Achieving the World Health Organization (WHO) target of zero paediatric tuberculosis (TB) deaths will require an understanding of the underlying risk factors for mortality.

To identify risk factors for mortality and assess the impact of human immunodeficiency virus (HIV) testing during anti-tuberculosis treatment in children in 13 TB-HIV programmes run by Médecins Sans Frontières.

In a retrospective cohort study, we recorded mortality and analysed risk factors using descriptive statistics and logistic regression. Diagnosis was based on WHO algorithm and smear microscopy.

A total of 2451 children (mean age 5.2 years, SD 3.9) were treated for TB. Half (51.0%) lived in Asia, the remainder in sub-Saharan Africa; 56.0% had pulmonary TB; 6.4% were diagnosed using smear microscopy; 211 (8.6%) died. Of 1513 children tested for HIV, 935 (61.8%) were positive; 120 (12.8%) died compared with 30/578 (5.2%) HIV-negative children. Risk factors included being HIV-positive (OR 2.6, 95%CI 1.6-4.2), age <5 years (1.7, 95%CI 1.2-2.5) and having tuberculous meningitis (2.6, 95%CI 1.0-6.8). Risk was higher in African children of unknown HIV status than in those who were confirmed HIV-negative (1.9, 95%CI 1.1-3.3).

Strategies to eliminate childhood TB deaths should include addressing the high-risk groups identified in this study, enhanced TB prevention, universal HIV testing and the development of a rapid diagnostic test.