92 Chapter 4 Introduction The increasing burden of diabetes mellitus (DM) in low- and middle-income countries (LMICs) poses a significant risk for major global tuberculosis (TB) control efforts [1,2]. This is even as the COVID-19 pandemic halted and reversed gains from past TB efforts and impacted several TB indicators [3–5]. With an effective global COVID-19 response, healthcare services and other economic activities have recovered. Still, different infrastructure and health system challenges that limit effective DM and other noncommunicable disease (NCD) responses in most LMICs persist. This has enabled a concurrent increase in DM and other NCDs in LMICs that mostly saw infectious diseases, particularly HIV and TB[2]. Moreover, the World Health Organization (WHO) recognises DM as a significant risk for TB disease and unfavourable treatment outcomes in people receiving treatment for TB and drug-resistant TB (DRTB)[1,6–9]. To address this risk, the WHO has provided a framework to guide country programs on the bidirectional screening and integrated treatment for TB in NCD programs (including DM) [10] and the integration and prevention of NCDs in infectious disease programs [11]. These guiding documents further advocate for political commitment, policy, and financing to sustain collaborative actions for TB and comorbidities. They also encourage the institution of appropriate monitoring, evaluation, and research measures to enable a better understanding of the burden of DM and TB comorbidity among people living with HIV. This would guide the integration of patient-centred services across programs and diseases regardless of the population affected. The global prevalence of DM in people receiving treatment for TB is estimated to be 15 - 16% [12,13]. This prevalence varies by region: 6.7 - 8% in Africa, 17% in Asia, 5.9 – 7.5% in Europe, 19 - 23.6% in North America, 7.7-11% in South America and 23.2% in Oceania [12,13]. Notwithstanding these estimates, the burden varies within countries as the prevalence of 44%, 16.7%, and 12% have been reported in India, Tanzania and Fiji respectively [13]. Male sex, older age, urban area residents, smoking, drinking alcohol, HIV coinfection, and a family history of DM are identified risk factors for DM in people receiving TB treatment [13,14]. In Eswatini, where the HIV prevalence in adults aged ≥15 years is 24.8%, with an ageing cohort of people living with HIV, the annual TB incidence is 348/100 000 population [15,16]. Access to DM services, including screening, diagnostic testing and drugs, is limited and varies by site, with some patients paying out-of-pocket for care [17–19]. Available data to guide NCD programming is limited. The International Diabetes Federation (IDF) in 2021 estimated a 3.6% prevalence of DM in adults in Eswatini [20]. A hospital-based outpatient study indicated the age-adjusted prevalence of pre-diabetes and type 2 DM
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