Background: Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) remain closely intertwined epidemics in sub-Saharan Africa. HIV-associated immunosuppression increases the risk of active TB and may complicate treatment outcomes, while poor adherence to anti-TB therapy undermines disease control. Aim: This study determined the prevalence of TB–HIV coinfection, the level of anti-TB drug adherence, and associated factors among TB patients attending the Specialist Hospital, Sokoto, Nigeria. Materials and Methods: A hospital-based cross-sectional study was conducted among 187 adult TB patients receiving treatment at the Specialist Hospital, Sokoto. Participants were selected using systematic sampling. Data were collected using a structured, interviewer-administered questionnaire and a review of clinical records. Descriptive statistics, chi-square tests, and multivariate logistic regression analyses were performed using IBM SPSS version 25, with statistical significance set at p<0.05. Results: The prevalence of TB–HIV coinfection was 19.0%. Coinfection was significantly associated with male sex, non-Hausa ethnicity, formal education, Christianity, and urban residence (p<0.05). Independent predictors included male sex (aOR=2.56; 95% CI: 1.01–6.49), non-Hausa ethnicity (aOR=0.20; 95% CI: 0.07–0.54), and rural residence (aOR=0.43; 95% CI: 0.20–0.93). Overall, 58.8% of participants demonstrated low adherence to anti-TB medications. Drug adherence was significantly associated with family structure, ethnicity, educational status, perceived social support, mood disorders, and coping strategies. Predictors of better adherence included non-formal education (aOR=2.38; 95% CI: 1.12–5.08), monogamous family structure (aOR=2.10; 95% CI: 1.00–4.42), strong perceived family support (aOR=0.45; 95% CI: 0.23–0.88), and active coping strategies. Conclusion: TB–HIV coinfection remains a significant burden among TB patients in Sokoto, while adherence to anti-TB therapy is suboptimal. Strengthening adherence support and addressing key sociodemographic and psychosocial determinants may improve treatment outcomes and enhance TB control efforts.