Background: Tuberculosis preventive therapy (TPT) reduces tuberculosis incidence among people living with HIV (PLHIV), yet uptake has been sub-optimal. We evaluated trends of TPT prescribing among people initiated on antiretroviral therapy (ART).

Setting: Thirty-six public sector clinics in South Africa.

Methods: We retrospectively analyzed individual-level clinical data abstracted from clinics in the Free State and North West provinces, South Africa. We included PLHIV who initiated ART 2005-2022 and had ≥1 HIV-related clinic visits on or after 15 September 2021. The timing of TPT prescribing was defined by the earliest recorded TPT prescription date as: (1) TPT prescription within ≤6 months, (2) TPT prescription >6 months, or (3) no recorded TPT prescription on or after ART initiation.

Results: Among 48,718 ART initiators, 23,168 (47.6%) were prescribed TPT on or after ART initiation; 15,510 (31.8%) were prescribed TPT ≤6 months and 7,658 (15.7%) were prescribed TPT >6 months after ART initiation. Early TPT prescribing increased from 0.7% in the 2005-2010 cohort to 71.3% in 2022 ART initiators, while TPT prescribing >6 months after ART initiation declined from 28.5% in the 2005-2010 cohort to 1.3% among those who initiated ART in 2022. Cumulative TPT prescribing was 29.2% in the 2005-2010 cohort, 34.2% in the 2011-2015 cohort, and 72.6% in the 2022 cohort.

Conclusions: Over 2005-2022, TPT prescribing shifted markedly toward initiation near the time of ART initiation, with early prescribing exceeding 70% by 2022. Cumulative prescribing remained low among people from earlier ART cohorts, underscoring the need for targeted catch-up strategies.