14 Chapter 1 Some patients without a previous history of diabetes have been diagnosed with impaired blood glucose or diabetes at TB diagnosis. This observation is termed transient or stress hyperglycemia; the blood glucose normalises a few weeks after the patient has commenced TB treatment [32]. An elevation in stress hormones and cytokines in response to TB infection is proposed as being responsible for this [32]. This thesis focuses on DM–TB epidemiology, not transient or stress hyperglycemia. Rationale TB burden and TB-related deaths are high in Sub-Saharan Africa, with TB diagnosis and treatment challenges. Concurrently, the highest increase in diabetes mellitus cases will occur in Sub-Saharan Africa by 2045. Available evidence indicates an ongoing epidemiological transition in Sub-Saharan Africa, with changes in lifestyle, inactivity, dietary patterns, smoking, alcohol, and ageing patterns, all contributing to increased diabetes risk with high burdens of tuberculosis and HIV. With a limited understanding of DM–TB comorbidity in Sub-Saharan Africa, this thesis describes the epidemiology of DM–TB in a low-resource setting, the effect of blood glucose on TB treatment outcomes, the opportunities to improve TB patient management practices, the impact of COVID-19 on TB services and recommendations to improve integrated care for DM and TB. Setting The research described in this thesis was conducted in Eswatini (formerly Swaziland). Eswatini is a landlocked country in Southern Africa. It is surrounded by South Africa, except in the northeast, where it shares a border with Mozambique. It has a population of 1.2 million people [33] with four administrative regions – Hhohho, Lubombo, Manzini and Shiselweni (Figure 4). It is classified as a lower middle-income country by the World Bank [33], with a GDP per capita of $3,987 [33]. It has one of the highest global HIV prevalence at 24.8% and an annual TB incidence of 348/100,000 population [34,35].
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