118 Chapter 5 Introduction The World Health Organization (WHO) recommends bidirectional screening for diabetes mellitus (DM) and tuberculosis (TB) [1]. In this approach, DM patients are screened for TB while TB patients are screened for DM to identify cases of each condition that could have been missed. Bidirectional screening is vital in low- and middle-income countries (LMIC) with a high TB prevalence and surge in non-communicable diseases (NCD), including DM [2–4]. The International Diabetes Federation (IDF) estimates that in 2021, 537 million adults were living with diabetes; 50% of these are undiagnosed, while 75% reside in LMICs [4]. This indicates every opportunity for screening should be maximized for improved case finding and treatment as the number of cases is expected to increase to 643 million by 2030 [4]. Similarly, TB accounted for 1.5 million deaths in 2020 [5]. Before 2020, significant progress was made in the global TB response and countries were on track to eradicate TB by 2035, however, the COVID-19 pandemic reversed this progress [6–8]. DM is a recognised risk factor for TB [9–11]. Conversely, TB disease process or its treatment is recognised to alter glucose metabolism resulting in impaired blood glucose [9,12,13]. Hence, the recommendation for bidirectional screening and integrated management by WHO [1]. Different LMICs have integrated bidirectional screening and treatment services for the two conditions with varying outcomes [14–17]. WHO defines integrated services delivery as “the management and delivery of health services so that patients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system” [18]. Services integration offers several benefits. First, in the early identification of cases to limit the spread of infection and development of complications; second, early identification and treatment of DM can reduce the risk for TB infection; third, integration can help optimise the treatment outcomes and retention in care for the different conditions; fourth, integration can improve documentation, monitoring, and reporting of DM and TB, and finally, it can limit resource requirement for health services delivery [19]. In Eswatini, the HIV prevalence is 24.8% in adults aged 15 years and above [20]. Consistent with the high HIV prevalence is the TB incidence of 319/100,000 as of 2021 [21]. Available data from IDF indicates the prevalence of DM is 3·6% in adults, and the age-adjusted prevalence of impaired glucose tolerance is 6·9% [22]. A recent study among outpatient attendees at a tertiary health facility in Eswatini indicates the prevalence of DM and impaired glucose tolerance is 7·3% and 6·5% respectively [23], and 6% and 30% respectively in HIV patients [24]. An estimated 15% of outpatient visits in 2020 were for NCDs, and 4% of these were related to DM [25]. Data on the prevalence of DM in TB patients is not available.
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