Tuberculosis and tuberculosis-human immunodeficiency virus in post-conflict West Africa: Lessons for integrated surveillance from 2000 to 2022

Abstract

Background: Post-conflict health systems experienced surveillance and delivery challenges that hindered tuberculosis (TB) and TB-human immunodeficiency virus (HIV) control. Recent evidence shows that fragile and conflict-affected health systems still lack integrated TB-HIV services, routine testing, and reliable data, delaying lower incidence rates even as case detection rises.
Aim: This study examined TB and TB-HIV dynamics in Liberia and Sierra Leone to identify practice-oriented lessons for integrated surveillance and system resilience.
Setting: Study was conducted on data from Liberia and Sierra Leone, 2000–2022.
Methods: A two-country annual panel was assembled from World Health Organisation (WHO) TB indicators, World Bank gross domestic product (GDP) and health expenditure per capita, and conflict events. Primary estimation used two-way fixed effects with Driscoll-Kraay inference, and robustness checks used linear mixed-effects and ordinary least squares (OLS) with Heteroskedasticity–consistent standard error estimator, type 3 (HC3). A 2016–2022 subset assessed TB-HIV testing coverage. Effect sizes with Driscoll-Kraay 95% confidence intervals (CIs) were emphasised.
Results: Across specifications, higher GDP per capita was consistently associated with lower TB incidence. Tuberculosis-human immunodeficiency virus co-infection indicators showed varied associations. In 2016–2022, TB-HIV testing coverage was positively associated with TB incidence, suggesting that expanded testing may increase detection before incidence declines. Health expenditure per capita was similarly positively associated with incidence in 2016–2022, consistent with higher spending during periods of increased case detection. Results were robust across alternative estimators, and standard collinearity diagnostics did not indicate problematic multicollinearity.
Conclusion: In post-conflict settings, strengthening economic capacity, integrating TB-HIV services, and improving surveillance quality were foundational for sustained TB control. Short-run increases in detected cases should be anticipated as testing expands. Programme resources, integration, and data systems were needed to convert detection gains into incidence reduction.
Contribution: The study identified practice-oriented lessons for integrated surveillance and system resilience in post-conflict settings.