157 7 General Discussion and requires further investigation. Unconfirmed reports on the effect of dolutegravir on blood glucose indicate it impairs blood glucose metabolism, resulting in elevated blood glucose or even diabetes in some patients [13]. Dolutegravir is part of a threedrug regimen currently recommended by WHO for the treatment of HIV and has been adopted by different countries, including Eswatini [14,15]. It has been implicated in weight gain, which is associated with blood pressure; hence, it could explain the association between hypertension and unfavourable outcomes [16]. Hypertension as a predictor of unfavourable TB treatment outcomes indicates the need for continuous monitoring and treatment of patients for comorbid conditions, as hypertension can impair different organ functions, limiting outcomes [17]. Unemployment limits access to basic needs, including housing, food and healthcare, thus lowering the quality of life and negatively impacting treatment outcomes. The protective effect of education has been reported in the literature, increasing employment opportunities and access to health education and healthcare [18]. Consistent with findings from Sub-Saharan Africa, most patients with unfavourable treatment outcomes died [19], indicating the need to identify and address the different causes of TB-related mortality beyond HIV. Compared to other studies [20–22], elevated baseline blood glucose was not associated with unfavourable TB treatment outcomes in our study. Health services integration The integration of DM–TB care, access to DM-TB services by patients and opportunities for improved service provision varies across Sub-Saharan Africa. A review describing the adoption of the WHO Collaborative Framework for Care and Control of Tuberculosis and Diabetes indicates that evidence of implementation is available in only 35 out of 94 registered countries, mainly emphasizing screening for both conditions [23]. From our qualitative study, most healthcare workers provide integrated DM-TB care, although with challenges that hinder effective service delivery. These include limited staffing, the absence of guidelines, limited knowledge of DM and TB amongst healthcare workers, limited availability of testing kits for screening, diagnosis and monitoring of DM and TB, and frequent stockouts of DM and TB medications. These findings are similar to those from Ethiopia, India and Zimbabwe, where, in addition to health system-related issues, some patient-related factors such as socioeconomic status and availability of psychosocial support also hindered access to care [23–25]. The cost of managing diabetes is enormous for most patients, often requiring repeat hospital appointments for different services and out-of-pocket payments for medication and laboratory investigations [26]. A comorbid TB infection with diabetes only adds more expenses for the patient, who may need additional financial, psychosocial, and nutritional support to complete TB treatment. However, this extra support may not always be available.
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