Background. People living with HIV (PLWH) make up a significant proportion of the population in sub-Saharan Africa, and there exists a significant gap in research on the burden and associated risk factors for extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in this population. We describe the risk factors associated with ESCrE colonization in nonhospitalized PLWH. Methods. This is a secondary data analysis of nonhospitalized adult PLWH included in a regional surveillance cohort study describing colonization with ESCrE in Botswana. Participants underwent rectal swab sampling to identify ESCrE. Bivariate and multivariable analysis was used to determine risk factors associated with ESCrE colonization. Results. A total of 546 adult PLWH were recruited over 3 districts and were included in this analysis. The mean (standard deviation) age was 42 (10.4) years, and 448 (82.1%) were women. Our findings demonstrated that 27.3% (149/546) of participants screened positive for ESCrE rectal colonization. Independent risk factors {adjusted odds ratio (aOR) [95% CI]} for ESCrE colonization included recent hospitalization (3.37 [1.13–9.98]), at least 1 household member with ESCrE colonization (1.74 [1.01–3.00]), and recruitment before the countrywide COVID-19 lockdown (2.01 [1.33–3.04]). Recent antibiotic use had an elevated OR for ESCrE colonization that did not achieve statistical significance in the adjusted analysis (aOR: 1.84 [.92–3.68]). Conclusions. Hospitalization and colonization of other household members with ESCrE are important factors associated with colonization with ESCrE, as seen in other populations. The prevalence of ESCrE following the COVID-19 lockdown was significantly lower, suggesting the presence of factors that were protective against colonization. It is unclear how long these effects lasted. Keywords. colonization; Enterobacterales; extended-spectrum cephalosporins; HIV; Antibiotic resistance.

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