of modifiable factors on sex and age disparities for unfavorable outcomes in Peruvian population with tuberculosis

Background Tuberculosis remains a major public health problem in Peru, with persistent unfavorable outcomes driven by comorbidities, harmful behaviors, and structural barriers to care. These factors are unevenly distributed across populations, contributing to disparities by sex and age. The aim of this study was to evaluate the impact of modifiable factors on sex- and age-related disparities in unfavorable outcomes among the Peruvian population with tuberculosis. Methods Retrospective cohort study with national data from the Peruvian Tuberculosis Management Information System (SIGTB) between 2016 and 2023. Adults with tuberculosis, newly registered and complete clinical evaluations were included. Unfavorable outcomes comprised death, dropout or loss to follow-up, and treatment failure. Disparities were assessed by sex and age group (< 60 vs. ≥60 years). Modifiable factors included region and area of residence, health insurance, HIV/AIDS coinfection, diabetes mellitus, alcohol consumption, smoking, and drug use. The impacts were quantified using Population Attributable Fractions (PAF%). Results Among 177,185 adults with tuberculosis, 14.69% experienced an unfavorable outcome, more frequently among males (16.66%) and older adults (21.35%). HIV/AIDS coinfection showed the largest impact overall (PAF%=40.85), followed by alcohol consumption (PAF%=10.84) and drug use (PAF%=8.19). HIV/AIDS consistently exhibited the highest PAF% across sex and age groups, particularly among females and younger adults. Drug use showed marked sex disparities, with higher impacts among females, especially for dropout or loss to follow-up. Annual analyses indicated persistently high impacts of HIV/AIDS and increasing disparities related to substance use after the pandemic. Conclusion Modifiable factors like HIV/AIDS coinfection, alcoholism, and drug use account for a substantial proportion of unfavorable tuberculosis outcomes in Peru, with pronounced disparities by sex and age. These findings highlight the need for equity-focused TB strategies integrating comorbidity management, substance-use interventions, and resilient health systems.