Sex disparities in tuberculosis outcomes: evidence from a multicenter Italian cohort (Italian South TB Network (ISTB-Net)

Abstract

Background: Sex disparities in tuberculosis (TB) outcomes are not well characterized, especially in high-income countries where social vulnerability and migration influence access to care. Although men globally experience a higher TB burden, the interaction between sex, migration, and social determinants is complex and extends beyond biological factors. This study evaluated sex differences in clinical and programmatic TB outcomes in a high-income European country with a significant substantial migrant population. Methods: A retrospective multicentre cohort study was conducted across 16 Infectious Diseases Units in seven Italian regions from (January 2021 to September 2025). Outcomes included time to sputum conversion (in pulmonary TB), length of hospital stay (LOS), adverse events (AEs) and their severity, incomplete treatment (defined as failure, death, or loss to follow-up), and loss to follow-up (LTFU). Mixed-effects models were applied using two prespecified adjustment sets: sex, centre, and core confounders (Model A); and sex, centre, and clinically relevant baseline imbalances (Model B). Sub-analyses examined the impact of migration status. Results: Of 982 TB patients, 229 (23.3%) were women and 753 (76.7%) were men. Women exhibited lower rates of smoking (24.4% vs 36.7%), diabetes (7.9% vs 15.8%), and COPD/bronchiectasis (4.5% vs 10.3%). The median sputum conversion time was 21 days for both sexes. Adjusted analysesindicated shorter LOS among women (Model A: − 22% [95%CI − 32 to − 10]; Model B: − 19% [95%CI − 28 to − 9]). Time to sputum conversion was slightly shorter in women in Model A (− 13%; 95%CI −23% to −1%) but not in Model B (− 9%; 95%CI −17% to 1%). The risk and severity of AEs were similar between sexes. In Model B, women had lower odds of incomplete treatment (OR 0.64 [95%CI 0.41 to 0.99]) and LTFU (OR 0.62 [95%CI 0.38 to 0.99]). Migrants experienced worse overall outcomes, but the effect of sex did not differ by migration status. Conclusion: Women had consistently shorter hospital stays and greater treatment continuity without increased toxicity, indicating that sex differences in TB outcomes are likely attributable to social and behavioural factors rather than biological differences. Supportive associative networks and non-governmental organisations may help reduce sex disparities, underscoring the importance of sex- and migration-responsive TB care models in Europe.