156 Chapter 7 Diabetes – Tuberculosis Comorbidity This thesis described diabetes mellitus (DM) and tuberculosis (TB) comorbidity in a lowresource setting, the effect of blood glucose on TB treatment outcomes, the impact of COVID-19 on TB services, and recommendations to improve integrated DM-TB care. Given the high burden of TB and DM-related mortality in Sub-Saharan Africa, urgent attention is required to limit mortality from the two conditions and to promote health [1–3]. As most cases of DM are undiagnosed [4], and countries in Sub-Saharan Africa still struggle to find TB cases [3], innovative approaches for screening, timely diagnosis, and managing DM and TB are essential. Although the association between DM and TB has been described previously [5–9], there are few studies on blood glucose changes during TB treatment in non-diabetic individuals. In our scoping review to assess the available evidence on this subject, we noted that the observed high prevalence of diabetes and pre-diabetes at diagnosis reduced or normalized during TB treatment, with only a few patients remaining with elevated blood glucose at the end of treatment. This transient increase in blood glucose has been linked to unfavourable TB treatment outcomes, emphasizing the importance of integrating blood glucose monitoring with TB care during TB treatment for every patient, not just those with diabetes. Abnormalities in blood glucose during TB treatment will be missed if patients without diabetes are not monitored, contributing to unfavourable TB treatment outcomes. The described epidemiology of DM-TB presented in this thesis is similar to what is reported in the general literature, with some variations given the differences across SubSaharan African populations. Our prevalence of 8% elevated baseline blood glucose is similar to the reported prevalence from studies conducted in Tanzania and Uganda and a pooled prevalence of studies from Sub-Saharan Africa [8]. We conducted our study in Eswatini, which has a largely homogeneous population with similar dietary patterns and risks for TB infection. So, prevalence across regions in the country did not vary as expected in a more densely populated country with diverse cultures, nutritional habits, risks of TB infection and access to health services [9,10]. The prevalence was higher in people aged 40 and above and those with a reactive HIV status than in younger people and those with a negative HIV status. This finding is consistent with the general literature, as people aged 40 and above are more likely to have an NCD. Metabolic and inflammatory changes and medication taken by HIV-positive patients may also contribute to their diabetes risks [5,9,11,12]. A family history of diabetes and a positive HIV status predicted elevated blood glucose, while hypertension and unemployment were associated with unfavourable TB treatment outcomes. High school education was protective against unfavourable TB outcomes. The effect of HIV status on blood glucose is conflicting
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