Determinants of unsuccessful tuberculosis treatment outcomes among patients under facility-based directly observed therapy (DOT) follow-up in Rwanda (2021–2023): a retrospective analysis of national surveillance data

Abstract Background Tuberculosis (TB) causes more than one million deaths annually. Achieving high treatment success is essential to interrupt transmission, yet unsuccessful treatment outcomes persist despite standardized facility-based directly observed therapy (DOT). This study assessed determinants of unsuccessful TB treatment among patients under facility-based directly observed therapy in Rwanda. Methods We conducted a nationwide retrospective analysis of 9,149 TB patient records reported in Rwanda’s national electronic TB database (e-TB) covering July 2021–December 2023. We included drug-susceptible TB patients managed under standard treatment and facility-based DOT across 568 health facilities, including correctional institutions. The outcome was unsuccessful treatment, defined as death, treatment failure, or loss to follow-up. Multivariable logistic regression identified independent determinants, reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results Among 9,149 TB patients, 11% experienced unsuccessful treatment outcomes, primarily due to death (8%). In outcome-specific analysis, increasing age was associated with death (40–59 years: aOR 1.60, 95% CI 1.32–1.94; ≥60 years: aOR 2.80, 95% CI 2.24–3.49) but was inversely associated with loss to follow-up. HIV co-infection was independently associated with both death (aOR 2.99, 95% CI 2.47–3.61) and loss to follow-up (aOR 2.42, 95% CI 1.77–3.29). Compared with correctional facilities, treatment in hospitals showed an association with death (aOR 11.96, 95% CI 8.42–16.99), while both hospitals and health centres/private clinics were associated with increased loss to follow-up. Clinically diagnosed tuberculosis was associated with higher odds of death but lower odds of loss to follow-up. Marked geographic variation was observed, with higher mortality in the Northern and Southern provinces and increased loss to follow-up in Kigali City. Conclusions The tuberculosis treatment success rate for patients receiving health facility-based DOT in Rwanda (89%) was slightly below the national average of 90% indicating room for improvement. Unsuccessful outcomes were mainly driven by death and were associated with older age, HIV co-infection, and health system factors, particularly treatment in hospitals and health centres compared with correctional facilities. To reduce unsuccessful treatment outcomes, programs should prioritize continuity of care and differentiated support for high-risk groups, particularly older adults and HIV-positive patients.