Diabetes Evaluation in TB Patients in Eswatini for Improving TB/HIV Care and Treatment (DETECT) Study

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PROJECT SUMMARY HIV, tuberculosis (TB), and diabetes mellitus (DM) are major causes of morbidity and mortality globally. DM and prediabetes (preDM) are growing rapidly worldwide but 69% of persons living with DM in sub-Saharan Africa are unaware they have DM. Persons living with HIV are more likely to have DM than those without HIV, and DM is especially prevalent among newly diagnosed TB patients globally. Poorly controlled DM increases the risk of TB and leads to suboptimal TB treatment outcomes. Diagnosing DM early in TB treatment and assessing the adequacy of glycemic control are important. HIV, TB, and DM are all in the top 10 causes of mortality in Eswatini, and DM prevalence in Eswatini is 6.6%; 36.1% of the population is overweight and 14.8% obese. With one of the world’s most severe HIV and TB epidemics (HIV prevalence=27%, TB incidence=329 per 100,000, and 66% of TB patients are HIV-positive), Eswatini is an optimal setting to evaluate what proportion of TB patients are on the DM spectrum ([DMS], i.e., have DM or preDM), how their TB treatment outcomes compare to TB patients without DMS, and whether they vary by HIV status. The DETECT (Diabetes Evaluation in TB patients in Eswatini for improving TB/HIV Care and Treatment) study will use mixed methods to assess DMS prevalence and incidence as well as TB treatment outcomes in TB patients in Eswatini and explore the suitability of lifestyle management intervention strategies to facilitate TB treatment success and glycemic control. We will screen all adult TB patients diagnosed and treated in Ministry of Health facilities in the Manzini Region for DMS during the study period, and abstract TB treatment outcomes from medical records. We will administer a quantitative survey regarding DMS risk factors and lifestyle preferences to two measurement cohorts of TB patients with and without DMS and retest them for DMS at the end of TB treatment. We will also conduct qualitative in-depth interviews with TB/DMS patients, healthcare providers, and key informants to elicit insights on barriers to and facilitators of TB treatment success and glycemic control in TB/DMS patients and assess feasibility and acceptability of potential lifestyle intervention components. The study will leverage long-standing collaborations between ICAP, the Eswatini National TB Control, AIDS, and Non-Communicable Diseases Programs, and a well-trained, highly productive team with substantial experience in implementation science research in sub-Saharan Africa to inform the improvement of TB/DMS care in the context of HIV infection in high TB and HIV burden settings. Following this study, in collaboration with the MOH and based on the above results, we will develop a multicomponent, culturally-tailored behavioral intervention strategy to support the improvement of TB outcomes and glycemic control in TB/DMS patients. The intervention strategy’s effectiveness, cost-effectiveness, and acceptability will be tested in a future, larger trial.