Framework for

collaborative action
on tuberculosis
and comorbidities
Framework for
collaborative action
on tuberculosis
and comorbidities
Framework for collaborative action on tuberculosis and comorbidities

ISBN 978-92-4-005505-6 (electronic version)

ISBN 978-92-4-005506-3 (print version)

© World Health Organization 2022

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike
3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided
the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO
endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt
the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a
translation of this work, you should add the following disclaimer along with the suggested citation: “This translation
was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of
this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation
rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/).

Suggested citation. Framework for collaborative action on tuberculosis and comorbidities. Geneva: World Health
Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO.

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests
for commercial use and queries on rights and licensing, see https://www.who.int/copyright.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables,
figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain
permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned
component in the work rests solely with the user.

General disclaimers. The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory,
city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines
on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or
recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication. However,
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility
for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising
from its use.

Design by Inis Communication.

Contents

Acknowledgements iv

Abbreviations and acronyms vii

Definitions viii

Executive summary ix

Introduction 1
Background and rationale 1
Overview of key comorbidities  2
Key drivers of the TB epidemic 2
Other health-related risk factors and comorbidities 4
Principles 7
Goal, aim and objectives 9
Scope 9
Process of development 9
Planned dissemination 10
Target audience 10

Framework for collaborative action on TB and comorbidities 12

A. Strengthen governance and accountability for collaborative action 14
B. Conduct an analysis of access to quality services for TB and comorbidities  19
C. Coordinate planning and resource mobilization for collaborative action  24
D. Implement and scale up people-centred services for TB and comorbidities 32
E. Strengthen monitoring, evaluation and research 40

References 45

Annex 1. Relevant WHO documents 56

Annex 2. Barriers to and enablers of collaborative care 58

Annex 3. Declaration of interests 71

iii
 Acknowledgements

This Framework was developed by Annabel Baddeley and Anna Carlqvist (consultant), with inputs
from Kerri Viney and Farai Mavhunga, under the overall direction of Tereza Kasaeva, director,
all at WHO Global TB Programme. The Global TB Programme gratefully acknowledges all the
experts and reviewers who contributed to the development of this Framework, as well as the
TB survivors who shared their experiences during interviews, and the contributors to the case
studies.

Experts consulted during focus group discussions, stakeholder

consultation and external review
Akaki Abutidze (Infectious Diseases, AIDS and Clinical Immunology Research Center, Georgia),
Priyanka Agarwal (National TB Elimination Programme, India), Nadia Ait-Khaled (International
Union Against TB and Lung Disease, Algeria), Nasim Akhtar (National TB Control Program,
Pakistan), Denise Arakaki Sanchez (Ministry of Health, Brazil), Lawrence Atundo (AMPATH-BMSF
Lung Cancer Care and Research Program, Kenya), Samram Azhar (Ministry of Health, Pakistan),
Irina Barbirosh (Ministry of Justice, Republic of Moldova), Veronika Becerra (Ministry of Health,
Peru), Sara Bernardini (World Food Programme [WFP] headquarters, Italy), Anurag Bhargava
(Yenepoya Medical College, India), Carmen Contreras (Partners in Health, Peru), Jacob Creswell
(Stop TB Partnership, Switzerland), Degu Dare (KNCV Tuberculosis Foundation, Netherlands),
Anand Date (United States Centers for Disease Control and Prevention, United States of America
(USA)), Riitta Dlodlo (International Union Against Tuberculosis and Lung Disease, Zimbabwe),
Svetlana Doltu (Act for Involvement, Republic of Moldova), Waqo Ejersa (National TB, Leprosy
and Lung Disease Programme, Kenya), Allan Fabella (Department of Health, Disease Prevention
and Control Bureau, Infectious Disease Division [National TB Control Program], the Philippines),
Razia Fatima (Common unit to manage TB, HIV/AIDS and Malaria, Pakistan), Kathy Fiekert
(KNCV Tuberculosis Foundation, Netherlands), Mike Frick (Treatment Action Group, USA),
Martha Angélica García Avilés (National TB Programme, Mexico), Anna Marie Celina Garfin
(Department of Health, Disease Prevention and Control Bureau, Infectious Disease Division
[National TB Control Programme], the Philippines), Celeste Gracia Edwards (Global Fund to
Fight AIDS, Tuberculosis and Malaria, Switzerland), Mauro Guarinieri (International Network of
People who use Drugs, Switzerland), Jorge Hancco (Ministry of Health, Peru), Anthony Harries
(International Union Against TB and Lung Disease, France), Harry Hausler (TB HIV Care , Civil
Society Task Force on TB, South Africa), Henry Hernandez (Ministry of Health, Peru), Laura Elena
Gloria Hernández (Ministry of Health, Mexico), Rosemarie Holandes (Department of Health,
Disease Prevention and Control Bureau, Infectious Disease Division [Noncommunicable Disease
Division], the Philippines), Akhtar Hussain (International Diabetes Federation, Belgium), Khaleda
Islam (Independent consultant, Bangladesh), Shamiul Islam (National TB Control Programme,
Bangladesh), Zahedul Islam (Alliance for Public Health, Ukraine), Bushra Jamil (Common unit
to manage TB, HIV/AIDS and Malaria, Pakistan), Franz Kaluhoni (Division Special Programmes,
Otjozondjupa region, Namibia), Fatima Karmadwala (member of Civil Society Task Force on
TB and TB survivor, United Kingdom of Great Britain and Northern Ireland), Fungai Kavenga
(National TB Programme, Zimbabwe), Oanh Khuat Thi Hai (Center for Supporting Community
Development Initiatives, Viet Nam), Huong Kieu Thi Mai (Center for Supporting Community
Development Initiatives, Viet Nam), Nana Kiria (National Center of TB and Lung Diseases,

iv Framework for collaborative action on tuberculosis and comorbidities

Georgia), Jacqueline Kisia (National TB, Leprosy and Lung Disease Programme, Kenya), Tenzin
Kunor (We Are TB; member of Civil Society Task Force on TB and TB survivor, USA), María
de Lourdes Martínez Olivares (National TB Programme, Mexico), Fatima Leticia Luna López
(National TB Programme , Mexico), Knut Lönnroth (Karolinska Institute, Sweden), Diana Mallari
(National TB Control Program, the Philippines), Litman Mamani Masco (Ministry of Health, Peru),
Sanjay Kumar Mattoo (National TB Elimination Programme, India), Lalit Mehandru (National TB
Elimination Programme, India), Muhammad Mputu (USAID Sustaining Technical and Analytical
Resources [STAR] Project, Zambia), Phangisile Mtshali (Bristol Myers Squibb Foundation, South
Africa), Regina Mucuha (Nutrition Programme, Kenya), Justice Mudavanhu (NCD Programme,
Zimbabwe), Helena Mungunda (National TB and Leprosy Programme; USAID/STAR Project/
Elements Global Services, Namibia), Ndilimeke Mutikisha (Public and Environmental Health
Division, Namibia), Ndahafa Nandjebo (National TB and Leprosy Programme, Namibia), Odon
Nkongolo (Ohangwena Health Directorate, Namibia), Mary Nyagah (National TB, Leprosy and
Lung Disease Programme, Kenya), Gillian Nyamari (Nutrition Programme, Kenya), Boru Okotu
(National TB, Leprosy and Lung Disease Programme, Kenya), Hamimu Omary Kigumi (National TB
and Leprosy Programme, United Republic of Tanzania), Aminata Ouattara (UNAIDS, Switzerland),
Imran Pambudi (National TB Programme, Indonesia), Aneeta Pasha (Interactive Research and
Development, Civil Society Task Force on TB, Pakistan), Harolalaina Rakotondrazanany (National
TB Programme, Madagascar), Njaka Ramalanjaona (WFP country office, Madagascar), Henry
Perez Reyes (Ministry of Health, Mexico), Shobini Rajan (National AIDS Control Programme,
India), Teri Roberts (Elizabeth Glaser Pediatric AIDS Foundation, Switzerland), Liliana Romero
Vega (Ministry of Health, Brazil), Jeremy Ross (TreatAsia, Thailand), Nunurai Ruswa (National TB
and Leprosy Programme, Namibia), Mary Rose Santiago (FHI360, the Philippines), Rita Shililifa
(National TB and Leprosy Programme, Namibia), Sanghyuk Shin (University of California Irvine,
USA), Miriam Schneidman (independent consultant, USA), Karolina Shiyagaya (Division Special
Programmes, Oshana region, Namibia), Kamran Siddiqi (University of York, United Kingdom),
Michael Smith (WFP headquarters, Italy), Alistair Story (Find&Treat, University College London,
United Kingdom), Annika Sweetland (Columbia University, USA), Allan Tarimo (National TB and
Leprosy Programme, United Republic of Tanzania), Ina Tcaci (UNODC, Republic of Moldova), Esti
Widiastuti (Noncommunicable Diseases Department, Indonesia), Mukadi YaDiul (United States
Agency for International Development [USAID], USA), Aung Yu Naing (Asian Harm Reduction
Network, Myanmar), Nonhlanhla Xaba (WFP regional office, South Africa), Dzmitry Zhurkin
(Republican Scientific-Practical Center of Pulmonology and Phthisiatry, Belarus), Luunga Ziko
(Centre for Infectious Disease Research in Zambia [CIDRZ], Zambia)

Technical consultants
Rachel Beanland (WHO consultant, France), Amrita Daftary (York University, Canada), Uzochukwu
Egere (Liverpool School of Tropical Medicine, United Kingdom), Stephanie Law (McGill University,
Canada), Tom Wingfield (Liverpool School of Tropical Medicine, United Kingdom)

WHO headquarters
Oyetayo Akala (Department of Noncommunicable Diseases), Annabel Baddeley (Global TB
Programme), Shannon Barkley (Special Programme on Primary Health Care), Dennis Falzon
(Global TB Programme), Nathan Ford (Global HIV, Hepatitis and STIs Programmes), Dongbo Fu
(Department of Health Promotion), Maria de las Nieves Garcia Casal (Department of Nutrition
and Food Safety), Sayohat Hasanova (Global TB Programme), Bianca Hemmingsen (Department
of Noncommunicable Diseases), Ernesto Jaramillo (Global TB Programme), Avinash Kanchar
(Global TB Programme), Dzmitry Krupchanka (Department of Mental Health and Substance Use),

Acknowledgements v
 Irwin Law (Global TB Programme), Aiysha Malik (Department of Mental Health and Substance
Use), Farai Mavhunga (Global TB Programme), Cicilia Parwati (Global TB Programme), Vladimir
Poznyak (Department of Mental Health and Substance Use), Vinayak Prasad (Department of
Health Promotion), Gojka Roglic (Department of Noncommunicable Diseases), Sarah Rylance
(Department of Noncommunicable Diseases), Charalampos Sismanidis (Global TB Programme),
Susan Sparkes (Department of Health Systems Governance and Financing), Lana Syed (Global
TB Programme), Maike van Niekerk (Department of Mental Health and Substance Use), Mark
van Ommeren (Department of Mental Health and Substance Use), Sabine Verkuijl (Global TB
Programme), Clarisse Veylon Hervet (Global TB Programme), Kerri Viney (Global TB Programme),
Marco Vitoria (Global HIV, Hepatitis and STIs Programmes), Temo Waqanivalu (Department of
Noncommunicable Diseases), Hongyi Xu (Department of Noncommunicable Diseases)

WHO regional and country offices staff

Pedro Avedillo (Regional Office for the Americas), Kenza Bennani (Regional Office for the Eastern
Mediterranean), Martin van den Boom (Regional Office for the Eastern Mediterranean), Maria
Regina Christian (Country Office for Indonesia), Aina Erastus (Country Office for Namibia), Ileana
Fleitas (Country Office for Mexico), John Juliard Go (Country Office for the Philippines), Jonas
Gonseth (Regional Office for the Americas), Viatcheslav Grankov (Country Office for Belarus),
Jose Guallar (Regional Office for the Americas), Rohini Gupta (Country Office for India), Thomas
Hiatt (Country Office for the Philippines), Tauhidul Islam (Regional Office for the Western Pacific),
Bhavin Jani (Country Office for United Republic of Tanzania), Joel Keravec (Country Office for
Brazil), Kassa Ketema (Country Office for Sierra Leone), Shahzad Khan (Country Office for
Pakistan), Laeeq Khawaja (Country Office for Pakistan), Hugues Lago (Regional Office for Africa),
Rachel Seungyun Lee (Regional Office for the Western Pacific), Rafael Lopez (Regional Office for
the Americas), Huq Mahfuzul Syed (Country Office for Bangladesh), Nino Mamulashvili (Country
Office for Georgia), Partha Pratim Mandal (Regional Office for South-East Asia), Ruben Mayorga
(Regional Office for the Americas), Virginia Molina Cuevas (Country Office for Mexico), Ernesto
Montoro (Regional Office for the Americas), Edmundo Morales (Country Office for Mexico),
Fausta Mosha (Regional Office for Africa), Antons Mozalevskis (Regional Office for Europe),
Edmore Munongo (Country Office for Zimbabwe), Elick Narayan (Regional Office for the Western
Pacific), Fabian Ndenzako (Regional Office for Africa), Andre Ndongosieme (Regional Office
for Africa), Edgardo Nepo (Country Office for Peru), Mkhokheli Ngwenya (Country Office for
Zimbabwe), Renato Oliveira (Regional Office for the Americas), James Otieno (Country Office for
Kenya), Malik Parmar (Country Office for India), Vivian Pérez (Country Office for Peru), Hernán
Rodríguez (Country Office for Peru), Nazis Arefin Saki (Country Office for Bangladesh), Hans
Salas (Country Office for Peru), Maria Jesus Sánchez (Country Office for Mexico), Nicole Seguy
(Regional Office for Europe), Mukta Sharma (Regional Office for South-East Asia), Soledad
Urrutia (Regional Office for the Americas), Alexandru Voloc (Country Office for the Republic of
Moldova), Hubert Wang (Country Office for Madagascar), Rajendra Yadav (Country Office for
the Philippines), Kouadio Yeboue (Regional Office for Africa), Askar Yedilbayev (Regional Office
for Europe)
Funding from the Bristol Myers Squibb Foundation, the Republic of Korea and United States
Agency for International Development (USAID) is gratefully acknowledged.

vi Framework for collaborative action on tuberculosis and comorbidities

Abbreviations and acronyms

AIDS acquired immunodeficiency syndrome

ART antiretroviral therapy
BMI body mass index
CCM country coordinating mechanism
COVID-19 coronavirus disease
DHIS2 District Health Information Software
HBV hepatitis B virus
HCV hepatitis C virus
HIV human immunodeficiency virus
IPC infection prevention and control
IQR interquartile range
MAF-TB Multisectoral accountability framework for TB
MDR-TB multidrug-resistant tuberculosis
MDT multidisciplinary team
mhGAP Mental Health Gap Action Programme
MOOC massive open online course
MUAC middle upper arm circumference
NCD noncommunicable disease
NGO nongovernmental organization
NSP national strategic plan
NTP national tuberculosis programme
OAMT opioid agonist maintenance therapy
ONN Office National de Nutrition
PHC primary health care
PPM public–private mix
PWID people who inject drugs
PWUD people who use drugs
SARA Service Availability and Readiness Assessment
SDGs Sustainable Development Goals
TB tuberculosis
TNFα tumour necrosis factor alpha
UHC universal health coverage
UN HLM United Nations high-level meeting
VCC Vulnerable populations, Communities and Comorbidities Unit
WFP World Food Programme
WHO World Health Organization

vii
 Definitions

Civil society organizations: Non-profit organizations that operate independently from the state
and from the private-for-profit sector, e.g. advocacy groups, faith-based and community-based
and community-led organizations, and other nongovernmental organizations.
Comorbidity: A concurrent disease or health condition in a person with tuberculosis (TB).
Disorders due to substance use: According to the International Classification of Diseases
(ICD)-11 (1), the term “disorders due to substance use” refers to a group of disorders that arise
from a single or repeated use of substances that have psychoactive properties, including certain
medications. For the purposes of this Framework, “disorders due to substance use” is divided
into “disorders due to alcohol use” (or “alcohol use disorders”), which refer specifically to the
use of alcohol, and “disorders due to drug use” (or “drug use disorders”), which refer to the use
of psychoactive substances other than alcohol and nicotine.
Health-related risk factor: A condition, disease or behaviour that increases the likelihood of
developing TB.
High-quality health care: Health services that are safe, effective and people-centred, providing
timely, equitable, integrated and efficient care (2).
Multimorbidity: The presence of two or more concurrent diseases or health conditions in a
person with TB.
Operational research: Research aimed at improving programme performance, or to assess the
feasibility, effectiveness or impact of new interventions and to guide policy recommendations (3).
People-centred services: A human rights-based approach to care that consciously adopts the
perspectives of individuals, carers, families and communities as participants in, and beneficiaries
of, trusted health systems that respect social preferences and are organized around the
comprehensive needs of people rather than individual diseases (4).
Primary care: A key process in the health system that supports accessible, continued,
comprehensive and coordinated patient-focused care at the first point of contact (5).
Primary health care: A whole-of-society approach to health that aims to maximize the level and
distribution of health and well-being through three components: (i) primary care and essential
public health functions as the core of integrated health services; (ii) multisectoral policy and
action; and (iii) empowered people and communities (5).
Social determinants of health: Non-medical factors that influence health outcomes. Examples
include, but are not limited to, income and social protection, education, food security, housing,
basic amenities and the environment, social inclusion and non-discrimination, and access to
affordable health services of decent quality (6).
Tuberculosis (TB): The disease state due to Mycobacterium tuberculosis (7). In this document,
it is commonly referred to as “TB disease” to distinguish it from TB infection.
Tuberculosis (TB) infection: A state of persistent immune response to stimulation by
Mycobacterium tuberculosis antigens with no evidence of clinically manifest active TB (7).
Universal health coverage: Under universal health coverage, individuals and communities
have access to high-quality promotive, preventive, curative, rehabilitative and palliative essential
health services without experiencing financial hardship (8).

viii Framework for collaborative action on tuberculosis and comorbidities

Executive summary

Globally, tuberculosis (TB) remains one of the leading causes of death due to a single infectious
agent. The main TB comorbidities and health-related risk factors include human immunodeficiency
virus (HIV), disorders due to the use of alcohol, undernutrition, tobacco smoking, diabetes
mellitus, mental disorders, silicosis and viral hepatitis. Addressing health-related risk factors
and comorbidities among people with TB is essential for ending the TB epidemic. To achieve
this, care should be organized around the end user, rather than around the respective diseases.
There is substantial global commitment to address TB and comorbidities collaboratively.
Integrated patient-centred care and prevention for TB, including for HIV-associated TB and
other comorbidities are key components of pillar one of the End TB Strategy (9). The importance
of integrated people-centred services is reiterated by the political declarations of the respective
United Nations high-level meetings (UN HLMs) on the fight against TB (10), on noncommunicable
diseases (NCDs) (11), on HIV and AIDS (12), and on universal health coverage (UHC) (8).
Although global guidance on interventions to address TB and comorbidities exists, its uptake
has been variable. Therefore, the World Health Organization (WHO), in consultation with key
stakeholders, has developed a Framework for collaborative action on TB and comorbidities to
enhance the response to TB and comorbidities, contributing towards addressing multimorbidity
as part of people-centred care. The Framework is complementary to, and intended to be used
in conjunction with, WHO guidelines on the prevention, screening, diagnosis and treatment of
TB and key comorbidities. The strategies presented in this document endeavour to build strong
collaboration across health programmes, affected communities, civil society, public and private
health sectors, non-health actors and other stakeholders involved in health and social protection
for people with TB and comorbidities.
This Framework is intended for use by people working in ministries of health, particularly in
national programmes or departments responsible for TB, HIV, NCDs, primary health care, tobacco
cessation, undernutrition and substance use. It is also targeted at relevant line-ministries, policy-
makers, international technical and funding organizations, researchers, nongovernmental and
civil society organizations. In addition, it is intended for primary care workers, specialist health
practitioners, and community health workers who support the response to TB and comorbidities
both in the public and private sectors.
The Framework is organized in the following five sections, each of which lists key activities for
scaling up collaborative action on TB and comorbidities. These sections are: (A) Strengthen
governance and accountability for collaborative action; (B) Conduct an analysis of access to
quality services for TB and comorbidities; (C) Coordinate planning and resource mobilization
for collaborative action; (D) Implement and scale up people-centred services for TB and
comorbidities; and (E) Strengthen monitoring, evaluation and research.

ix
 Summary of the Framework for collaborative
action on TB and comorbidities

A Strengthen governance and accountability for collaborative action

A.1 Strengthen political commitment, coordination and accountability for collaborative action on
TB and comorbidities
A.2 Support financing and legislation that promote people-centred care
A.3 Ensure meaningful engagement of civil society and affected communities at all stages of planning,
implementation, monitoring and evaluation

B Conduct an analysis of access to quality services for TB and comorbidities

B.1 Assess the joint burden of TB and comorbidities
B.2 Determine access to services and the financial burden for people with TB and comorbidities
B.3 Map health service delivery for TB and comorbidities
B.4 Identify gaps in services and conduct root cause analysis

C Coordinate planning and resource mobilization for collaborative action

C.1 Identify priority comorbidities and interventions
C.2 Define and reorient models of care for TB and comorbidities towards people-centred services,
primary health care and universal health coverage
C.3 Conduct collaborative planning and budgeting to scale up people-centred services for TB and
comorbidities
C.4 Align advocacy and communication across health programmes

D Implement and scale up people-centred services for TB and comorbidities

D.1 Jointly develop policies, guidelines and procedures for collaborative action on TB and comorbidities
D.2 Mobilize a qualified multidisciplinary workforce, including among private providers and non-
health sectors for collaborative action
D.3 Ensure access to essential medicines, vaccines, diagnostics and health technologies for TB and
comorbidities
D.4 Engage civil society and communities affected by TB and comorbidities in refining and delivering
people-centred services
D.5 Optimize access to social protection to prevent financial hardship due to TB and comorbidities
D.6 Facilitate uptake of digital technologies to deliver health and social protection services across
programmes
D.7 Introduce phased scale-up of people-centred services for TB and comorbidities

E Strengthen monitoring, evaluation and research

E.1 Adopt indicators and set targets for collaborative action on TB and comorbidities
E.2 Strengthen surveillance for comorbidities among people with TB, and surveillance for TB among
people with comorbidities and health-related risk factors in accordance with WHO recommendations
E.3 Introduce and scale up monitoring and evaluation of collaborative action on TB and comorbidities
at all levels
E.4 Conduct joint reviews of quality and coverage of services to inform programming
E.5 Conduct operational and implementation research to inform policy, programming and service
delivery

x Framework for collaborative action on tuberculosis and comorbidities

Introduction

Background and rationale

Globally, tuberculosis (TB) remains a significant cause of ill health and is a leading cause of
death due to an infectious agent. In 2020, five key health-related risk factors for TB, namely,
diabetes, human immunodeficiency virus (HIV), disorders due to alcohol use, tobacco smoking
and undernutrition accounted for 4.5 million (45%) new and relapse TB episodes globally (13).
Other significant health-related risk factors for TB disease include silicosis and disorders due
to drug use. These health-related risk factors are considered comorbidities when a person also
has TB. People with TB frequently experience other comorbidities including mental disorders
and viral hepatitis. All these comorbid conditions are associated with poorer TB treatment
outcomes and adverse socioeconomic impact. Moreover, people with TB may develop chronic
lung disease, requiring care and rehabilitation after completing treatment for TB. The COVID-19
pandemic shares common risk factors for poor outcomes with TB and has led to increased
poverty, undernutrition, mental health burden and stigma associated with social distancing
measures (14). Further, the disruption of services during the pandemic has highlighted the need
for integrated, people-centred approaches, and implementation of improved, evidence-based
models of care (15).
Addressing individual comorbidities, multimorbidity and health-related risk factors for TB
is therefore crucial as part of accelerated efforts to end TB. Thus, pillar one of the End TB
Strategy focuses on integrated patient-centred care and prevention, including action on TB and
comorbidities (9). In September 2018, the Political Declaration of the United Nations High Level
Meeting (UN HLM) on the fight against tuberculosis (10) reaffirmed the commitment to ending
the TB epidemic globally by 2030, in line with the Sustainable Development Goals (SDGs) (16).
In the declaration, Member States committed to a comprehensive response that addresses TB
and comorbidities, and social and economic determinants of the epidemic, that protects and
fulfils all people’s human rights and dignity. This commitment was echoed in the respective UN
HLM declarations on noncommunicable diseases (NCDs) and HIV in 2018 and 2021, respectively,
in which Member States committed to assuring integrated people-centred services for TB, HIV,
NCDs and mental health (10,11).
Although global guidance on interventions to address TB and key comorbidities exists (see
Annex 1), its uptake by most countries has been limited. One exception is the uptake of guidance
and policy on HIV-associated TB, which has been progressively scaled up globally in many
settings, due to strong advocacy and investment in both the TB and HIV programmes. Building
upon the success of the WHO policy on collaborative TB/HIV activities (17), the Framework for
collaborative action on TB and comorbidities, hereafter referred to as the Framework, aims to
support countries in the evidence-informed introduction and scale-up of holistic people-centred
services for TB and comorbidities, with the ultimate goal of comprehensively addressing TB and
multimorbidity. Beyond the impact on TB, collaborative action on TB and comorbidities may also
improve efficiency of resource use, reduce healthcare visits, address fragmentation in health
systems and improve health outcomes.

1
 Overview of key comorbidities
For the purposes of this Framework, a health-related risk factor is a condition or behaviour that
increases the risk of TB disease. When combined with TB, health-related risk factors are also
considered comorbidities, and may increase the risk of poor TB treatment outcomes. There
are five main health-related risk factors that drive the TB epidemic globally, namely, diabetes,
disorders due to alcohol use, HIV, smoking and undernutrition. However, the impact of these
conditions on TB differs between countries. This Framework supports the uptake of WHO
guidance on these comorbidities, and will also be applicable for scaling up action on other
comorbidities as evidence emerges. An overview of the related interventions is given in Table 1.
Table 2 summarizes the health-related risk factors and comorbidities, for which there are WHO-
recommended interventions.

Table 1. Interventions to address TB and comorbidities

Reduce the burden of TB among

people with health-related risk factors Reduce the burden of comorbidities
and comorbidities among people with TB

Find and treat TB among people with Find and treat comorbidities among people
key health-related risk factors for TB with TB through screening, diagnosis and
disease, through screening or intensified treatment of comorbidities associated with
case-finding, diagnosis and appropriate poor TB treatment outcomes
treatment
Prevent TB among people with identified Prevent comorbidities among people with TB
health-related risk factors through the
provision of TB preventive treatment and
infection prevention and control

Key drivers of the TB epidemic

Disorders due to alcohol use

Disorders due to alcohol use triple the risk of TB disease, and accounted for 740 000 new TB
episodes in 2020 (13). Notably, there are considerable sex differences in the proportion of TB
episodes attributed to alcohol use disorders. In 2020, the proportion of TB episodes attributed
to alcohol was 13% among men and 1.7% among women (13). The estimated global prevalence
of disorders due to alcohol use among adults (aged 15+ years) was 5.1% in 2016; however, there
are significant regional differences, with the prevalence of alcohol use disorders among adults
ranging from 0.8% in the Eastern Mediterranean Region to 8.8% in the European Region (18).
In 2016, alcohol was the cause of an estimated 254 000 deaths from TB (18). People with TB
who consume alcohol are twice as likely to have a poor TB treatment outcome (treatment
failure, death, or loss to follow-up) (19). Alcohol use disorder is listed in the WHO TB screening
guidelines as a risk factor to consider when prioritizing TB screening among people attending
healthcare settings (20). Regular clinical monitoring and psychological support, including
counselling for alcohol cessation, are recommended among people with TB who also have
alcohol use disorder (21).

2 Framework for collaborative action on tuberculosis and comorbidities

Diabetes mellitus
Diabetes is associated with a two-to-three-fold risk of TB disease, and a higher risk of multidrug-
resistant TB (MDR-TB). People with TB and diabetes are twice as likely to die during TB treatment,
and have a four-fold risk of TB relapse after treatment completion (22–24). In 2020, an estimated
369 000 new episodes of TB were attributable to diabetes, and in 2019 just over 15% of people
with TB were estimated to have diabetes globally, compared with 9.3% among the general adult
population (aged 20–79 years) (13,25,26). This equates to about 1.5 million people with TB and
diabetes who required coordinated care and follow-up to optimize the management of both
conditions. Diabetes is estimated to increase globally by 50% between 2019 and 2045, with a
median increase of 99% (interquartile range [IQR]: 69–151%) in countries with a high burden
of TB (13). In 2011, WHO and the International Union Against Tuberculosis and Lung Disease
published the Collaborative framework for care and control of tuberculosis and diabetes (27).
Collaborative activities outlined in the framework include the establishment of mechanisms for
collaboration, detection and management of TB among people with diabetes, and detection
and management of diabetes among people with TB.

HIV
People living with HIV are at 18 times higher risk of developing TB than the rest of the
population (28), and in 2020, an estimated 787 000 people with HIV developed TB (29). People
with advanced HIV are at higher risk of developing TB disease (30). TB remains a leading cause
of hospitalization and in-hospital death among adults and children living with HIV worldwide,
and accounts for about a third of all HIV-related deaths (13,31). A global review of autopsy
studies, among people who had died from HIV, found 40% prevalence of TB among adults, with
only 45% of TB diagnosed before death (32). In 2004, WHO released the Interim WHO policy
on collaborative TB/HIV activities, which was updated in 2012. TB/HIV collaborative activities
include the establishment and strengthening of mechanisms for delivering services for TB and
HIV, reducing the burden of TB among people living with HIV, and reducing the burden of HIV in
patients with presumptive and diagnosed TB. The scale-up of these activities is estimated to have
saved 9 million lives during 2005–2020, according to modelling for the Global TB Report 20211.

Tobacco smoking
Globally, in 2020 an estimated 991 million people aged 15 years or older smoked tobacco,
with an estimated prevalence of 28.9% among men and 5.2% among women (33). Among the
10 countries with the highest incidence of TB2, the median smoking prevalence is 35% (IQR:
18–45%) for men, and 2% (IQR: 1–3%) for women (13,33). Tobacco almost doubles the risk of
developing TB, with an estimated 730 000 new episodes of TB attributable to tobacco use in
2020 (13). Tobacco use is associated with poor TB treatment outcomes, and the implementation
of tobacco cessation activities can improve TB treatment outcomes and reduce relapse rates
(34). Further, people with diabetes who also smoke have an elevated risk of TB compared to
people with diabetes who do not smoke, suggesting that multimorbidity due to diabetes and

1
To estimate the number of deaths averted by collaborative TB/HIV activities, the actual numbers of TB deaths can be compared
with the number of TB deaths that would have occurred in the absence of antiretroviral therapy (ART) provided alongside TB
treatment for people with HIV-associated TB. This number can be estimated conservatively as the number of estimated incident
cases multiplied by the relevant estimated case fatality ratio for untreated HIV-associated TB. The estimates are conservative
because they do not account for the impact of TB services or availability of ART or TB preventive treatment on the level of TB
incidence; they also do not account for the indirect, downstream impact of these interventions on future levels of infections,
cases and deaths.
2
The 10 countries with highest TB incidence in 2020, in alphabetical order, were: Bangladesh, China, Democratic Republic of the
Congo, India, Indonesia, Nigeria, Pakistan, the Philippines, South Africa and Viet Nam (161).

Introduction 3
 smoking may synergistically increase the risk of TB (35). Since 2008, WHO has recommended
screening for tobacco use and tobacco cessation activities among people with TB as part of
broader tobacco control initiatives (36).

Undernutrition
Undernutrition accounted for an estimated 1.9 million new TB episodes in 2020, making it one of
the most significant drivers of TB (13). People with undernutrition are three times more likely to
develop TB disease compared with people who do not have undernutrition, and undernutrition
is a common consequence of TB. Moreover, the risk of TB disease, as well as the severity of lung
disease, increases as body mass index (BMI) decreases, for which there is consistent evidence
across different settings and with different underlying burdens of TB (37,38). Undernutrition has
also been identified as a risk factor for poorer TB treatment outcomes as well as TB mortality,
with increased weight as a predictor of better treatment outcomes (39,40). Since 2013, WHO
has recommended nutritional status assessment and counselling, as well as co-management
of TB and undernutrition (41). Further, WHO recommends screening for TB among people with
undernutrition (20).

Other health-related risk factors and comorbidities

Chronic respiratory disease

Chronic respiratory disease includes silicosis, asthma, chronic obstructive pulmonary disease
and lung cancer. Silicosis quadruples the risk of developing TB, with the risk of TB disease
increasing with increasing severity of silicosis (42). In southern African countries, HIV is a common
comorbidity of silicosis among miners. Combined, HIV and silicosis further heighten the risk
of developing TB disease, compared with HIV or silicosis alone (43). WHO recommends TB
screening among workers who are currently or previously exposed to silica, and people with
silicosis are eligible for receiving TB preventive treatment (7,20).
In TB-endemic areas, a history of TB disease is strongly associated with the presence of chronic
respiratory disease in adults (44,45); therefore, people who have recovered from TB may require
care and lung rehabilitation after completion of TB treatment (44,46,47). The signs and symptoms
of TB are similar to those of other lung diseases. Hence, strengthened collaboration between TB
services and services addressing other lung diseases is critical to facilitate swift referrals, early
diagnosis and appropriate treatment, as outlined in the Practical Approach to Lung Health (48).

COVID-19
The coronavirus disease (COVID-19) pandemic has led to a global decline in notification of TB
disease, due to the disruption of TB services (13,14). WHO has recommended a set of measures
to maintain continuity of essential TB services during the COVID-19 pandemic (14). There is
also evidence that people with COVID-19 who have TB have an elevated risk of mortality (49).
Similarly, people with HIV and HIV-associated TB are also at higher risk of more severe COVID-19
with higher mortality rates (50). Other key risk factors for poor outcomes for both COVID-19
and TB include diabetes and smoking (13,14,51), supporting a multimorbidity approach such as
simultaneous screening and testing where indicated (14). COVID-19 and TB are both infectious
diseases that are transmitted primarily through close contact and share key symptoms such as
cough, fever and difficulty in breathing (14). Services should therefore be aligned to facilitate
rapid diagnosis, referral for differential diagnosis and timely treatment as applicable, with due
attention to infection prevention and control (IPC).

4 Framework for collaborative action on tuberculosis and comorbidities

Table 2. Health-related risk factors and TB comorbidities, with related
interventions recommended in current WHO guidelines

Interventions to reduce the burden of TB

among people with comorbidities and
Health-related risk factors for TB health-related risk factors
TB Infection
Find and preventive prevention and
Key drivers for TB treat TB treatment control
Diabetes ✔ ⬚ ✔
Disorders due to alcohol use ✔ ⬚ ✔
HIV ✔ ✔ ✔
Smoking ⬚ ⬚ ✔
Undernutrition ✔ ⬚ ✔
Other health-related risk factors and
comorbidities
Disorders due to drug use ✔ ✔ ✔
Silica exposure, silicosis ✔ ✔ ✔
Viral hepatitis ✔ ⬚ ✔
Other clinical risk factors: treatment
with anti-TNFα3, dialysis, organ or ✔ ✔ ✔
haematological transplantation
Comorbidities associated with poorer Interventions to reduce the burden of
TB treatment outcomes comorbidities among people with TB
Find and treat Counsel on and
Key drivers for TB comorbidities prevent comorbidities
Diabetes ✔ ⬚
Disorders due to alcohol use ✔ ✔
HIV ✔ ✔
Smoking ✔ ✔
Undernutrition ✔ ✔
Other comorbidities
COVID-19 ✔ ⬚
Mental disorders ✔ ✔
Viral hepatitis ✔ ✔
✔: recommendation exists; ⬚: currently no recommendation

3
Currently, there is no recommendation on TB screening for people receiving anti-TNFα treatment; however, treatment of TB
infection is recommended.

Introduction 5
 Disorders due to drug use
People with disorders due to drug use (injecting and non-injecting) have an elevated risk of both
TB infection and TB disease, irrespective of their HIV status, and TB is a leading cause of HIV-
related mortality among people who inject drugs (PWID) (52–54). Drug use disorders are also
associated with comorbidities such as HIV, viral hepatitis and mental disorders (52). People with
drug use disorders are more likely to have been incarcerated at least once (55), which increases
their exposure and vulnerability to TB and other comorbidities (56).
Marginalization of people who use drugs (PWUD), resulting from criminalization, stigma
and discrimination, impedes their access to and retention in health care including TB care
(53,57,58). This is exacerbated by the limited availability of prevention, treatment and care
for drug use, including opioid agonist maintenance therapy (OAMT) (53,54). The existence of
common comorbidities such as HIV, mental disorders and viral hepatitis among PWUD may
further delay TB treatment, and require careful clinical management to minimize drug–drug
interactions, optimize adherence and achieve treatment success (59–61). WHO recommends a
comprehensive package of services to address infectious diseases among PWUD, including but
not limited to harm reduction services, prevention and management of TB, HIV, viral hepatitis
and mental health conditions, as well as structural interventions such as supportive legislation,
decriminalization and addressing stigma and discrimination (62–65). WHO has also produced
a range of guidelines and technical tools to support Members States in their efforts to develop
and expand effective, evidence-based and ethical prevention and treatment interventions for
PWUD and those with disorders due to drug use (63–65).

Mental disorders
Mental health conditions are common among people with TB. A systematic review estimated
that 45.2% of people with any form of TB have depression (61), and there is an elevated risk of
depression, anxiety and psychosis among people with MDR-TB (61,66). The most common social
stressors reported are stigma, discrimination, isolation, and a lack of social support (66). TB and
mental disorders together can lead to greater morbidity and poorer TB treatment outcomes (67);
however, providing integrated mental health interventions within TB services can boost the
rates of treatment completion (68). WHO recommends the provision of psychological support
for people with TB (69).

Viral hepatitis
The estimated global prevalence of chronic viral hepatitis in 2019 was 296 million for hepatitis
B virus (HBV) and 58 million for hepatitis C virus (HCV) (70). There is considerable geographical
variation in the prevalence of viral hepatitis among people with TB, ranging from 0.5% to 44%
for HBV, and from 3.4% to 45% for HCV (71). Certain populations such as PWID and people in
prisons are among those most at risk of both TB and viral hepatitis coinfection (in particular
HBV and HCV) (56,60), although other populations are also at risk if they live or have lived in
regions or settings that are endemic for these infections. Estimates show that among PWID who
have TB, two in three also have viral hepatitis, compared to one in three for HIV (60). Drug-
induced liver injury is up to six times higher among persons coinfected with HBV or HCV who
are receiving anti-TB drugs, and mortality rates are also higher during TB treatment among
people with HCV (72). TB screening, and diagnostic assessment if indicated, is advised as part
of the clinical evaluation of patients being considered for HBV and/or HCV treatment (73).
Screening for viral hepatitis among people with TB who inject drugs is recommended as part
of harm reduction services (74).

6 Framework for collaborative action on tuberculosis and comorbidities

Other clinical risk factors: treatment with anti-tumour necrosis factor
alpha (TNFα), dialysis, organ transplantation
A number of other clinical risk factors have been identified in high-risk groups, which increase
the risk of developing TB disease among people with TB infection. At high risk are people who
receive anti-TNFα, those receiving dialysis, and candidates for organ transplantation (75). WHO
recommends systematic testing and treatment of TB infection among these high-risk groups to
prevent the development of TB disease (7).

Principles
The Framework is based on six principles that are fundamental to implementation. These are
as follows.

1. Evidence-based response
An effective response to TB and comorbidities should be evidence-based and data-driven. Data
should be continuously collected and analysed to identify and prioritize problems, develop
solutions, and optimize interventions along the continuum of care. The main areas for analysis
are: data on the joint burden and impact of TB and comorbidities, including the prevalence of
key comorbidities among people with TB and the effect of comorbidities on treatment outcomes
and quality of life; risk profiles, knowledge, financial vulnerability, expectations and behaviour of
affected people or people at risk; and capacity, performance, limitations and distribution of the
health system and social services (76). It is important to map and utilize existing data sources
where available to avoid duplication of efforts. The implementation of policies, programmes and
interventions should be accompanied by continuous data collection on their reach and impact.
Meetings of key stakeholders from within and beyond the health sector should be convened
regularly to review data and adapt collaborative action in accordance with the evolving needs,
and to scale up successful models of care.

2. Multisectoral engagement and accountability

Multisectoral engagement is critical for advancing the global TB response as well as for
collaborative action on TB and comorbidities. To ensure accountability, the roles and
responsibilities of the respective actors should be clearly defined, and actions accompanied by
ongoing monitoring, evaluation and review of performance and impact. Civil society and affected
communities have a fundamental role to play in all components of accountability related to TB,
including through community-led monitoring. To accelerate progress to end the TB epidemic,
WHO released the Multisectoral accountability framework for TB (MAF-TB) in 2019 (77), which
aims to facilitate action and accountability of governments and all stakeholders, at the global,
regional and country levels. To deliver a fully comprehensive response to TB and comorbidities,
countries should ensure that collaborative action is considered during the development of the
national MAF-TB. To this end, the coordination of multisectoral action for TB and comorbidities
at the national and subnational levels should be integrated with the coordination platforms and
mechanisms for the MAF-TB.

Introduction 7
 3. People-centred services
People-centred services provide holistic, individualized, empowering and respectful care,
organized around the comprehensive needs of the person rather than around individual
diseases (78,79). This is important for addressing TB and comorbidities given the additional
health and support needs. People-centred services can improve continuity of care, strengthen
collaboration within and across the health sector, and promote health equity (4). Individuals,
carers, families and communities should be considered active participants and collaborators in
care, who are empowered through education and support to make decisions around their care
(4,5,80). People-centred services are inherently human rights-based, recognizing and working
towards protecting and promoting the human right to health for each individual. Models of
care should be adapted to individuals’ needs throughout the continuum of care, extending from
pre-diagnosis to beyond the completion of TB treatment (78). A people-centred approach can
promote autonomy and shared decision-making, improve outcomes for people with TB and
comorbidities, ensure equitable access to services and contribute to achieving universal health
coverage (UHC).

4. Protection and promotion of human rights, ethics and equity

Every person has a fundamental right to health, including access to high-quality care and social
protection (81). Social determinants of health, such as socioeconomic status, education and
housing, significantly influence the risk of TB disease and common comorbidities, produce
inequalities, and frequently impede or delay access to prevention, diagnosis, treatment and
care (82,83). To ensure the human right to health, access to services should be equitable for all
regardless of factors such as age, sex, gender, sexuality, race or ethnicity, and socioeconomic
status. Policies, strategies and services for TB and comorbidities should explicitly address human
rights, ethics and equity, and should be guided by the principles of non-discrimination and
equality, participation and inclusion, and accountability (81). Services should also be sensitive to
communities who face overlapping vulnerabilities and risk factors, such as migrants, prisoners,
PWUD, sexual minorities, and transgender people. Applying a human rights-based approach to
collaborative action on TB and comorbidities will improve health outcomes for individuals and
communities and promote equity (9).

5. Strong coalition with affected communities and civil society

Persons affected by or at risk of TB and comorbidities, their communities and civil society
should be actively engaged in defining needs, prioritizing actions, designing and implementing
interventions to address TB and comorbidities, and monitoring, evaluating and reviewing their
impact. They are also important partners in delivering health education, advocacy and peer
support for those undergoing treatment as well as for the wider community (9). Communities
include a diverse set of actors, such as individual users of health services, and their families
and extended support network. The needs of affected communities are continuously evolving
along with broader shifts in the socioeconomic and political context. Building collaborative
relationships with the community enables the co-development of models of care that respond to
the evolving needs and preferences for care, including for people with TB and comorbidities (5).

6. Universal health coverage

In the political declaration from the 2019 UN HLM on universal health coverage, countries
committed to achieving UHC by 2030 (8). This declaration recognized the importance of equity,
social justice and social protection, and committed to strengthen the efforts to address TB as

8 Framework for collaborative action on tuberculosis and comorbidities

part of wider efforts to achieve UHC. In working towards UHC, countries should define national
essential packages of care, prioritizing key interventions (84). Further, countries should ensure
financial risk protection and eliminate impoverishment due to health-related expenses. Efforts to
achieve UHC also place a special emphasis on the poor, vulnerable and marginalized segments
of the population, many of whom are at elevated risk of experiencing TB and comorbidities.
Therefore, to improve health for all, collaborative action on TB and comorbidities should be
aligned with and feed into the national UHC agenda.

Goal, aim and objectives

Goal
The goal of the Framework is to decrease the joint burden of TB and comorbidities, in line with
the End TB Strategy targets, and the United Nations High Level Meeting commitments on TB,
noncommunicable diseases, HIV and universal health coverage.

Aim
The aim of the Framework is to improve access to people-centred services for TB, comorbidities
and health-related risk factors.

Objectives
The objectives of the Framework are to:
1. establish and strengthen collaboration across health programmes and across sectors for
delivering people-centred services for TB and comorbidities;
2. provide guidance on assessment, planning, prioritization, scale-up and evaluation of people-
centred services for TB and comorbidities; and
3. facilitate scale-up of WHO recommendations on TB, comorbidities and health-related risk
factors for TB and poor TB treatment outcomes.

Scope
The Framework provides a structure and suggested mechanisms for establishing and
strengthening collaborative action across disease programmes and relevant sectors outside
the health system, to ensure the delivery of evidence-based and people-centred care for people
with, or at risk of, TB and comorbidities.

Process of development
The development of the Framework for Collaborative Action on TB and Comorbidities was
coordinated by the Vulnerable populations, Communities and Comorbidities (VCC) Unit of the
WHO Global TB Programme. A WHO Steering Group was set up in 2020, which included members
from across the WHO Global TB Programme, TB advisors and focal points responsible for
selected comorbidities from all the six WHO regions, and the WHO Departments of Global HIV,
Hepatitis and STIs Programmes; Health Promotion; Health Systems Governance and Financing;
Mental Health and Substance Use; Noncommunicable Diseases; Nutrition and Food Safety; and

Introduction 9
 the Special Programme on Primary Health Care. Meetings of the Steering Group were convened
at the end of 2020 and regularly throughout 2021, to guide the development of the Framework.
To inform the Framework, evidence was gathered including from the existing literature,
during consultations with national and regional staff, and through interviews with TB survivors
and key stakeholders. A policy review was conducted in 2020 to assess the uptake of WHO
recommendations on TB and comorbidities within national TB strategic plans, national
guidelines for TB and respective comorbidities. A systematic review on barriers to and enablers
of collaborative care for people with TB and comorbidities was commissioned in 2021. Focus
group discussions to elicit key barriers and enablers to scaling up collaborative action on TB and
comorbidities were conducted during June–August 2021 with representatives from 16 countries
(Bangladesh, Belarus, Brazil, Georgia, India, Indonesia, Kenya, Mexico, Namibia, Pakistan, Peru,
the Philippines, Sierra Leone, United Republic of Tanzania, Zambia, Zimbabwe) from all six WHO
regions. Participants included representatives from ministries of health, national TB programmes,
programmes for key comorbidities, health systems and related focal points from the WHO
country and regional offices. Interviews with people with lived experience of TB and one or
more comorbidities were conducted during August–September 2021, to assess barriers to and
preferences for accessing people-centred health care. A summary of the barriers and enablers
identified in the literature and during the consultations and interviews is provided in Annex 2. A
stakeholder consultation with a broad array of experts was held in October 2021 to seek inputs
into the draft Framework. This consultation also included representatives from the Civil Society
Task Force on TB as well as TB survivors to ensure a people-centred perspective. A revised draft
was peer-reviewed by an external review group during December 2021–January 2022. Experts
consulted during the development of the Framework completed a declaration of interests form
in accordance with WHO processes (see Annex 3).

Planned dissemination
The Framework will be translated and published electronically on the WHO Global TB Programme
website. It will be referenced within subsequent clinical guideline updates and operational
handbooks for TB and the respective comorbidities. To accelerate scale-up of action on TB and
comorbidities, WHO will work closely with implementing partners to disseminate the Framework
through regional and subregional meetings. Training modules will be developed to assist in the
adoption of this Framework together with the respective guidelines.

Target audience
The Framework is intended for use by people working in ministries of health, particularly national
programmes or relevant departments responsible for TB, HIV, NCDs, primary health care,
tobacco cessation, undernutrition, substance use and mental health. The Framework is targeted
at relevant line-ministries, policy-makers, international technical and funding organizations,
researchers, nongovernmental and civil society organizations, as well as primary care workers,
specialist health practitioners, and community health workers who support the response to TB
and comorbidities in both the public and private sectors.

10 Framework for collaborative action on tuberculosis and comorbidities

Introduction 11
 Framework for collaborative action on
TB and comorbidities

The Framework for collaborative action on TB and comorbidities outlines actions to support
countries in the introduction and scale-up of collaborative action on TB and comorbidities
(Fig. 1). It is oriented around six core principles and is organized in sections A to E, which list
key actions for ensuring people-centred services. These sections have been ordered logically to
support the stepwise introduction and scale-up of collaborative action on TB and comorbidities.
The Framework should be used to support the scale-up of WHO recommendations and guidelines
on TB and comorbidities as listed in Annex 1, as well as related updated guidelines and guidance
available on the Global TB Programme Knowledge Sharing Platform (85). Health programmes
should ultimately aim to implement collaborative action for all identified comorbidities along
the continuum of care, including prevention, diagnosis and treatment, as well as care after the
completion of TB treatment. A phased approach, starting with a few comorbidities informed by
local epidemiology and feasibility of implementation will facilitate progress towards this goal.
Services should be continuously evaluated and adapted accordingly.

12 Framework for collaborative action on tuberculosis and comorbidities

Fig. 1. Framework for collaborative action on TB and comorbidities

IMPACT
REDUCE DEATH AND SUFFERING DUE TO TB AND COMORBIDITIES

INTERVENTIONS

Find and treat TB Prevent TB among Find and treat Prevent

among people people with comorbidities comorbidities
with key health- identified health- among people among people
related risk factors related risk factors with TB with TB

Strengthen Strengthen governance

monitoring, and accountability for
evaluation and collaborative action
research

ACTIONS TO SCALE
UP PEOPLE-CENTRED
CARE FOR TB AND
COMORBIDITIES
Implement and scale Conduct an analysis
up people-centred of access to quality
services for TB and services for TB and
comorbidities comorbidities

Coordinate planning
and resource
mobilization for
collaborative
action

PRINCIPLES

Evidence- Multisectoral People-centred Protection and Strong Universal

based engagement services promotion of coalition health
response and human rights, with affected coverage
accountability ethics and communities
equity and civil
society

Framework for collaborative action on TB and comorbidities 13

 A. Strengthen governance
and accountability for
collaborative action

A.1 Strengthen political commitment, coordination and accountability

for collaborative action on TB and comorbidities
A.2 Support financing and legislation that promote people-centred care
A.3 Ensure meaningful engagement of civil society and affected
communities at all stages of planning, implementation, monitoring
and evaluation

Collaboration across health programmes, with clear mechanisms for accountability and active
engagement of affected people and communities, is critical for people-centred care for TB
and comorbidities (76,77,86). Evidence from the TB/HIV response has shown that coordinating
bodies that operate at all levels of the health system with active participation of all relevant
stakeholders – including affected people and communities, civil society, and the respective health
programmes – is feasible and can effectively establish political commitment and ownership of
collaborative activities at the country level (87,88). Existing health-sector coordination platforms
should be identified and built upon to address comorbidities while strengthening collaboration
between the health programmes and reducing duplication of efforts (see Section A.1). The health
programmes, or relevant departments of the ministry of health, to be considered as members
of the coordination platform include the national HIV programme, NCD programme, primary
health care programme, nutrition programme, and programmes for mental health, disorders due
to substance use and smoking cessation. It may also be appropriate to include representatives
from other relevant ministries or government departments involved in the provision of health
services, e.g. prisons or mining services, to strengthen practical on-the-ground planning and
implementation.
Some areas for action, such as legislation, financing, social protection and nutrition, may lie
outside the purview of the national TB programme and collaborating health programmes.
It is essential therefore to develop strong partnerships with stakeholders from outside the
health system, including funding agencies, to advocate for and assist in addressing these areas
(see Section A.2). Moreover, in countries where a national multisectoral mechanism for TB has
already been established (e.g. as part of the MAF-TB), the coordinating platforms for TB and
comorbidities should have clear linkages with this mechanism to optimize synergies.
Affected people and communities, and civil society, should be empowered to play an active
and ongoing role in defining health needs, developing solutions, prioritizing actions, delivering
health care and advocacy messages, as well as in monitoring, evaluation and review (77,89).
Governance structures should create an enabling environment for continuing dialogue and
partnership at all levels (5) (see Section A.3).

14 Framework for collaborative action on tuberculosis and comorbidities

A.1 Strengthen political commitment, coordination and accountability for
collaborative action on TB and comorbidities

Countries should strengthen platforms for coordination of collaborative action on TB and

comorbidities that are functional at the national, regional, district and facility levels. Where
such platforms, working groups or coordinating bodies already exist, e.g. for TB/HIV, their terms
of reference may be revised to include coordination for other comorbidities. The coordination
of multisectoral actions to address comorbidities should be included in the national MAF-TB.
■ Depending on the level of the coordinating platform, members may include
representatives from:

national TB programme;

other relevant health programmes including primary health care directorates;

national health insurance programme;

other relevant ministries or government departments as appropriate;

international organizations;

professional associations;

researchers and academic institutions;

private-for-profit sector;

civil society organizations;

community health workers and peer supporters; and

people at risk of or affected by TB and comorbidities.
■ Suggested outputs for the coordination platform include but should not be limited to:

agreement on terms of reference for the coordination platform, including roles and
responsibilities of the national TB programme, other health programmes and relevant
sectors in implementing, scaling up, monitoring and evaluating collaborative action on
TB and comorbidities at all levels;

coordination of action on TB and comorbidities throughout the programme management
cycle from assessment, planning and resource mobilization, scale-up and monitoring
and evaluation;

liaison with and reporting to the multisectoral coordination mechanism for TB, and for
the relevant comorbidities, e.g. national AIDS commission;

facilitation of the involvement of civil society, nongovernmental and community
organizations, and individuals; and

ensuring alignment of advocacy and communication on TB and comorbidities and health-
related risk factors.

Framework for collaborative action on TB and comorbidities 15

 CASE STUDY:
People-centred approach to tuberculosis, HIV and opioid agonist
maintenance therapy in Moldovan prisons
Context: Incarcerated populations are at higher risk of tuberculosis (TB) and blood-borne
viruses such as HIV and viral hepatitis (52,56,90). Key drivers of the joint burden of disease
include detention of people who use drugs (PWUD), in combination with overcrowding and
lack of access to adequate prison health services (52,56). In the Republic of Moldova, the TB
incidence was more than ten-fold higher in prisons (1166/100 000 population) compared
to that in the overall community (86/100 000) in 2018 (91), and the HIV prevalence more
than four times higher among people in prisons (2.6%) compared to that in the community
(0.6%) in 2015 (92). Incarcerated people are served by specialized prison health services,
separate from the civilian health system. Provision of opioid agonist maintenance therapy
(OAMT) is associated with improved TB treatment outcomes and reduced transmission of
HIV and viral hepatitis; however, coverage of OAMT services is limited, including among
incarcerated people. Hence, simultaneous provision of TB treatment, antiretroviral therapy
(ART) and OAMT has the potential to significantly reduce the joint burden of disease in
prison settings.
Intervention: In the Republic of Moldova, a programme has been established to
comprehensively address TB, HIV and substance use among incarcerated people, leveraging
the political commitment to deliver the same standard of health care to people in prisons
as for the general population. The national Global Fund Country Coordinating Mechanism
(CCM), which includes representatives from the Ministry of Justice, health sector, academic
institutions, social services, nongovernmental organizations (NGOs) and civil society,
coordinated the development of funding requests and oversaw implementation of the
programme. Changes in legislation in 2004 and 2005 permitted the provision of OAMT
both in the civil sector and in penitentiary services, respectively (93), which enabled the
introduction of integrated services for TB, HIV and OAMT in prisons. By 2021, OAMT had
been introduced in 13 out of 17 penitentiary institutions in Moldova. To ensure equitable
healthcare provision for people in the penitentiary system, the Ministry of Health and
Ministry of Justice jointly conducted training on the co-management of TB, HIV and OAMT.
Multidisciplinary teams were then set up in the national penitentiary hospital, providing
comprehensive medical care for TB, HIV and OAMT, as well as psychosocial support.
Several measures were introduced to ensure continuity of care and effective coordination.
Collaboration with NGOs across the country was established, to facilitate linkage to care
for those who require ongoing treatment for TB and comorbidities upon release from
prison services. An integrated health information system was set up to capture data
and ensure that medical information is accessible in both the civil health system and
prison health services. A financial sustainability plan was also developed, whereby the
prison administration has taken on the financial burden for the procurement of first-
line TB medications, while ART, OAMT and medical equipment are covered by the
respective national programmes for HIV and drug use, Global Fund and various donors.
Lessons learnt: Key facilitators for implementation of the integrated patient-centred
model of triple care for TB, HIV and OAMT in prisons included strong political commitment
and an enabling legal framework to ensure equivalence of care for incarcerated people
through the training of prison medical staff to provide integrated care and using shared
electronic recording and reporting systems. Constructive dialogue and collaboration with
civil society organizations also helped overcome barriers to access to care and treatment,
and to close gaps in the treatment cascade.

16 Framework for collaborative action on tuberculosis and comorbidities

A.2 Support financing and legislation that promote people-centred care

To create an enabling environment for people-centred care, programmes in collaboration with

stakeholders should:
■ Support the scale-up of financing models that promote integrated people-centred care,
and that incentivize provision of comprehensive services as part of the national health
financing and strategic purchasing strategies.
■ Promote and support legislation and financing that allow engagement of peer supporters
with lived experience of related health conditions to deliver people-centred TB care.
■ Advocate for legislation that permits qualified providers to screen, diagnose and prescribe
treatment for both TB and comorbidities (e.g. OAMT, TB treatment) in the same facility
according to best practice and WHO recommendations.
■ Promote and support measures to uphold the human right to health, including for those
most at risk of or affected by TB and comorbidities (e.g. people in the criminal justice
system, PWUD). Measures may include:

capacity building of civil society organizations to monitor and address stigma
and discrimination;

promotion of other initiatives to address stigma and discrimination;

targeted advocacy to support decriminalization of drug use in accordance with UN
commitments and WHO recommendations; and

strengthen linkages with prison services to ensure equitable access to comprehensive
care for people with TB and comorbidities including harm reduction services.

A.3 Ensure meaningful engagement of civil society and affected communities

at all stages of planning, implementation, monitoring and evaluation

Effective engagement of civil society and affected communities is essential for developing and
implementing people-centred services for TB and comorbidities. The following strategies are
recommended:
■ Engage civil society and affected communities in policy formulation, planning,
implementation, monitoring, evaluation and review, as well as operational research, for
collaborative action.
■ Expand community engagement by including interventions for the prevention, detection,
treatment, care and support for TB and comorbidities within community-based and
community-led activities for TB and for other health areas, in line with WHO guidance.
■ Empower and engage affected communities and civil society in advocacy for scale-up
of non-discriminatory, high-quality care for TB and comorbidities, and for availability of
related resources through domestic and external sources.

Framework for collaborative action on TB and comorbidities 17

 CASE STUDY:
Action on tuberculosis and mental health at the community
level, Peru
Context: Peru is classified by WHO as a country with a high burden of MDR-TB. In Lima
North, Peru, the loss-to-follow up rates among people with drug-susceptible and drug-
resistant tuberculosis (TB) were 10% and 42%, respectively, in 2015. People with TB
frequently experience mental health conditions such as anxiety or depression (66,68).
Though mental disorders are associated with poorer TB treatment outcomes, including
loss to follow-up and treatment failure (67), healthcare workers in the TB programme often
lack capacity to manage these comorbidities. To address the burden of mental disorder
comorbidity, the national TB programme has introduced an intervention to build capacity
among healthcare workers and improve the comprehensive management of mental health
among people with TB in Lima North.
Intervention: In 2015, the regional emergency programme for TB prevention and control
in Lima North, Peru committed to addressing mental disorders among people with TB. This
initiative received strong support from the local mayors, the nongovernmental organization
Socios en Salud (Partners in Health), and from several universities. To advance collaborative
action on TB and mental health, the capacity of multidisciplinary teams (MDTs) for TB
has been strengthened by involving psychologists. Further, healthcare workers in the TB
programme receive training on mental health interventions according to the WHO Mental
Health Gap Action Programme (mhGAP) guidelines, including supervised practical sessions.
Thus, the MDTs can collaboratively assess the needs of people with TB and comorbidities
and provide specialist care for both TB and mental health conditions as a one-stop-shop
service. Broader psychosocial care is also provided for the family and community, in the
form of group psychotherapy and activities such as yoga or musical therapy, with the aim
to improve mental health and address stigma.
Lessons learnt: The integration of services addressing TB and mental health was facilitated
by strong political commitment and buy-in, as well as engagement of external partners.
Routine data from Lima North report a reduction of loss to follow-up to 2% and 4% for
people taking treatment for drug-susceptible and drug-resistant TB, respectively, between
2015 and 2021.

18 Framework for collaborative action on tuberculosis and comorbidities

 B. Conduct an analysis of access
to quality services for TB and
comorbidities

B.1 Assess the joint burden of TB and comorbidities

B.2 Determine access to services and the financial burden for people with
TB and comorbidities
B.3 Map health service delivery for TB and comorbidities
B.4 Identify gaps in services and conduct root cause analysis

To guide planning, priority setting and implementation, it is essential to understand the joint
burden in terms of morbidity and mortality due to TB and comorbidities, the accessibility of care
relevant for TB and comorbidities, and the socioeconomic impact of TB and comorbidities (89).
These vary considerably between and within countries, depending on factors such as health
system structures, degree of decentralization of health services and the broader socioeconomic
determinants of health. Many countries have a range of existing data sources which can inform
an assessment of the disease burden, risk factors and service availability (76), and help in
the identification of any evidence gaps that need addressing. Assessment should start with
a comprehensive mapping and analysis of existing resources such as surveillance data,
demographic and health surveys, prevalence studies and mortality records. These data can
be analysed as part of overall country review and planning processes for TB and the relevant
comorbidities, to avoid duplication of efforts. Gaps in evidence identified during this process
can provide direction for further data collection.
The People-centred framework for TB programme planning and prioritization (76) recommends
using three types of data: epidemiological, people-centred, and system-related, as detailed
in Sections B.1–B.3. These data help build a complete picture of the epidemiological burden,
affected populations and service availability for care and prevention of TB and comorbidities.
Epidemiological data should include the burden of disease and its distribution by factors such as
geography, sex and age, which can be found in, e.g. epidemiological reviews, national surveillance
systems, mortality studies or national vital registration systems (see Section B.1). People-centred
data include data on risk factors, stigma, financial vulnerability, patient expectations, and
behaviour of people with or at risk of disease, which can be sourced from, e.g. patient pathway
analyses, demographic and health surveys and health expenditure and utilization surveys (see
Section B.2). System-related data include data on the capacity, performance, limitations and
distribution of health and social services, which can be harnessed from, e.g. health systems
reviews or readiness assessment mapping (see Section B.3), such as the Service Availability and
Readiness Assessment (SARA) (94).

Framework for collaborative action on TB and comorbidities 19

 Once data have been consolidated, they should be reviewed in consultation with stakeholders to
identify programmatic gaps as well as missed opportunities. The root causes of these problems
should then be identified (76) (see Section B.4). It is crucial that these efforts should not only
evaluate collaborative action, but also inform programming and highlight readiness for new
interventions on TB and comorbidities to be introduced. Hence, the assessment of disease burden
and health system capacity should be an ongoing and iterative process, regularly updated as
the epidemiology and joint response to TB and comorbidities evolve.

B.1 Assess the joint burden of TB and comorbidities

Assessing the joint epidemiological burden of TB and comorbidities will enable countries to
develop effective services and focus efforts where needs are greatest. To achieve this, countries
should:
■ Use existing data sources for an initial assessment of the joint burden of TB and key
comorbidities and health-related risk factors (e.g. diabetes, disorders due to substance
use, HIV, mental disorders, tobacco and undernutrition).
■ Address data gaps on the joint burden, where these exist. Methods for addressing data
gaps may include, but are not limited to, sentinel surveys, small-scale studies among people
with TB, and periodic cross-sectional surveys.

B.2 Determine access to services and the financial burden for people with TB
and comorbidities

To understand the barriers and facilitators to accessing people-centred services from the
perspective of the end user, the programmes in collaboration with stakeholders should:
■ Determine the access to services for TB and comorbidities, using appropriate methodologies,
such as patient pathway analyses, surveys or operational research to increase understanding
of the gaps and opportunities for screening, diagnosis, treatment and prevention.
■ Determine the financial burden to people affected by TB and comorbidities through
methods that may include but should not be limited to national demographic and health
surveys, health expenditure and utilization surveys and household surveys.
■ Assess access to existing social protection schemes that mitigate the financial impact of
TB and comorbidities.

20 Framework for collaborative action on tuberculosis and comorbidities

CASE STUDY:
Introducing and scaling up collaborative action on tuberculosis
and diabetes, Mexico
Context: People with diabetes mellitus (diabetes) have a higher risk of tuberculosis (TB)
disease and poor TB treatment outcomes. The prevalence of diabetes is rising rapidly
in many countries with a high burden of TB, requiring coordinated action to optimize
screening coverage, rates of diagnosis and treatment outcomes for both diseases. In
Mexico, the prevalence of diabetes has increased from 14.2% in 2010 to 16.9% in 2021,
with a projected rise to 18.3% by 2030 (26).
Intervention: Collaborative action on TB and diabetes was first introduced in Mexico in
2012, using an adaptation of the WHO Collaborative framework for care and control of
tuberculosis and diabetes. Initially, the Ministry of Health conducted a study in 15 primary
care facilities to evaluate the feasibility and effectiveness of collaborative action on TB and
diabetes in Mexico. The facilities were selected based on the estimated joint burden of
TB and diabetes, the availability of infrastructure for screening and co-management of TB
and diabetes, and the willingness of health authorities to participate in the programme.
Bidirectional screening, that is, screening for TB in people with diabetes and screening for
diabetes in people with TB, was provided by trained nurses, and people diagnosed with
TB and diabetes received treatment for both conditions in the same primary care clinic.
Glycaemic control was monitored by regular measurements of random and fasting blood
glucose, and HbA1c. Weekly counselling sessions were conducted to strengthen adherence
to treatment and promote a healthy diet and physical activity (95).
In 2013, the national TB guidelines (Norma Oficial Mexicana) incorporated guidance on
diabetes to promote scale-up of collaborative action on TB and diabetes. This includes
guidance on bidirectional screening and co-management of TB and diabetes, as well as
the provision of TB preventive treatment for people with diabetes who had had contact
with a person with TB (96).
The strategies to implement and scale up collaborative action on TB and diabetes include
regular meetings with representatives of the TB and diabetes programmes; training of
healthcare workers in the respective programmes on co-management of TB and diabetes;
and the introduction of national joint indicators capturing (i) the proportion of people with
TB screened for diabetes; (ii) prevalence of diabetes among people with TB; and (iii) treatment
of TB infection among people with diabetes who have had contact with TB. In addition,
recording and reporting tools were updated to capture data on the indicators and a question
on productive cough was added to chronic disease monitoring cards. The government has
also been exploring avenues for strengthening federal commitment to ensure that treatment
for diabetes can be provided for free alongside TB treatment, and for engaging community
TB treatment supporters for delivery of diabetes care at the community level (97).
In 2020 in Mexico, 17 603 new and relapse TB episodes were notified, among whom
84.7% were either screened for diabetes by the TB services or a pre-existing diagnosis of
diabetes was established. A total of 5361 people had diabetes, representing 36% of those
who were asked about or screened for diabetes.
Lessons learnt: The initial small-scale implementation demonstrated that primary care-
based collaborative TB and diabetes activities are feasible, and showed improved TB
treatment outcomes among those who received collaborative services (95). The introduction
and scale-up of collaborative action was facilitated by the incorporation of collaborative
care for TB and diabetes in national guidelines and norm-setting documents, awareness
raising among healthcare workers on the association between TB and diabetes, and a
focus on people-centred care.

Framework for collaborative action on TB and comorbidities 21

 B.3 Map health service delivery for TB and comorbidities

In coordination with affected communities, key stakeholders and relevant multidisciplinary

experts, programmes should consolidate the existing data on availability of services to guide the
development, planning, implementation and delivery of collaborative action along the cascade
of care from screening and diagnosis to treatment and prevention. To achieve this, they should:
■ Determine the availability, deployment, qualification, supervision and mentoring of the
health workforce including affiliated cadres such as community health workers and
social workers.
■ Conduct mapping of public and private facilities and other state and non-state actors
who provide services for TB, comorbidities and health-related risk factors, including for
vulnerable, at risk and marginalized populations, e.g. people with undernutrition, prisoners,
migrants, PWUD, residents of long-stay mental healthcare institutions.
■ Identify what services are delivered and assess their quality and safety.
■ Determine the availability of equipment, tools and commodities to screen for, diagnose,
treat and prevent TB and comorbidities.
■ Assess the feasibility and acceptability of introducing collaborative action on TB and
comorbidities, for healthcare workers and affected communities.

B.4 Identify gaps in services and conduct root cause analysis

A review of all relevant data is critical for informing and prioritizing collaborative action on TB
and comorbidities. To achieve this, countries should:
■ Analyse data on epidemiology, people-centred services and the health system to identify
gaps and opportunities in services.
■ Conduct root cause analysis to understand the reasons for these gaps, and inform strategies
to address the gaps (e.g. lack of policy, lack of standard operating procedures, infrequent
training) (76).
■ Identify gaps in data and evidence that could be used to inform the agenda for
operational research.

22 Framework for collaborative action on tuberculosis and comorbidities

CASE STUDY:
Behavioural support for smoking cessation among people with
tuberculosis, Pakistan
Context: In Pakistan, the prevalence of smoking among people aged 15 years and older
was 25% among men and 3% among women in 2020 (33). Further, Pakistan is classified
by WHO as a country with a high burden of tuberculosis (TB), with a TB incidence of
259/100 000 in 2020 (29). In 2020, the estimated number of TB episodes attributable
to smoking was 53 000 for men and 3600 for women. Smoking increases the risk of TB
disease, is associated with worse TB treatment outcomes and doubles the risk of TB-related
death (34). Integration of TB treatment and tobacco cessation services is one of the
priorities for TB and comorbidities in the End TB Strategy.
Intervention: In Pakistan, a bespoke smoking cessation intervention has been developed
for people with TB, in a collaborative partnership between the national TB programme
and the University of York. The intervention consists of brief (8 minutes) behavioural
support sessions that provide messages on TB, healthy behaviour and advice on how
to quit tobacco smoking, delivered by the regular TB programme staff. Following an
initial trial over 3 years (the “TB & Tobacco” trial), healthcare workers were interviewed
to suggest changes for optimization of the intervention prior to scale-up. As a result of
these consultations, recording and reporting systems were revised to record smoking
status at registration and treatment completion, training was shortened to one half-day
and provincial TB programme leads were engaged.
An evaluation of the initial trial showed that 25% of people with TB quit tobacco use, as
measured by self-reported abstinence and verified biochemically at 6 and 12 months (34).
Those who quit had better TB treatment outcomes, including higher rates of sputum
conversion and treatment success, and lower rates of TB relapse compared to those
who did not stop tobacco use. In collaboration with the provincial TB programme, the
intervention was scaled up in 59 out of 121 health facilities in the Khyber Pakhtunkhwa
Province, representing urban, rural, private and public centres.
Lessons learnt: Key facilitators include the close collaboration between researchers
and provincial and national programmes to evaluate effectiveness and impact on TB
treatment outcomes. Commitment from organizations involved was reflected in joint
funding of the intervention. Consultation with healthcare workers who implemented the
intervention helped to identify opportunities to improve feasibility and acceptability as
part of assessment for scale-up.

Framework for collaborative action on TB and comorbidities 23

 C. Coordinate planning and
resource mobilization for
collaborative action

C.1 Identify priority comorbidities and interventions

C.2 Define and reorient models of care for TB and comorbidities towards
people-centred services, primary health care and universal health
coverage
C.3 Conduct collaborative planning and budgeting to scale up people-
centred services for TB and comorbidities
C.4 Align advocacy and communication across health programmes

Primary health care (PHC), which delivers services that are integrated, comprehensive and
affordable, is a cornerstone of UHC (98). Programmes should aspire to decentralize and integrate
services for TB and all key comorbidities at the primary care level. Countries may need to
prioritize action on TB and comorbidities based on an assessment of the evidence outlined
in Section B. Data review, root cause analysis and prioritization should be conducted in close
consultation with key stakeholders. The criteria for prioritization may include, but should not
be limited to, the morbidity and mortality burden, cost implication, ethical considerations and
acceptability (see Section C.1). The WHO People-centred framework for tuberculosis programme
planning and prioritization (76), and the WHO Compendium of data and evidence-related tools
for use in TB planning and programming (99) provide further guidance on prioritization.
People-centred services for TB and comorbidities should be tailored to the needs and preferences
of affected persons as far as possible and should aim to minimize the time and financial costs
incurred by the end user for accessing care. To this end, programmes should work together to
define and reorient models of care that assure the provision of integrated services, preferably
at the same time and location, and as close as possible to people who need them (see Section
C.2 and Box 1). Integrated models of care are feasible, acceptable, cost-effective and have high
rates of TB treatment success (34,68,100–102). The engagement of community health workers
can also enhance health system performance and efficiency, and capitalize on local resource
mobilization (103).
The process of joint planning and budgeting for collaborative action on TB and comorbidities
helps to strengthen efficiencies (see Section C.3). Beyond the impact on TB, collaborative
action on TB and comorbidities may improve broad health outcomes, improve efficiency of
resource use, and promote people-centred and integrated services. To ensure sustainability,
planning should be harmonized with the country’s national health strategic plans, health-
system strengthening agenda and overall efforts towards achieving UHC. Key areas for planning
collaborative action on TB and comorbidities to be covered include quality-assured health

24 Framework for collaborative action on tuberculosis and comorbidities

services; a well-performing health workforce; well-functioning information systems; equitable
access to essential medicinal products, vaccines and technologies; good health financing; and
leadership and governance. Planning for collaborative action on TB and comorbidities should
include joint efforts to identify suitable funding sources and programme synergies, e.g. for
nutrition support. Stakeholders from across and outside the health sector should collaborate
on domestic and external resource mobilization, and evidence should be used to advocate for
higher political commitment. Advocacy is a vital tool for advancing collaborative action, and
has higher chances of success when implemented jointly. Programmes should work together
to seek allies and develop joint advocacy strategies and align communication to garner buy-in
for and promote collaborative action (see Section C.4).

C.1 Identify priority comorbidities and interventions

Prioritization is critical for scaling up action on all comorbidities. In collaboration with stakeholders,
programmes should:
■ Identify comorbidities and interventions to be prioritized for national policy adaptation and
adoption, based on reviews of the burden of TB and comorbidities according to criteria
agreed with the coordination platform or related technical working group. The criteria to be
considered in discussion for prioritization may include but not be limited to the morbidity
and mortality burden, cost implications, ethical considerations and acceptability.
■ Continuously review national and local priorities as the joint burden of TB and the different
comorbidities evolves and collaborative action matures.

C.2 Define and reorient models of care for TB and comorbidities towards
people-centred services, primary health care and universal health coverage

To design people-centred models of care according to the local context, programmes should:
■ Engage civil society and affected communities in developing models to deliver person-
and family-centred care according to the preferences of affected persons.
■ Orient services towards primary care and ambulatory services.
■ Maximize opportunities to manage TB and comorbidities in the same place at the same
time, including through the use of telemedicine.
■ Develop models of care that address the needs of the vulnerable, at risk and marginalized
populations through strengthened collaboration with key stakeholders to provide
comprehensive social and nutritional support.
■ Ensure that IPC is prioritized during the design and reorientation of models of care.
■ Ensure that interventions and products to address TB and comorbidities are included within
the country’s essential package of health services.

Framework for collaborative action on TB and comorbidities 25

 Fig. 2. Models of integrated care for people with TB and comorbidities

Separate services

Screened positive Comorbidity services

for comorbidity in
TB services screen and then refer
for diagnosis of TB

TB services

Screened
positive for TB
in comorbidity
TB services screen services
Diabetes services
and then refer
for diagnosis of
comorbidity
HIV services
Increasing level of integration

Comorbidity TB diagnosed
diagnosed in comorbidity
in TB services services

Diabetes services HIV services

TB services

Comorbidity services screen for and

diagnose or rule out TB, then refer
TB services screen for and
for TB treatment or prevention
diagnose comorbidities, then
refer for treatment

Co-located services

TB services TB services Diabetes services Comorbidity services

screen for HIV services screen for and
and diagnose diagnose or rule
comorbidities, out TB, then refer
then refer for for TB treatment
treatment or prevention by
by another another healthcare
healthcare worker worker

One-stop-shop

Screening, diagnosis,
treatment and prevention
for TB and comorbidity
Primary
at the same facility by the Care Centre
same healthcare worker Community health worker

Adapted from Chifundo (2010) (104), De Foo et al. (2022) (105) and Legido-Quigley et al. (2013) (106)

26 Framework for collaborative action on tuberculosis and comorbidities

Box 1. Models of service delivery for TB and comorbidities

Models of service delivery for TB and comorbidities range from the least integrated,
where stand-alone disease-specific providers refer patients to the relevant specialist
services for comorbidities, to the most integrated, where all services across the
cascade of care for TB and key comorbidities are provided in a “one-stop-shop” by
one healthcare worker (105,106). Services may be provided at different levels of the
health system, depending on the availability of comprehensive primary care and the
degree of decentralization of the respective services. In some settings, TB services
may be decentralized to the primary care level, while services for comorbidities such
as diabetes and mental disorders may be available only at the secondary care level. In
this situation, the degree of integration can be increased only if diabetes and mental
health services are also decentralized closer to the end user.
Within these models, care may be provided by separate specialist healthcare workers
who refer patients to different services according to established pathways. Alternatively,
multidisciplinary teams comprising professionals with a mix of skills, including medical
and non-medical, required to meet the needs of the end user, may provide coordinated
care (107). Care can also be provided by one healthcare worker for both TB and
comorbidities, where the expertise is available, e.g. for TB/HIV (106). All models of care
may be strengthened by the engagement of community healthcare workers, outreach
teams and peer supporters.
The models of care described here are categorized according to where a person first
seeks care, and according to the degree of integration (Fig. 2). They are not prescriptive;
national programmes should define the models that best enable the provision of quality-
assured comprehensive services as close as possible to the end user.

Separate service delivery

Stand-alone service providers may screen for TB or relevant comorbidities, then refer
for diagnosis and treatment. For example, TB service providers may screen for mental
disorders using validated screening tools, then refer those who need further assessment.
Such models of care can be relatively simple to introduce at a low cost to health
services, utilizing available human resources (105). The healthcare workforce would
require training on screening tools such as brief questionnaires or point-of-care tests,
recording and reporting, and referral pathways. However, these least integrated services
require end users to attend multiple separate appointments in different locations to
receive a diagnosis and engage in treatment, which may be associated with loss to
follow-up and high out-of-pocket payments (105,106).
Alternatively, stand-alone service providers may screen and diagnose TB or relevant
comorbidities, then refer the person for treatment as required (105). For example, TB
services may diagnose diabetes or mental disorders, then refer for treatment initiation
and counselling on management. Conversely, diabetes services may screen for TB and
collect sputum for diagnosis as indicated. This model is closely aligned with people-
centred services and may reduce the number of separate healthcare appointments
needed; however, it may require additional staff capacity and logistical resources such
as point-of-care diagnostics and/or linkage to the sputum transportation network.

Framework for collaborative action on TB and comorbidities 27

 Co-located services
Co-location refers to separate service providers located in the same or adjacent premises.
Co-located models of care may further reduce the need to travel to multiple distant
facilities and enable a higher degree of integration between services. However, while
services are provided on the same premises, it is important to highlight the need for
close collaboration between the different service providers, e.g. to minimize the waiting
time between appointments, reduce the number of times a person needs to attend to
receive care for TB and the respective comorbidities, and enable integrated patient
health records (105,106). This model of care facilitates linkage to care and promotes
closer collaboration between providers but may be more time-consuming and costly
to the end user and their family compared to fully integrated models.

One-stop-shop
Under fully integrated models of care, collaborative services are provided in a one-
stop-shop for TB and comorbidities, including screening, diagnosis, sputum collection
for TB, treatment and care, by the same healthcare worker in the respective specialist
services or in primary health care services, on the same day. These may be provided in
primary care settings or through community outreach initiatives that are adapted to
the needs of service users and available close to where they live. Integrated models of
care may facilitate a holistic case management approach (68); reduce transport costs,
income loss and other costs associated with attending appointments; simplify recording
and reporting; and can be more time-efficient.
Changing to a fully integrated model of care may require alignment of financing,
human resources and multidisciplinary training, as well as logistical and infrastructural
investment. Preventing nosocomial spread of TB is a key consideration for integration,
therefore, comprehensive IPC measures should be enforced (108). However, concerns
over nosocomial TB transmission should not be a barrier to integration, as integrated
care supports early detection and treatment of undiagnosed infectious TB and may
result in a reduction of TB risk compared with separate services (106).
When establishing integrated services, it is important to note that one-stop-shop
services still require strong referral pathways. For example, referrals may be needed
for confirmation of diagnosis, specialist input or for ongoing management of TB-related
disability and comorbidities upon completion of TB treatment. Further, the preferences
of the person with TB and comorbidities should be considered, e.g. separate services may
be appropriate to maintain continuity of care for pre-existing comorbidities, to provide
highly specialized medical care, or may be preferred among people who experience
stigma in relation to comorbidities, such as injecting drug use.

28 Framework for collaborative action on tuberculosis and comorbidities

CASE STUDY:
Integrated screening and care for tuberculosis, viral hepatitis
and HIV, Georgia
Context: The joint burden of TB, HIV and viral hepatitis tends to be elevated among particular
high-risk groups, such as people in prison and people who inject drugs, yet, diagnosis and care
are frequently provided in separate facilities for each infection. In Georgia, where services for TB,
HIV and viral hepatitis have historically been provided by separate programmes, an integrated
model of screening and care has been developed to improve diagnosis and management of
TB, HCV and HIV at the primary care level (109,110). In 2018, when the intervention was first
introduced, the TB incidence in Georgia was 80/100 000 (29); among people diagnosed with
TB, 21% had HCV coinfection and 2% had HIV coinfection (91).
Intervention: An integrated model of screening and care for TB, HCV and HIV within primary
care was first introduced in 2018 in the Samegrelo-Zemo Svaneti region. With a population
of 330 000 and a significant share of internally displaced people, the region has a higher
burden of TB, HIV and HCV respectively, per capita compared to the country’s overall per
capita burden. Prior to implementation, a regional campaign was conducted, which comprised
advocacy, communication and social mobilization efforts to increase awareness of TB, HCV and
HIV among relevant stakeholders, including public health centres, local government, primary
care providers and civil society. Further, memoranda of understanding with defined roles
and responsibilities of stakeholders were agreed and signed between the partners in 2017.
To facilitate introduction of the primary care-based triple screening programme, local public–
private partnerships were developed. A regional steering committee was set up to lead
implementation and district multidisciplinary teams were established to provide monitoring
and support. A monitoring and evaluation framework defining indicators and annual targets
was developed in collaboration with the National Family Medicine Training Centre. Technical
assistance for developing the integrated screening model, and for conducting awareness-
raising and capacity building, was provided by the Global Fund. The local government allocated
a budget for the joint initiative, which included an incentive scheme for primary care providers.
Funding for tests and supplies was provided through state programmes.
Standardized protocols for integrated screening were developed, including a questionnaire on
signs and symptoms of TB and point-of-care rapid diagnostic tests for HCV and HIV. Primary
care providers were trained on screening and diagnostic procedures, ethical conduct, and on
web-based recording and reporting of results. Triple screening was then conducted by trained
primary care physicians in primary care facilities, as well as by outreach teams using a door-
to-door approach.
The intervention has been associated with increased coverage of screening and linkage to
care for TB, HCV and HIV. During the first 7 months of the intervention in Samegrelo-Zemo
Svaneti, triple screening was conducted for 88 178 people, exceeding the previous three years
combined. Among those screened, 192 had presumptive TB and were referred for further
testing, 22 of whom were subsequently diagnosed with TB disease. Further, 1277 people were
diagnosed with active HCV infection, and 37 with HIV. Following the pilot implementation, the
programme was scaled up to all regions in Georgia.
Lessons learnt: Key facilitators for implementation and scale-up of the primary care-based
model of care of triple screening for TB, HCV and HIV included strong political commitment,
investment and government leadership, the establishment of a steering committee with defined
and pre-agreed roles and responsibilities between partners, target setting, development of
an appropriate public–private mix, implementation of standardized clinical protocols and
public awareness campaigns. Decentralization and integration of TB, HCV and HIV services
in primary care can help overcome barriers to access to care and treatment, and close gaps
in the treatment cascade including reduced time between diagnosis and starting treatment.

Framework for collaborative action on TB and comorbidities 29

 C.3 Conduct collaborative planning and budgeting to scale up people-centred
services for TB and comorbidities

Based on the situation analysis, collaborative planning and budgeting is required to support
the introduction and scale-up of collaborative action on TB and comorbidities across the care
cascade and from the district level to nationwide coverage.
■ Key areas to consider in this process include:

community involvement at all levels;

quality-assured health and social services in the public and private sectors;
adequately trained, motivated and well-performing health workforce, social workers
an
and community health workers;

equitable and sustainable access to essential tools, medicines and products to enable
screening, diagnosis and management of comorbidities, such as weighing scales, blood
glucose strips, screening tools for mental health conditions, tobacco, alcohol and
substance use, medicines for comorbidities and nutrition support;

expansion of telemedicine and mHealth to bridge service delivery gaps; and

well-functioning, interoperable health information systems, and adequate workforce
capacity to conduct recording, reporting, analysis and review of data at all levels.
■ Harmonize national strategic plans, policies and guidelines for TB and the respective
comorbidities and ensure alignment within the national health plan.

C.4 Align advocacy and communication across health programmes

Advocacy targeted at influencing policy and implementation of interventions should engage a

range of stakeholders at all levels. In collaboration with the respective health programmes and
stakeholders, the national TB programme should:
■ Develop strategies for advocacy and communication informed by evidence review and
assessment (Section B).
■ Advocate for collaborative action on TB and comorbidities at all levels, as shown in Table 3.

30 Framework for collaborative action on tuberculosis and comorbidities

Table 3. Strategies for advocacy

Target audience and allies Advocacy focus and action

Leadership and government structures, Consolidate and present global, regional and
e.g. ministry of health, parliament, national evidence on the joint burden and
treasury, other relevant ministries, socioeconomic impact to garner political
regional and subnational government; commitment and funding for addressing TB
international organizations, donors and comorbidities
Private healthcare providers and Advocate for the inclusion of actions on TB and
associations comorbidities in public–private mix initiatives
Healthcare workers, community health Disseminate scientific advocacy on the impact
workers, allied health professionals of comorbidities on TB, and vice versa, and
evidence for related interventions
Academic and scientific institutions Advocate for the advancement of research
priorities
Civil society organizations, communities Engage and train civil society and TB survivors
and affected populations to support the development and dissemination
of messaging around TB and comorbidities
(see Section A.3) to build health awareness,
health literacy and reduce stigma. Identify
“champions”, ambassadors or influential
spokespeople for TB and comorbidities. Jointly
develop and disseminate health education
materials
General population Align advocacy and communications across
services to ensure inclusion of comorbidities
in TB-related communication, and of TB in
relevant communication on comorbidities.
Leverage on world health days, e.g. World HIV
Day, World Diabetes Day to raise awareness

Framework for collaborative action on TB and comorbidities 31

 D. Implement and scale up
people-centred services for
TB and comorbidities

D.1 Jointly develop policies, guidelines and procedures for collaborative

action on TB and comorbidities
D.2 Mobilize a qualified multidisciplinary workforce, including among
private providers and non-health sectors for collaborative action
D.3 Ensure access to essential medicines, vaccines, diagnostics and health
technologies for TB and comorbidities
D.4 Engage civil society and communities affected by TB and
comorbidities in refining and delivering people-centred services
D.5 Optimize access to social protection to prevent financial hardship due
to TB and comorbidities
D.6 Facilitate uptake of digital technologies to deliver health and social
protection services across programmes
D.7 Introduce phased scale-up of people-centred services for TB and
comorbidities

Common barriers to implementing collaborative services for TB and comorbidities include lack
of policies, guidelines or tools for operationalization (111), inadequate numbers of healthcare
workers and low levels of awareness and capacity to manage comorbidities (112–116), and
unavailability of equipment, consumables and medicines (114,117). Where services do exist,
stigma and discrimination faced by people with TB and comorbidities frequently preclude care-
seeking and engagement with treatment (111,118–120). Moreover, the costs of accessing health
care may be prohibitively high. Although TB services are generally free of charge, services for
comorbidities often incur costs at the point-of-care (111,117,121). In addition, there may be
high costs related to accessing TB services, such as transport costs and income loss (122).
The strategies described in Sections D.1–D.6 aim to address these barriers and to assist in
scaling up effective and responsive people-centred services. Affected populations and civil
society should be engaged throughout this process to jointly identify challenges, develop
solutions, design models of care and deliver services. Engagement of representatives from the
most marginalized groups – such as those with disorders due to substance use, HIV or mental
disorders – is especially important for addressing stigma and discrimination.

32 Framework for collaborative action on tuberculosis and comorbidities

Countries may adopt a phased approach to the scale-up of collaborative action, scaling up
services according to the local burden of the comorbidities, by geographical area and by
feasibility of interventions along the cascade of care (see Section D.7).

CASE STUDY:
Cough monitors to improve linkage between tuberculosis
services and the lung cancer control program, Kenya
Context: Among people with symptoms of tuberculosis (TB), alternative causes for the
respiratory symptoms, such as lung cancer or fibrosis, should be pursued if TB is ruled
out. Kenya is categorized as a country with a high burden of TB, with an incidence rate of
259/100 000 in 2020 (29). Further, in 2019, 0.44% of all deaths in Kenya were attributed
to lung cancer (123). Given the overlap of signs and symptoms between TB and lung
cancer, there is an opportunity to collaborate between relevant programmes to ensure
early detection, appropriate treatment and survival.
Intervention: In Kenya, a model of care has been developed, whereby cough monitors are
employed to improve cross-referral diagnosis of lung cancer for people with respiratory
symptoms in whom TB has been ruled out. The AMPATH Multinational Lung Cancer Control
Program was established through a partnership between the Ministry of Health, the
Ministry of Higher Education, Science and Technology and a consortium of universities. The
programme identifies individuals testing negative for TB and enables further investigation
of underlying lung disease. Cough monitors, who regularly work with TB clinics to facilitate
active case-finding, attend a one-day training to improve their skills and awareness of the
diagnosis of other lung diseases, including cancer. A weekly cough monitoring log and a
referral form captures the information on symptoms and duration. Cough monitors work
with TB services to identify symptomatic individuals for whom TB has been ruled out and
refer those who require further investigations to specialist services.
During the first year of implementation of the intervention, a total of 274 individuals
were referred for lung cancer investigations. Among referred individuals, 41% had lung
masses, and of these, 29 people (11% of all those referred for further investigation) were
diagnosed with lung cancer. Individuals without lung masses were diagnosed with other
respiratory conditions, including chronic pneumonia and fibrosis.
Lessons learnt: Early observations show that it is feasible and acceptable to engage cough
monitors in models of care for TB to facilitate referral for differential diagnosis after TB is
ruled out. The initiative has fostered collaboration between TB and lung cancer facilities,
improved referral mechanisms and aided in earlier diagnosis.

D.1 Jointly develop policies, guidelines and procedures for collaborative action
on TB and comorbidities

To maximize uptake of interventions, programmes should work together to develop guidance

and mainstream recommendations throughout policies, guidelines and tools. For broader
dissemination, programmes should:
■ Mainstream guidance in the respective guidelines for TB and comorbidities.

Framework for collaborative action on TB and comorbidities 33

 ■ Ensure alignment within other guidelines, e.g. for primary care, community health
workers, community-based and community-led care, prison health workforce and
mining organizations.
■ Develop and strengthen standard operating procedures and clinical algorithms to support
and promote routine implementation. Tools should focus on:

routine screening, diagnosis, co-management and prevention of TB and comorbidities
according to recommendations for the different comorbidities;

linkage to counselling, peer support, social care and nutritional support; and

referral and counter-referral when indicated, including for continuity of care for
comorbidities after completion of TB treatment.

D.2 Mobilize a qualified multidisciplinary workforce, including among private

providers and non-health sectors for collaborative action

Strategies for mobilizing an effective workforce for TB and comorbidities include:

■ Defining roles and responsibilities of the health workforce in accordance with the models
of care.
■ Linking with national efforts on task shifting, task sharing and community health worker
initiatives to expand the reach of collaborative action.
■ Developing and updating job descriptions to reflect changes in responsibilities, for task
shifting or task sharing4, as well as for supervision, mentoring and quality improvement.
■ Strengthening strategies for recruitment, retention and distribution of healthcare workers
appropriate to the needs for TB and comorbidities, and as part of the broader health
workforce strengthening strategy.
■ Building the necessary competencies among healthcare workers (including among private
providers and healthcare workers in other sectors) to deliver quality care for TB and
comorbidities, aligned with PHC:

advocate for updating of pre-service curricular training to address TB and comorbidities;

collaborate to provide training and capacity building on interventions to address TB and
comorbidities, including among private providers and non-health sectors, as locally relevant;

build capacity for recording, reporting, analysis and review of data on collaborative action
to inform programming;

promote and support the formal integration and remuneration for services of community
health workers and peer supporters within the health system;

engage affected populations in healthcare worker training on health-related needs and
psychosocial vulnerabilities, to prevent stigma and discrimination; and

promote continuing professional development on TB and comorbidities.

4
Task shifting refers to the rational redistribution of tasks from qualified healthcare workers to healthcare workers with less
training such as community health workers (162), whereas task sharing refers to the sharing of tasks across equally qualified
cadres of healthcare workers (163).

34 Framework for collaborative action on tuberculosis and comorbidities

D.3 Ensure access to essential medicines, vaccines, diagnostics and health
technologies for TB and comorbidities

To facilitate access to quality-assured essential medicines, products and equipment, it is vital to:
■ Lobby for inclusion of prevention measures, screening tools, diagnostic tests including
point-of-care tests, medication and care for TB and comorbidities within the essential
package of care under UHC.
■ Ensure all commodities are quality-assured.
■ Collaborate with international organizations, such as the World Food Programme, and
NGOs working on food security and nutrition to facilitate access to nutritional support.
■ Develop adequate laboratory network capacity or strong linkages to existing laboratory
networks (e.g. expand sputum transportation network to where relevant comorbidity
services are delivered; invest in expanded use of common diagnostic platforms for TB,
HIV, viral hepatitis, SARS-CoV-2, etc.).
■ Strengthen capacity in procurement and supply management, including training, storage
and management information systems to reduce stock-outs.
■ Where possible, stock medications for key comorbidities in TB services, and vice versa, to
minimize the need for referral for diagnosis and treatment.

Framework for collaborative action on TB and comorbidities 35

 CASE STUDY:
Nutrition programme in Madagascar supporting people with
tuberculosis
Context: Undernutrition is a key driver of the tuberculosis (TB) epidemic and a significant
risk factor for poor TB treatment outcomes. Undernutrition is also a common consequence
of TB disease. In Madagascar, the average 3-year prevalence of undernourishment was
43% in 2018–2020, ranking as the fifth most severely affected country worldwide (124). In
2021, an assessment conducted by the World Food Programme (WFP) indicated that 80%
of people with newly diagnosed TB in Madagascar were malnourished, and WHO estimates
that 31 000 (47%) new TB episodes in the country were attributable to undernutrition
in 2020. Nutrition support has been demonstrated to improve adherence (125), and
nutritional assessment, counselling and support are essential components of TB treatment
support.
Intervention: To address the nutritional needs of people with TB in southern Madagascar,
the National TB Programme (NTP), in collaboration with the WFP, has established and scaled
up a nutrition rehabilitation intervention for people with TB. The intervention comprises
nutritional assessment and counselling for all people with TB, and provision of specialized
nutritious foods for those who are found to be malnourished. Supplementation continues
until target criteria are met (body mass index [BMI] or middle upper arm circumference
[MUAC], depending on the individual being assessed).
The intervention was first introduced by WFP in 2005 in southern Madagascar, the area
with the highest levels of poverty, food insecurity and TB in the country. In 2014, the NTP
committed to incorporating nutritional care into the National Strategic Plan (NSP) for
the fight against TB 2015–2019. The programme was funded by the National Office for
Nutrition (Office National de Nutrition [ONN]), complemented by the Global Fund.
As part of scale-up of the intervention, the NTP identified more than 120 facilities in
regions with a high prevalence of TB, and where the burden of undernutrition among
people with TB was very high. Experience from the WFP nutrition programme informed
the NTP in setting up a standardized national protocol for the nutritional assessment
and care of people with TB. To facilitate assessment of nutritional status, WFP supplied
anthropometric equipment to all TB diagnostic and treatment centres. Distribution of
specialized nutritious foods to TB facilities was coordinated by WFP, including regular
deliveries every 2 months to ensure sufficient stock.
To monitor the need for and the impact of nutritional support for people with TB, the
NTP has included indicators on nutrition in the suite of NTP data collection tools. In 2021,
WFP conducted an assessment of the impact of the nutritional support programme, which
indicated a nutritional recovery rate of 90% among those who received the intervention.
Lessons learnt: The partnership between the NTP, WFP and ONN has enabled successful
scale up of interventions to address malnutrition among people with TB in southern
Madagascar. Logistic support provided by WFP enabled a robust assessment of the
nutritional status of people with TB and a reliable supply of specialized nutritious foods.
Implementation and scale-up was phased according to an assessment of the joint burden
of TB, malnutrition and food insecurity. The development of a standardized protocol on
nutrition assessment and support enabled routine implementation of the intervention.
Routine monitoring and evaluation, including standardized indicators, has helped to
monitor the joint burden and effectiveness of the response.

36 Framework for collaborative action on tuberculosis and comorbidities

D.4 Engage civil society and communities affected by TB and comorbidities in
refining and delivering people-centred services

Engage civil society and affected and at-risk populations (e.g. people with diabetes, PWUD and
people living with HIV), as well as their families and communities to support in the following
areas:
■ Healthcare delivery, including through peer support initiatives.
■ Assessing quality of care.
■ Advocacy for improved quality and coverage of services where needed.
■ Monitoring and addressing stigma and discrimination.
■ Implementation of outreach and education initiatives to strengthen health literacy on TB
and comorbidities, and to inform on how and where appropriate care and prevention can
be accessed.

D.5 Optimize access to social protection to prevent financial hardship due to

TB and comorbidities

Social protection measures mitigate the direct and indirect financial burden of engaging in
care for TB and comorbidities. In collaboration with social welfare and other relevant agencies,
optimize access to social protection, to prevent financial hardship due to TB and comorbidities,
through the following actions:
■ Strengthening collaboration with the relevant social services and stakeholders to
facilitate linkage with the existing social protection interventions, e.g. nutritional support,
employment guarantee, safe housing and poverty alleviation.
■ Lobbying for health insurance cover for people with TB and comorbidities to minimize
out-of-pocket payments, to cover the cost of essential products and services that are not
freely available in the public healthcare system.
■ Lobbying for funding to support non-medical costs (e.g. transport costs) and income
losses related to treatment.
■ Including information on provision of social protection in health worker training and health
education materials.

Framework for collaborative action on TB and comorbidities 37

 D.6 Facilitate uptake of digital technologies to deliver health and social
protection services across programmes

Digital technologies to support scale-up of collaborative action on TB and comorbidities

include telemedicine and video-supported treatment, computer-aided detection of TB-related
abnormalities on chest radiography, digital data collection tools. To enhance uptake,
countries should:
■ Adopt and adapt new tools and technologies for prevention, diagnosis and treatment
to enhance integration and allow interoperability between TB and comorbidity
information systems.
■ Safeguard privacy and confidentiality when digital technologies are used to record health
information and provide services for TB and comorbidities.
■ Develop plans for longer term sustainability of digital technology, including for physical
equipment and software updates.
■ Exploit other applications of digital technologies to deliver services, for example integrated
eLearning courses such as massive open online courses (MOOCs) to improve healthcare
worker capacity and health information.
■ Collect data on the barriers to and performance of digital technologies, to continuously
improve interventions as well as data capture.

D.7 Introduce phased scale-up of people-centred services for TB and

comorbidities

Informed by ongoing monitoring, review and prioritization, countries should incrementally scale
up services for TB and comorbidities with the aim of nationwide coverage. Phased scale-up
should consider the following:
■ Cascade of care, e.g. first introduce screening for TB and comorbidities in the respective
services, then gradually expand to the full cascade including prevention and co-management
of TB and comorbidities in the same facility.
■ Geographical setting, e.g. starting in one or two districts with phased nationwide
decentralization to the community level.
■ Strengths of the existing services, e.g. in countries where TB services have a strong network
but services for diabetes are less well established, start with screening and co-management
of diabetes among people attending TB services.
■ Opportunities to build on the existing networks of integrated care such as TB/HIV services
or primary care, e.g. develop services that address multimorbidity by introducing screening
for several comorbidities and health-related risk factors, such as mental health conditions,
diabetes and malnutrition within TB/HIV services. This may also be done within models of
differentiated service delivery for HIV treatment and care.

38 Framework for collaborative action on tuberculosis and comorbidities

CASE STUDY:
Scaling up collaborative TB/HIV activities in the concentrated
HIV epidemic setting of India
Context: In 2020, India had the highest number of people with tuberculosis (TB) globally,
estimated at 2.59 million, with an incidence rate of 188/100 000 (29). Further, India had the
second highest number of people with HIV-associated TB disease. While TB is endemic
across India, the HIV epidemic in India is concentrated among high risk groups and in
six out of the 35 states and union territories; in 2019, the estimated countrywide HIV
prevalence was 0.22% among adults 15-49 years, while the estimated HIV prevalence
among people with incident TB was 2.2% in 2020 (13,126). Scale-up of collaborative TB/
HIV activities in countries with a high burden of TB with concentrated HIV epidemics is
challenging due to insufficient political commitment and financing to decentralize HIV
services. Collaborative TB/HIV activities in India were first established in the six high burden
states and were progressively scaled up nationwide, providing a good example for other
countries with concentrated HIV epidemics.
Intervention: In India, TB/HIV collaborative activities have been effectively established and
strategically scaled up, from targeted interventions in high-burden states to nationwide
coverage of services. Between 2005 and 2010, a national TB/HIV framework was developed,
a coordination mechanism and technical working group were established, and joint
training modules and surveillance were implemented in all states. In addition, an intensified
package of TB/HIV activities was launched, which included HIV testing for all people
diagnosed with TB and referral for those eligible for antiretroviral therapy (ART). The
intensified TB/HIV package was initially implemented in states with a high HIV burden
with the capacity for HIV testing and programme management, and subsequently scaled
up to nationwide coverage by 2012.
Following the publication of the WHO Policy on collaborative TB/HIV activities in 2012,
the national TB/HIV framework was revised. Between 2015 and 2018, one-stop-shop
services for TB and HIV were rolled out across all ART centres with intensified case-finding,
molecular WHO-recommended rapid diagnostic tests, a daily TB treatment regimen, TB
preventive treatment and strengthened infection prevention and control measures. In
addition, guidelines were developed for TB and HIV interventions in prisons and other
places of detention, and active case-finding initiatives were implemented for high-risk
groups. In 2019, a policy on HIV-testing for all people undergoing investigation for TB
was introduced. Activities were accompanied by regular meetings between the HIV and
TB programme managers for joint review of data. Between 2008 and 2020, the proportion
of people with TB and with an HIV test result increased from 11% to 92%. Further, in 2020,
94% of people living with HIV were screened for TB, and more than 1.1 million people
with HIV had received TB preventive treatment.
Lessons learnt: The phased scale-up of TB/HIV activities was informed by the
epidemiology and service readiness, focusing first on states with a high burden of HIV
and existing management capacity. The available health infrastructure was progressively
and strategically expanded to decentralize and extend the reach of TB/HIV activities,
for example by introducing HIV screening by point-of-care tests at the primary health
subcentre level and by ensuring that TB services were provided at ART clinics (127). The
introduction and phased scale-up of TB/HIV collaborative activities were facilitated by
political commitment and the development of policy guidelines, as well as by regular
monitoring and review by both programmes to ensure that targets were achieved.

Framework for collaborative action on TB and comorbidities 39

 E. Strengthen monitoring,
evaluation and research

E.1 Adopt indicators and set targets for collaborative action on TB and
comorbidities
E.2 Strengthen surveillance for comorbidities among people with TB,
and surveillance for TB among people with comorbidities and health-
related risk factors in accordance with WHO recommendations
E.3 Introduce and scale up monitoring and evaluation of collaborative
action on TB and comorbidities at all levels
E.4 Conduct joint reviews of quality and coverage of services to inform
programming
E.5 Conduct operational and implementation research to inform policy,
programming and service delivery

Target-setting, monitoring and evaluation, regular review and operational research are critical
enablers for scaling up collaborative action on TB and comorbidities. These have been essential
facilitators for introducing, implementing and scaling up collaborative TB/HIV activities (127).
Clear definitions of indicators can drive progress and accountability, especially if linked with
established accountability mechanisms such as MAF-TB (77).
Indicators that may be adopted at the national level are included in the WHO guidelines on
monitoring and evaluation of collaborative TB/HIV activities, for TB and diabetes and for TB and
tobacco (27,36,128). In addition, guidance on new and updated indicators will also be included
within WHO guidance and operational handbooks for TB and the respective comorbidities, which
will be published on the Global TB Programme Knowledge Sharing Platform (85). Countries
should set time-bound targets to scale up collaborative action on TB and comorbidities, which
can strengthen collaboration between programmes, promote involvement across sectors and
help to mobilize political commitment (17) (see Section E.1).
Surveillance and regular assessment should be conducted to inform programming (see Section
E.2). Multiple data sources can be utilized during monitoring, evaluation, reporting and review
(5,129), as outlined in Section B. The existing surveillance systems can provide valuable, real-time
information on service utilization and health outcomes. The WHO toolkit for analysis and use of
routine health facility data (130) provides a standardized approach to analysing routine facility
data for the national, district and facility levels, which may be adapted for assessing services for
TB and comorbidities. Data from a range of non-health sectors could also be utilized to promote
multisectoral action and accountability. The sources may include, inter alia, the prison sector,
mining sector and social services (5).

40 Framework for collaborative action on tuberculosis and comorbidities

The rapid development of digital technology provides novel opportunities for collecting and
analysing data (5,129,131). Programmes should strive to implement interoperable electronic
recording and reporting such as the District Health Information Software (DHIS2) (132), which
can facilitate co-management, referral and follow-up, as well as real-time analysis of emerging
trends in epidemiology. Such systems should however safeguard the confidentiality of patient
data throughout implementation (81,133).
As part of scale-up, recording and reporting tools should be updated to capture and strengthen
data on the continuum of care for TB and comorbidities. Human resource capacity should be
developed to collect and analyse data (see Section E.3). It is critical that data are jointly reviewed
on a regular basis, and used to drive performance improvement, as part of existing review
processes (see Section E.4). Where data gaps exist, operational research should be conducted
to fine-tune programming and people-centred service delivery (see Section E.5).

E.1 Adopt indicators and set targets for collaborative action on TB and
comorbidities

When adopting indicators and setting targets, the following factors should be considered:
■ Select and adopt standardized joint indicators for TB and comorbidities in accordance
with recommendations for the respective comorbidities and local epidemiological burden.
■ Set and adapt national targets according to the local epidemiology and readiness of the
health system to achieve the targets.

E.2 Strengthen surveillance for comorbidities among people with TB, and
surveillance for TB among people with comorbidities and health-related
risk factors in accordance with WHO recommendations

Surveillance of the joint burden of TB and comorbidities should inform priority setting, budgeting,
planning and implementation. To strengthen surveillance, countries should:
■ Select methods for surveillance in accordance with the national context, available resources
and WHO recommendations for the respective comorbidities. The most appropriate
method will vary depending on the comorbidity, the epidemiology and health systems
context, and may include:

use of routine health systems data;

periodic cross-sectional surveys among a nationally representative sample;
prevalence surveys; and
TB

sentinel surveys.
■ Train staff at all levels to collect, analyse, report and use data.
■ Plan for, adopt and scale up electronic recording and reporting systems (e.g. DHIS2) that
are interoperable between programmes at all levels of the health system, while maintaining
confidentiality. To support this, programmes should:

Framework for collaborative action on TB and comorbidities 41


harmonize recording and reporting systems across programmes and services and introduce
unique patient identifiers to facilitate information sharing and minimize duplication;

ensure availability and maintenance of physical equipment and build the required
technical capacity among healthcare workers to document and access patient health
information on electronic health records;

establish mechanisms to capture data relating to implementation by private, non-
governmental and non-health sectors; and

adapt standardized paper-based recording and reporting systems to collect data on TB
and comorbidities, where electronic recording and reporting is not yet feasible.

E.3 Introduce and scale up monitoring and evaluation of collaborative action

on TB and comorbidities at all levels

To support the collection, reporting and use of data that reflect the joint burden and
implementation, countries should:
■ Embed indicators of TB and comorbidities into routine recording and reporting.
■ Build capacity including human resources, training and tools, at the subnational and
health facility level for recording, reporting, monitoring, evaluation and review, as well
as supervision.
■ Introduce systematic cross-checking, reconciliation, analysis and review of data between
programmes on a regular basis down to the clinic level.
■ Disseminate results to healthcare workers through supervision and mentoring to incentivize
continued implementation, monitoring and evaluation.

E.4 Conduct joint review of quality and coverage of services to inform

programming

In collaboration with the relevant health programmes, the national TB programme should
review action on TB and comorbidities as part of the regular review processes of the respective
programmes at the national and subnational levels (e.g. epidemiological reviews, national TB
programme reviews, HIV programme reviews, and quarterly supervision visits). During the review
process, countries should:
■ Engage with the stakeholders, healthcare providers and affected communities to appraise
the evidence.
■ Identify shortcomings and unmet needs.
■ Based on collected data and evidence for effective interventions, adapt and adjust the
response to TB and comorbidities according to the evolving situation.

42 Framework for collaborative action on tuberculosis and comorbidities

CASE STUDY:
Simultaneous screening and testing for tuberculosis and
COVID-19 in Manila, the Philippines
Context: The COVID-19 pandemic resulted in a global drop in the reported number of
people newly diagnosed with tuberculosis (TB), from 7.1 million in 2019 to 5.8 million in
2020 (13). The reduced access to TB diagnosis and treatment resulted in an increase in
the estimated number of deaths due to TB for the first time in over a decade (13). The
Philippines has a high burden of TB, with an incidence rate of 539/100 000 in 2020 (29).
Diagnostic and treatment services for TB are provided by the National TB Programme
(NTP) within a range of public and private health facilities.
Intervention: A model of simultaneous screening and testing for TB and COVID-19 was
introduced in August 2021 in the city of Manila, to address the drop in TB case notifications.
The development and implementation of this model was informed by several assessments
on the impact of COVID-19 on TB screening and rates of diagnosis, jointly conducted
by academia, international organizations and the Ministry of Health. The assessments
included a modelling study on the impact of COVID-19 on reaching the national TB
notification targets, an analysis of TB notification rates before and after the introduction
of community quarantine, and a rapid assessment of the impact of COVID-19 on the
provision of TB services. To garner political commitment and stakeholder buy-in, the results
of these assessments were presented to key stakeholders including the local government,
management of health facilities and TB laboratories.
TB screening was offered to all people attending COVID-19 swabbing facilities, and TB
testing was offered to all people with confirmed COVID-19 who were admitted to an
isolation facility. The roles and responsibilities of stakeholders were outlined clearly before
implementation, and communication activities were designed to increase awareness and
uptake of services among the public. Additional laboratory staff were hired to perform Xpert
MTB/Rif testing, and field teams received continuous mentoring and support. Monitoring
and evaluation was established with regular on-site and remote joint monitoring activities
conducted by technical and operational teams. A project-specific database recorded real-
time updates, and TB notifications were captured in the NTP’s integrated TB information
system. Indicators on number of persons screened in the respective services, and number
of persons diagnosed with TB, were reviewed at regular meetings between the technical
and operational teams, Manila Health Department NTP team and other stakeholders.
During the first 2 months, 1106 individuals underwent symptom-based TB screening
in facilities where swabbing for SARS-CoV-2 was performed, 889 of whom were then
screened using chest X-ray. Among these, 243 were tested using Xpert MTB/RIF and 11
were diagnosed with TB. In isolation facilities, 404 people were tested for TB, among whom
5 people received a TB diagnosis.
Lessons learnt: Key facilitators to the introduction of simultaneous screening for COVID-19
and TB included the use of multiple and complementary assessments to identify gaps
and garner political commitment. Close collaboration with stakeholders including the
local government, management of COVID-19 facilities, TB laboratories and TB services
facilitated the integration of TB screening and testing services within COVID-19 services.
Further, communication and health education activities aimed at the public helped to
increase awareness and generate demand for services.

Framework for collaborative action on TB and comorbidities 43

 E.5 Conduct operational and implementation research to inform policy,
programming and service delivery

Operational and implementation research is key to improving people-centred services. To this

end, the following actions are recommended:
■ Identify research priorities for TB and comorbidities based on data and evidence gaps
identified during assessment (see Section B) and review, and in line with national priorities
and research gaps highlighted in the relevant WHO guidelines.
■ Promote research to determine the financial burden of TB and comorbidities on those
affected and on the health system.
■ Assess the costs and cost-effectiveness of alternative integrated models of care.
■ Explore the potential contribution of comorbidities to the burden of TB disease and
mortality, including for emerging threats such as COVID-19.
■ Strengthen and encourage operational and implementation research on TB and
comorbidities at all levels to identify challenges and develop effective solutions.
■ Develop funding applications and proposals for operational and implementation research
and economic analyses of TB and comorbidities in collaboration between TB and the
relevant services, informed by the results of national evaluations.
■ Facilitate the translation of research findings into revised and strengthened policy,
programming and service delivery.

44 Framework for collaborative action on tuberculosis and comorbidities

References

1. International Classification of Diseases 11th Revision [website]. World Health Organization; 2019
(https://icd.who.int/en, accessed 5 March 2022).
2. Quality health services: a planning guide. Geneva: World Health Organization; 2020. Licence:
CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/336661, accessed 11 March 2022).
3. Priorities in operational research to improve tuberculosis care and control. Geneva: World Health
Organization; 2011 (https://apps.who.int/iris/handle/10665/44662, accessed 11 March 2022).
4. Sixty-Ninth World Health Assembly. Framework on integrated people-centred health services:
report by the Secretariat. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/
handle/10665/252698, accessed 11 March 2022).
5. Operational framework for primary health care: transforming vision into action. Geneva: World Health
Organization and the United Nations Children’s Fund (UNICEF); 2020. Licence: CC BY-NC-SA 3.0 IGO
(https://apps.who.int/iris/handle/10665/337641, accessed 11 March 2022).
6. Social determinants of health [website]. World Health Organization; 2021 (https://www.who.int/
health-topics/social-determinants-of-health#tab=tab_1, accessed 11 March 2022).
7. WHO consolidated guidelines on tuberculosis. Module 1: prevention – tuberculosis preventive
treatment. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO (https://apps.
who.int/iris/handle/10665/331170, accessed 11 March 2022).
8. United Nations. Political declaration of the United Nations high-level meeting on universal health
coverage. New York: WHO; 2019 (https://undocs.org/en/A/RES/74/2, accessed 11 March 2022).
9. The End TB Strategy. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/
handle/10665/331326, accessed 11 March 2022).
10. United Nations General Assembly. Political declaration of the United Nations high-level meeting on
the fight against tuberculosis. New York: United Nations; 2018 (https://undocs.org/en/A/RES/73/3,
accessed 11 March 2022).
11. United Nations General Assembly. Political declaration of the third high-level meeting of the General
Assembly on the prevention and control of non-communicable diseases. 73rd Session. Resolution
Adopted by the General Assembly; 10 October 2018 (https://apps.who.int/gb/ebwha/pdf_files/EB148/
B148_7-en.pdf, accessed 11 March 2022).
12. United Nations General Assembly. Political declaration on HIV and AIDS: ending inequalities and
getting on track to end AIDS by 2030. 73rd Session. 74th Plenary Meeting; 8 June 2021 (https://
www.unaids.org/sites/default/files/media_asset/2021_political-declaration-on-hiv-and-aids_en.pdf,
accessed 11 March 2022).
13. Global tuberculosis report 2021. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA
3.0 IGO (https://apps.who.int/iris/handle/10665/346387, accessed 11 March 2022).
14. WHO Information Note COVID-19: considerations for tuberculosis (TB) care, 5 May 2021. World Health
Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/341126,
accessed 11 March 2022).

45
 15. Pedrazzoli D, Wingfield T. Biosocial strategies to address the socioeconomic determinants and
consequences of the TB and COVID-19 pandemics. Am J Trop Med Hyg. 2021;104:407–9. doi: 10.4269/
ajtmh.20-1641.
16. United Nations. Transforming our world: the 2030 agenda for sustainable development. 70th Session.
Resolution Adopted by the General Assembly; 25 September 2015 (https://www.un.org/ga/search/
view_doc.asp?symbol=A/RES/70/1&Lang=E, accessed 11 March 2022).
17. WHO policy on collaborative TB / HIV activities. Guidelines for national programmes and other
stakeholders. Geneva: World Health Organization; 2012 (https://apps.who.int/iris/handle/10665/44789,
accessed 11 March 2022).
18. Global status report on alcohol and health 2018. Geneva: World Health Organization; 2018. Licence:
CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/274603, accessed 11 March 2022).
19. Ragan EJ, Kleinman MB, Sweigart B, Gnatienko N, Parry CD, Horsburgh CR et al. The impact of alcohol
use on tuberculosis treatment outcomes: a systematic review and meta-analysis. Int J Tuberc Lung
Dis. 2020;24:73–82. doi: 10.5588/ijtld.19.0080.
20. WHO consolidated guidelines on tuberculosis. Module 2: screening – systematic screening for
tuberculosis disease. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO
(https://apps.who.int/iris/handle/10665/340255, accessed 11 March 2022)
21. WHO consolidated guidelines on tuberculosis. Module 4: treatment – drug-resistant tuberculosis
treatment. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO (https://apps.
who.int/iris/handle/10665/332397, accessed 11 March 2022).
22. Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: a systematic review
of 13 observational studies. PLoS Med. 2008;5:e152. doi: 10.1371/journal.pmed.0050152.
23. Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lönnroth K et al. The impact of diabetes on tuberculosis
treatment outcomes: a systematic review. BMC Med. 2011;9:81. doi: 10.1186/1741-7015-9-81.
24. Liu Q, Li W, Xue M, Chen Y, Du X, Wang C et al. Diabetes mellitus and the risk of multidrug resistant
tuberculosis: a meta-analysis. Sci Rep. 2017;7:1090. doi: 10.1038/s41598-017-01213-5.
25. Noubiap JJ, Nansseu JR, Nyaga UF, Nkeck JR, Endomba FT, Kaze AD et al. Global prevalence of
diabetes in active tuberculosis: a systematic review and meta-analysis of data from 2.3 million patients
with tuberculosis. Lancet Glob Health. 2019;7:e448–e460. doi: 10.1016/S2214-109X(18)30487-X.
26. International Diabetes Federation. IDF Diabetes Atlas 9th edition 2019 [website]. IDF Diabetes Atlas
(https://diabetesatlas.org/atlas/ninth-edition/, accessed 11 March 2022).
27. World Health Organization and International Union against Tuberculosis and Lung Disease.
Collaborative framework for care and control of tuberculosis and diabetes. Geneva: World Health
Organization; 2011 (https://apps.who.int/iris/handle/10665/44698, accessed 11 March 2022).
28. Tuberculosis: Fact Sheet [website]. World Health Organization; 2021 (https://www.who.int/news-
room/fact-sheets/detail/tuberculosis, accessed 11 March 2022).
29. WHO TB burden estimates [website]. Global Tuberculosis Report. World Health Organization; 2021
(https://www.who.int/teams/global-tuberculosis-programme/data, accessed 11 March 2022).
30. Peters JS, Andrews JR, Hatherill M, Hermans S, Martinez L, Schurr E et al. Advances in the understanding
of Mycobacterium tuberculosis transmission in HIV-endemic settings. Lancet Infect Dis. 2019;19:e65–
e76. doi: 10.1016/S1473-3099(18)30477-8.
31. Ford N, Matteelli A, Shubber Z, Hermans S, Meintjes G, Grinsztejn B et al. TB as a cause of hospitalization
and in-hospital mortality among people living with HIV worldwide: a systematic review and meta-
analysis. J Int AIDS Soc. 2016 Jan 12;19(1):20714. doi: 10.7448/IAS.19.1.20714.

46 Framework for collaborative action on tuberculosis and comorbidities

32. Gupta RK, Lucas SB, Fielding KL, Lawn SD. Prevalence of tuberculosis in post-mortem studies of HIV-
infected adults and children in resource-limited settings: a systematic review and meta-analysis.
AIDS. 2015;29:1987–2002. doi: 10.1097/QAD.0000000000000802.
33. WHO global report on trends in prevalence of tobacco use 2000–2025, fourth edition. Geneva:
World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/348537, accessed 25 May 2022)
34. Siddiqi K, Keding A, Marshall AM, Dogar O, Li J, Huque R et al. Effect of quitting smoking on health
outcomes during treatment for tuberculosis: secondary analysis of the TB & Tobacco Trial. Thorax.
2022;77:74–78. doi: 10.1136/thoraxjnl-2020-215926.
35. Wagnew F, Eshetie S, Alebel A, Dessie G, Tesema C, Abajobir AA. Meta-analysis of the prevalence
of tuberculosis in diabetic patients and its association with cigarette smoking in African and Asian
countries. BMC Res Notes. 2018;11:298. doi: 10.1186/s13104-018-3390-x.
36. World Health Organization, International Union Against Tuberculosis and Lung Disease. A WHO
/ The Union monograph on TB and tobacco control : joining efforts to control two related global
epidemics. WHO; 2007 (https://apps.who.int/iris/handle/10665/43812, accessed 11 March 2022).
37. Lönnroth K, Williams BG, Cegielski P, Dye C. A consistent log-linear relationship between tuberculosis
incidence and body mass index. Int J Epidemiol. 2010;39:149–55. doi: 10.1093/ije/dyp308.
38. Van Lettow M, Kumwenda JJ, Harries AD, Whalen CC, Taha TE, Kumwenda N et al. Malnutrition and
the severity of lung disease in adults with pulmonary tuberculosis in Malawi. Int J Tuberc Lung Dis.
2004;8:211–17.
39. Waitt CJ, Squire SB. A systematic review of risk factors for death in adults during and after tuberculosis
treatment. Int J Tuberc Lung Dis. 2011;15:871–85. doi: 10.5588/ijtld.10.0352.
40. Sinha P, Lönnroth K, Bhargava A, Heysell SK, Sarkar S, Salgame P et al. Food for thought:
addressing undernutrition to end tuberculosis. Lancet Infect Dis. 2021;21:e318–e325. doi: 10.1016/
S1473-3099(20)30792-1.
41. Guideline: Nutritional care and support for patients with tuberculosis. World Health Organization;
2013 (https://apps.who.int/iris/handle/10665/94836, accessed 11 March 2022).
42. Ehrlich R, Akugizibwe P, Siegfried N, Rees D. The association between silica exposure, silicosis and
tuberculosis: a systematic review and meta-analysis. BMC Public Health. 2021;21:953. doi: 10.1186/
s12889-021-10711-1.
43. Corbett EL, Churchyard GJ, Clayton TC, Williams BG, Mulder D, Hayes RJ et al. HIV infection and
silicosis: the impact of two potent risk factors on the incidence of mycobacterial disease in South
African miners. AIDS. 2000;14:2759–68. doi: 10.1097/00002030-200012010-00016.
44. Byrne AL, Marais BJ, Mitnick CD, Lecca L, Marks GB. Tuberculosis and chronic respiratory disease: a
systematic review. Int J Infect Dis. 2015;32:138–46. doi: 10.1016/j.ijid.2014.12.016.
45. van Zyl Smit RN, Pai M, Yew WW, Leung CC, Zumla A, Bateman ED et al. Global lung health: the
colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD. Eur Respir J. 2010;35:27–33.
doi: 10.1183/09031936.00072909.
46. Liang HY, Li XL, Yu XS, Guan P, Yin ZH, He QC et al. Facts and fiction of the relationship between
preexisting tuberculosis and lung cancer risk: a systematic review. Int J Cancer. 2009;125:2936–44.
doi: 10.1002/ijc.24636.
47. Alene KA, Wangdi K, Colquhoun S, Chani K, Islam T, Rahevar K et al. Tuberculosis related disability:
a systematic review and meta-analysis. BMC Med. 2021;19:203. doi: 10.1186/s12916-021-02063-9.

References 47
 48. Practical approach to lung health: manual on initiating PAL implementation. Geneva: World Health
Organization; 2008 (https://apps.who.int/iris/handle/10665/69937, accessed 7 March 2022).
49. Western Cape Department of Health in collaboration with the National Institute for Communicable
Diseases, South Africa, Risk Factors for Coronavirus Disease 2019 (COVID-19) Death in a Population
Cohort Study from the Western Cape Province, South Africa. Clinical Infectious Diseases.
2021;73:e2005–e2015. doi: 10.1093/cid/ciaa1198.
50. Tamuzi JL, Ayele BT, Shumba CS, Adetokunboh OO, Uwimana-Nicol J, Haile ZT et al. Implications
of COVID-19 in high burden countries for HIV/TB: a systematic review of evidence. BMC Infect Dis.
2020;20:744. doi: 10.1186/s12879-020-05450-4.
51. Patanavanich R, Glantz SA. Smoking is associated with worse outcomes of COVID-19 particularly
among younger adults: a systematic review and meta-analysis. BMC Public Health. 2021;21:1554.
doi: 10.1186/s12889-021-11579-x.
52. Getahun H, Baddeley A, Raviglione M. Managing tuberculosis in people who use and inject illicit
drugs. Bull World Health Organ. 2013;91:154–6. doi: 10.2471/BLT.13.117267.
53. Deiss RG, Rodwell TC, Garfein RS. Tuberculosis and illicit drug use: review and update. Clin Infect Dis.
2009;48:72–82. doi: 10.1086/594126.
54. Grenfell P, Baptista Leite R, Garfein R, de Lussigny S, Platt L, Rhodes T. Tuberculosis, injecting drug
use and integrated HIV-TB care: a review of the literature. Drug Alcohol Depend. 2013;129:180–209.
doi: 10.1016/j.drugalcdep.2012.11.013.
55. Degenhardt L, Peacock A, Colledge S, Leung J, Grebely J, Vickerman P et al. Global prevalence of
injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in
people who inject drugs: a multistage systematic review. Lancet Glob Health. 2017;5:e1192–e1207.
doi: 10.1016/S2214-109X(17)30375-3.
56. Dolan K, Wirtz AL, Moazen B, Ndeffo-Mbah M, Galvani A, Kinner SA et al. Global burden of HIV,
viral hepatitis, and tuberculosis in prisoners and detainees. Lancet. 2016;388:1089–102. doi: 10.1016/
S0140-6736(16)30466-4.
57. Citro B, Soltan V, Malar J, Katlholo T, Smyth C, Sari AH et al. Building the evidence for a rights-based,
people-centered, gender-transformative tuberculosis response: an analysis of the Stop TB Partnership
community, rights, and gender tuberculosis assessment. Health Hum Rights. 2021;23:253–67.
58. Lan CW, Lin C, Thanh DC, Li L. Drug-related stigma and access to care among people who inject
drugs in Vietnam. Drug Alcohol Rev. 2018;37:333–9. doi: 10.1111/dar.12589.
59. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring:
recommendations for a public health approach. Geneva: World Health Organization; 2021. Licence:
CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/342899, accessed 11 March 2022).
60. Getahun H, Gunneberg C, Sculier D, Verster A, Raviglione M. Tuberculosis and HIV in people who
inject drugs: evidence for action for tuberculosis, HIV, prison and harm reduction services. Curr Opin
HIV AIDS. 2012;7:345–53. doi: 10.1097/COH.0b013e328354bd44.
61. Duko B, Bedaso A, Ayano G. The prevalence of depression among patients with tuberculosis: a systematic
review and meta-analysis. Ann Gen Psychiatry. 2020;19:30. doi: 10.1186/s12991-020-00281-8.
62. People who inject drugs [website]. World Health Organization (https://www.who.int/teams/global-
hiv-hepatitis-and-stis-programmes/populations/people-who-inject-drugs, accessed 7 March 2022).

48 Framework for collaborative action on tuberculosis and comorbidities

63. International standards for the treatment of drug use disorders: revised edition incorporating results
of field-testing. Geneva: World Health Organization and United Nations Office on Drugs and Crime;
2020. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/331635, accessed 11
March 2022).
64. Treatment and care for people with drug use disorders in contact with the criminal justice system:
alternatives to conviction or punishment. Geneva: World Health Organization and United Nations
Office on Drugs and Crime; 2019 (https://www.unodc.org/documents/UNODC_WHO_Alternatives_
to_conviction_or_punishment_ENG.pdf, accessed 7 March 2022).
65. Health, rights and drugs: harm reduction, decriminalization and zero discrimination for people who
use drugs. UNAIDS; 2019 (https://www.unaids.org/sites/default/files/media_asset/JC2954_UNAIDS_
drugs_report_2019_en.pdf, accessed 7 March 2022).
66. Alene KA, Clements ACA, McBryde ES, Jaramillo E, Lönnroth K, Shaweno D et al. Mental health
disorders, social stressors, and health-related quality of life in patients with multidrug-resistant
tuberculosis: a systematic review and meta-analysis. J Infect. 2018;77:357–67. doi: 10.1016/j.
jinf.2018.07.007.
67. Lee GE, Scuffell J, Galea JT, Shin SS, Magill E, Jaramillo E et al. Impact of mental disorders on active
tuberculosis treatment outcomes: a systematic review and meta-analysis. Int J Tuberc Lung Dis.
2020;24:1279–84.
68. Pasha A, Siddiqui H, Ali S, Brooks MB, Maqbool NR, Khan AJ. Impact of integrating mental health
services within existing tuberculosis treatment facilities. Medicine Access @ Point of Care; 2021. doi:
10.1177/23992026211011314.
69. WHO consolidated guidelines on tuberculosis. Module 4: treatment: tuberculosis care and support.
Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/353399, accessed 04 July 2022).
70. Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021 : accountability
for the global health sector strategies 2016–2021: actions for impact. Geneva: World Health
Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/341412,
accessed 11 March 2022).
71. Feleke BE, Feleke TE, Adane WG, Girma A. Impacts of hepatitis B and hepatitis C co-infection with
tuberculosis, a prospective cohort study. Virol J. 2020;17:113. doi: 10.1186/s12985-020-01385-z.
72. Bushnell G, Stennis NL, Drobnik AM, Proops DC, Ahuja SD, Bornschlegel K et al. Characteristics and
TB treatment outcomes in TB patients with viral hepatitis, New York City, 2000–2010. Epidemiol Infect.
2015;143:1972–81. doi: 10.1017/S0950268814002970.
73. WHO guidelines on hepatitis B and C testing. Geneva: World Health Organization; 2017. Licence:
CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/254621, accessed 11 March 2022).
74. Integrating collaborative TB and HIV services within a comprehensive package of care for people
who inject drugs : consolidated guidelines. Geneva: World Health Organization; 2016 (https://apps.
who.int/iris/handle/10665/204484, accessed 11 March 2022).
75. Evidence to decision framework – Appendix to the Guidelines on the management of latent
tuberculosis infection. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/
handle/10665/158915, accessed 11 March 2022).
76. People-centred framework for tuberculosis programme planning and prioritization – User guide.
Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/329472, accessed 11 March 2022).

References 49
 77. Multisectoral accountability framework to accelerate progress to end tuberculosis by 2030.
Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 (https://apps.who.int/iris/
handle/10665/331934, accessed 11 March 2022).
78. Horter S, Daftary A, Keam T, Bernays S, Bhanushali K, Chavan D et al. Person-centred care in TB. Int
J Tuberc Lung Dis. 2021;25:784–87. doi: 10.5588/ijtld.21.0327.
79. Odone A, Roberts B, Dara M, van den Boom M, Kluge H, McKee M. People- and patient-centred care
for tuberculosis: models of care for tuberculosis. Int J Tuberc Lung Dis. 2018;22:133–8. doi: 10.5588/
ijtld.17.0608.
80. Goodwin N. Thinking differently about integration: people-centred care and the role of local
communities. Int J Integr Care. 2014;14:e026. doi: 10.5334/ijic.1736.
81. Ethics guidance for the implementation of the End TB strategy. Geneva: World Health Organization;
2017. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/254820, accessed 11
March 2022).
82. Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics:
the role of risk factors and social determinants. Soc Sci Med. 2009;68:2240–6. doi: 10.1016/j.
socscimed.2009.03.041.
83. Bukhman G, Mocumbi AO, Atun R, Becker AE, Bhutta Z, Binagwaho A et al; Lancet NCDI Poverty
Commission Study Group. The Lancet NCDI Poverty Commission: bridging a gap in universal health
coverage for the poorest billion. Lancet. 2020;396:991–1044. doi: 10.1016/S0140-6736(20)31907-3.
84. Watkins DA, Jamison DT, Mills T, Atun T, Danforth K, Glassman A et al. Universal health coverage
and essential packages of care. In: Jamison DT, Gelband H, Horton S, Jha P, Laxminarayan R, Mock
CN, Nugent R, editors. Disease control priorities: improving health and reducing poverty. 3rd ed.
Washington (DC): The International Bank for Reconstruction and Development / The World Bank;
2017 Nov 27. Chapter 3.
85. WHO TB Knowledge Sharing Platform [website]. World Health Organization (https://tbksp.org/en/
home, accessed 7 March 2022).
86. United Nations Common Position on Ending HIV, TB and Viral Hepatitis through Intersectoral
Collaboration. World Health Organization, Regional Office for Europe.; 2018 (https://apps.who.int/
iris/handle/10665/342249, accessed 11 March 2022).
87. Eang MT, Vun MC, Eam KK, Sovannarith S, Sopheap S, Bora N et al. The multi-step process of building
TB/HIV collaboration in Cambodia. Health Res Policy Syst. 2012;10:34. doi: 10.1186/1478-4505-10-34.
88. Okot-Chono R, Mugisha F, Adatu F, Madraa E, Dlodlo R, Fujiwara P. Health system barriers affecting
the implementation of collaborative TB-HIV services in Uganda. Int J Tuberc Lung Dis. 2009;13:955–61.
89. Strategizing national health in the 21st century: a handbook. World Health Organization; 2016
(https://apps.who.int/iris/handle/10665/250221, accessed 11 March 2022).
90. Cords O, Martinez L, Warren JL, O’Marr JM, Walter KS, Cohen T et al. Incidence and prevalence of
tuberculosis in incarcerated populations: a systematic review and meta-analysis. Lancet Public Health.
2021;6:e300–e308. doi: 10.1016/S2468-2667(21)00025-6.
91. European Centre for Disease Prevention and Control, WHO Regional Office for Europe. Tuberculosis
surveillance and monitoring in Europe 2020. 2018 Data. World Health Organization, Regional Office
for Europe; 2020. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/331530,
accessed 11 March 2022).

50 Framework for collaborative action on tuberculosis and comorbidities

92. Altice FL, Azbel L, Stone J, Brooks-Pollock E, Smyrnov P, Dvoriak S et al. The perfect storm: incarceration
and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis
in Eastern Europe and Central Asia. Lancet. 2016;388:1228–48. doi: 10.1016/S0140-6736(16)30856-X.
93. Pompidou Group. Republic of Moldova, Drug situation and policy. Pompidou and Council of Europe;
2013 (https://www.coe.int/en/web/pompidou/country-profiles/moldova, accessed 8 March 2022).
94. Service Availability and Readiness Assessment (SARA): an annual monitoring system for service
delivery: reference manual. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/
handle/10665/149025, accessed 11 March 2022).
95. Castellanos-Joya M, Delgado-Sánchez G, Ferreyra-Reyes L, Cruz-Hervert P, Ferreira-Guerrero E, Ortiz-
Solís G et al. Results of the implementation of a pilot model for the bidirectional screening and joint
management of patients with pulmonary tuberculosis and diabetes mellitus in Mexico. PLoS One.
2014;9:e106961. doi: 10.1371/journal.pone.0106961.
96. Secretario de Salud Mexico. Norma Oficial Mexicana NOM-006-SSA2-2013, Para la prevención y
control de la tuberculosis. CNDH; 2013 (https://www.cndh.org.mx/DocTR/2016/JUR/A70/01/JUR-
20170331-NOR39.pdf, accessed 8 March 2022).
97. Synergising action to address the burden of tuberculosis and NCDs in vulnerable populations [website].
World Health Organization; 2019 (https://www.who.int/news-room/events/detail/2019/12/12/
default-calendar/synergising-action-to-address-the-burden-of-tuberculosis-and-ncds-in-vulnerable-
populations, accessed 8 March 2022).
98. Declaration of Astana. Global Conference on Primary Health Care. Astana, Kazakhstan; 25 and 26
October 2018. World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.
int/iris/handle/10665/328123, accessed 11 March 2022).
99. Compendium of data and evidence-related tools for use in TB planning and programming.
Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/344890, accessed 11 March 2022).
100. Gilbert JA, Shenoi SV, Moll AP, Friedland GH, Paltiel AD, Galvani AP. Cost-effectiveness of community-
based TB/HIV screening and linkage to care in rural South Africa. PLoS One. 2016;11:e0165614. doi:
10.1371/journal.pone.0165614.
101. Williams AO, Makinde OA, Ojo M. Community-based management versus traditional hospitalization
in treatment of drug-resistant tuberculosis: a systematic review and meta-analysis. Glob Health Res
Policy. 2016;1:10. doi: 10.1186/s41256-016-0010-y.
102. World Health Organization Regional Office for Europe. Accessibility and integration of HIV, TB and
harm reduction services for people who inject drugs in Portugal: a rapid assessment. Copenhagen:
WHO; 2012 (https://www.euro.who.int/__data/assets/pdf_file/0005/165119/E96531-v6-Eng.pdf,
accessed 8 March 2022).
103. Naher N, Balabanova D, Hutchinson E, Marten R, Hoque R, Tune SNBK et al. Do social accountability
approaches work? A review of the literature from selected low- and middle-income countries in
the WHO South-East Asia Region. Health Policy Plan. 2020;35(Supplement_1):i76–i96. doi: 10.1093/
heapol/czaa107.
104. Chifundo K. What is the best model of TB/HIV service delivery? Experience from Malawi. AIDS 2010-
XVIII Int AIDS Conf Abstr no MOPE0858; 2010.
105. De Foo C, Shrestha P, Wang L, Du Q, García-Basteiro AL, Abdullah AS et al. Integrating tuberculosis
and noncommunicable diseases care in low- and middle-income countries (LMICs): a systematic
review. PLoS Med. 2022;19:e1003899. doi: 10.1371/journal.pmed.1003899.

References 51
 106. Legido-Quigley H, Montgomery CM, Khan P, Atun R, Fakoya A, Getahun H et al. Integrating
tuberculosis and HIV services in low- and middle-income countries: a systematic review. Trop Med
Int Health. 2013;18:199–211. doi: 10.1111/tmi.12029.
107. China: Multidisciplinary teams and integrated service delivery across levels of care. Country case
studies on primary health care. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0
IGO (https://apps.who.int/iris/handle/10665/326085, accessed 11 March 2022).
108. WHO guidelines on tuberculosis infection prevention and control, 2019 update. Geneva: World Health
Organization; 2019. License: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/311259,
accessed 11 March 2022).
109. Compendium of good practices in the health sector response to viral hepatitis in the WHO European
Region. Copenhagen: WHO Regional Office for Europe; 2020. License: CC BY-NC-SA 3.0 IGO (https://
apps.who.int/iris/handle/10665/333494, accessed 11 March 2022).
110. Integrated screening for infectious diseases: a success story from Georgia [website]. World Health
Organization; 2021 (https://www.who.int/europe/news/item/21-05-2021-integrated-screening-for-
infectious-diseases-a-success-story-from-georgia, accessed 8 March 2022).
111. Salifu RS, Hlongwana KW. Barriers and facilitators to bidirectional screening of TB-DM in Ghana:
healthcare workers’ perspectives. PLoS One. 2020;15:e0235914. doi: 10.1371/journal.pone.0235914.
112. Lovero KL, Lammie SL, van Zyl A, Paul SN, Ngwepe P, Mootz JJ et al. Mixed-methods evaluation of
mental healthcare integration into tuberculosis and maternal-child healthcare services of four South
African districts. BMC Health Serv Res. 2019;19:83. doi: 10.1186/s12913-019-3912-9.
113. Tola HH, Shojaeizadeh D, Tol A, Garmaroudi G, Yekaninejad MS, Kebede A et al. Psychological and
educational intervention to improve tuberculosis treatment adherence in Ethiopia based on health
belief model: a cluster randomized control trial. PLoS One. 2016;11:e0155147. doi: 10.1371/journal.
pone.0155147.
114. Majumdar A, Wilkinson E, Rinu PK, Maung TM, Bachani D, Punia JS et al. Tuberculosis-diabetes
screening: how well are we doing? A mixed-methods study from North India. Public Health Action.
2019;9:3–10. doi: 10.5588/pha.18.0048.
115. Avoka VA, Osei E. Evaluation of TB/HIV collaborative activities: the case of South Tongu district,
Ghana. Tuberc Res Treat. 2020;4587179. doi: 10.1155/2020/4587179.
116. Zvolska K, Pankova A, Nohavova I, Huque R, Elsey H, Boeckmann M et al. A narrative review of
facilitators and barriers to smoking cessation and tobacco-dependence treatment in patients
with tuberculosis in low- and middle-income countries. Tob Induc Dis. 2020;18:67. doi: 10.18332/
tid/125195.
117. Degefa MG, Bezabih AM, Kahsay ZH, Belachew AB. Barriers and facilitators of nutrition assessment,
counseling, and support for tuberculosis patients: a qualitative study. BMC Nutr. 2021;7:58. doi:
10.1186/s40795-021-00463-x.
118. Gebremariam MK, Bjune GA, Frich JC. Barriers and facilitators of adherence to TB treatment in
patients on concomitant TB and HIV treatment: a qualitative study. BMC Public Health. 2010;10:651.
doi: 10.1186/1471-2458-10-651.
119. Boeckmann M, Warsi S, Noor M, Dogar O, Mustagfira EH, Firoze F et al; TB & Tobacco Consortium.
Health worker and patient views on implementation of smoking cessation in routine tuberculosis
care. NPJ Prim Care Respir Med. 2019;29:34. doi: 10.1038/s41533-019-0146-6.

52 Framework for collaborative action on tuberculosis and comorbidities

120. Sommerland N, Wouters E, Mitchell EMH, Ngicho M, Redwood L, Masquillier C et al. Evidence-based
interventions to reduce tuberculosis stigma: a systematic review. Int J Tuberc Lung Dis. 2017;21:81–
6. doi: 10.5588/ijtld.16.0788.
121. Contreras CC, Millones AK, Santa Cruz J, Aguilar M, Clendenes M, Toranzo M et al. Addressing
tuberculosis patients’ medical and socio-economic needs: a comprehensive programmatic approach.
Trop Med Int Health. 2017;22:505–11. doi: 10.1111/tmi.12844.
122. Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients
in low- and middle-income countries: a systematic review. Eur Respir J. 2014;43:1763–75. doi:
10.1183/09031936.00193413.
123. Institute for Health Metrics and Evaluation (IHME). GBD Compare | IHME Viz Hub [website]. IHME;
2021 (https://vizhub.healthdata.org/gbd-compare/, accessed 8 March 2022).
124. FAOSTAT: Madagascar [website]. Food and Agriculture Organization; 2021 (https://www.fao.org/
faostat/en/#country/129, accessed 11 March 2022)
125. Darnton-Hill I, Mandal PP, de Silva A, Bhatia V, Sharma M. Opportunities to prevent and manage
undernutrition to amplify efforts to end TB. Int J Tuberc Lung Dis. 2022;26:6–11. doi: 10.5588/
ijtld.21.0488.
126. India HIV estimates 2019 report. National AIDS control organisation and ICMR-National Institute
of Medical Statistics; 2019 (http://naco.gov.in/sites/default/files/INDIA%20HIV%20ESTIMATES.pdf,
accessed 25 May 2022)
127. Scaling up of collaborative TB/HIV activities in concentrated HIV epidemic settings: a case study from
India. World Health Organization; 2015 (https://apps.who.int/iris/handle/10665/154076, accessed
11 March 2022).
128. A guide to monitoring and evaluation for collaborative TB/HIV activities – 2015 revision. Geneva:
World Health Organization; 2015 (https://apps.who.int/iris/handle/10665/150627, accessed 11 March
2022).
129. Continuity and coordination of care: a practice brief to support implementation of the WHO
framework on integrated people-centred health services. Geneva: World Health Organization; 2018.
Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/274628, accessed 11 March
2022).
130. Analysis and use of health facility data: core health facility indicators. Geneva: World Health Organization;
2021 (https://www.who.int/docs/default-source/documents/ddi/facilityanalysisguidance-indicators.
pdf?sfvrsn=237c16a6_2, accessed 8 March 2022).
131. Handbook for the use of digital technologies to support tuberculosis medication adherence.
Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/259832, accessed 11 March 2022).
132. University of Oslo. DHIS2 [website]. DHIS2 (https://dhis2.org/, accessed 8 March 2022).
133. WHO guideline: recommendations on digital interventions for health system strengthening.
Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/311941, accessed 11 March 2022).
134. Consolidated HIV strategic information guidelines: driving impact through programme monitoring
and management. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO (https://
apps.who.int/iris/handle/10665/331697, accessed 11 March 2022).

References 53
 135. Management of physical health conditions in adults with severe mental disorders: WHO guidelines.
Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/275718, accessed 11 March 2022).
136. WHO consolidated guidelines on tuberculosis. Module 3: diagnosis – rapid diagnostics for tuberculosis
detection, 2021 update. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO
(https://apps.who.int/iris/handle/10665/342331, accessed 11 March 2022)
137. WHO consolidated guidelines on tuberculosis. Module 4: treatment: drug-susceptible tuberculosis
treatment. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO (https://apps.
who.int/iris/handle/10665/353829, accessed 04 July 2022).
138. WHO consolidated guidelines on tuberculosis. Module 5: Management of tuberculosis in children
and adolescents. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO (https://
apps.who.int/iris/handle/10665/352522, accessed 04 July 2022).
139. Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virus infection.
Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. (https://apps.who.int/iris/
handle/10665/273174, accessed 11 March 2022).
140. Guidelines for the prevention, care, and treatment of persons with chronic hepatitis B infection.
Geneva: World Health Organization; 2015 (https://apps.who.int/iris/handle/10665/154590, accessed
11 March 2022).
141. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization; 2010
(https://apps.who.int/iris/handle/10665/44395, accessed 11 March 2022).
142. Diagnosis and management of type 2 diabetes (HEARTS-D). Geneva: World Health Organization;
2020 (WHO/UCN/NCD/20.1). Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/
handle/10665/331710, accessed 11 March 2022).
143. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva:
World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/43948, accessed 11 March
2022).
144. mhGAP Intervention guide for mental, neurological and substance use disorders in non-specialized
health settings: mental health Gap Action Programme (mhGAP), version 2.0. Geneva: World Health
Organization; 2016 (https://apps.who.int/iris/handle/10665/250239, accessed 11 March 2022).
145. Essential nutrition actions: mainstreaming nutrition through the life-course. Geneva: World Health
Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/iris/handle/10665/326261,
accessed 11 March 2022).
146. A handbook on how to implement mTB-Tobacco. Geneva: World Health Organization and
International Telecommunication Union; 2019. Licence: CC BY-NC-SA 3.0 IGO (https://apps.who.int/
iris/handle/10665/325243, accessed 11 March 2022).
147. Rubenstein LS, Amon JJ, McLemore M, Eba P, Dolan K, Lines R et al. HIV, prisoners, and human rights.
Lancet. 2016;388:1202–14. doi: 10.1016/S0140-6736(16)30663-8.
148. Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin G et al. Challenges and opportunities
for implementing integrated mental health care: a district level situation analysis from five low- and
middle-income countries. PLoS One. 2014;9:e88437. doi: 10.1371/journal.pone.0088437.
149. Kadia BM, Dimala CA, Fongwen NT, Smith AD. Barriers to and enablers of uptake of antiretroviral
therapy in integrated HIV and tuberculosis treatment programmes in sub-Saharan Africa: a systematic
review and meta-analysis. AIDS Res Ther. 2021;18:85. doi: 10.1186/s12981-021-00395-3.

54 Framework for collaborative action on tuberculosis and comorbidities

150. Workneh MH, Bjune GA, Yimer SA. Assessment of health system challenges and opportunities for
possible integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region,
Ethiopia: a qualitative study. BMC Health Serv Res. 2016;16:135. doi: 10.1186/s12913-016-1378-6.
151. Navya N, Jeyashree K, Madhukeshwar AK, Anand T, Nirgude AS, Nayarmoole BM et al. Are they there
yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse –
a mixed methods study from Karnataka, India. BMC Health Serv Res. 2019;19:90. doi: 10.1186/
s12913-019-3913-8.
152. Chileshe M, Bond VA. Barriers and outcomes: TB patients co-infected with HIV accessing antiretroviral
therapy in rural Zambia. AIDS Care. 2010;22 Suppl 1:51–9. doi: 10.1080/09540121003617372.
153. Li SP, Zheng ZY, Meng QY, Yuan CH. Barriers to tuberculosis care for drug users in two provinces of
China: a qualitative study. Int J Tuberc Lung Dis. 2013;17:1358–63. doi: 10.5588/ijtld.12.0784.
154. Kheang ST, Theang H, Eam KK, Eang MT, Kong S, Loun C et al. Bidirectional screening of diabetes
mellitus and tuberculosis in Cambodia. J Trop Dis. 2019;7:326. doi: 10.35248/2329-891x.19.7.326.
155. Basir MS, Habib SS, Zaidi SMA, Khowaja S, Hussain H, Ferrand RA et al. Operationalization of
bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in Karachi,
Pakistan. BMC Health Serv Res. 2019;19:147. doi: 10.1186/s12913-019-3975-7.
156. van Crevel R, Critchley JA. The interaction of diabetes and tuberculosis: translating research to policy
and practice. Trop Med Infect Dis. 2021;6:8. doi: 10.3390/tropicalmed6010008.
157. Aung NHHL, Soe KT, Kumar AMV, Saw S, Aung ST. What are the barriers for uptake of antiretroviral
therapy in HIV-infected tuberculosis patients? A mixed-methods study from Ayeyawady Region,
Myanmar. Trop Med Infect Dis. 2020;5:41. doi: 10.3390/tropicalmed5010041.
158. Komba FF, Frumence G. Facility and patient barriers in the implementation of isoniazid preventive
therapy for people living with HIV attending Care and Treatment Centers, Songea Municipality,
Tanzania. Pan Afr Med J. 2021;38:197. doi: 10.11604/pamj.2021.38.197.26752.
159. Baja E, Lansang MA, Alejandria M, Castillo-Carandang N, Itable J, Serrano GK. Tuberculosis and
diabetes mellitus control and care: a rapid situational analysis for planning a coordinated program
response. PIDS Discuss Pap Ser. 2014
160. Daftary A, Padayatchi N. Social constraints to TB/HIV healthcare: accounts from coinfected patients
in South Africa. AIDS Care. 2012;24:1480–6. doi: 10.1080/09540121.2012.672719.
161. WHO global lists of high burden countries for TB, multidrug/rifampicin-resistant TB (MDR/RR-TB)
and TB/HIV, 2021–2025. Geneva: World Health Organization; 2021. Licence: CC BY-NCSA 3.0 IGO
(https://apps.who.int/iris/handle/10665/341980, accessed 11 March 2022).
162. World Health Organization, PEPFAR & UNAIDS. (2007). Task shifting: rational redistribution of tasks
among health workforce teams: global recommendations and guidelines. World Health Organization;
2007 (https://apps.who.int/iris/handle/10665/43821, accessed 11 March 2022).
163. South African Department of Health, South African National AIDS Council. A manual to guide
integration of TB / HIV services at primary health care facilities in South Africa. 2010.

References 55
 Annex 1. Relevant WHO documents

Table A1.1. Relevant current WHO policy documents

Comorbidity Relevant WHO policy documents
Chronic lung – Practical approach to lung health (48)
disease
COVID-19 – WHO Information Note: COVID-19 considerations for tuberculosis
(TB) care (14)
Diabetes – Collaborative framework for care and control of tuberculosis and
diabetes (27)
HIV – Consolidated guidelines on HIV prevention, testing, treatment,
service delivery and monitoring: recommendations for a public
health approach, 2021 update (59)
– Consolidated HIV strategic information guidelines: driving impact
through programme monitoring and management (134)
– Integrating collaborative TB and HIV services within a
comprehensive package of care for people who inject drugs:
consolidated guidelines (74)
– WHO policy on collaborative TB/HIV activities (17)
Mental disorders – Management of physical health conditions in adults with severe
mental disorders (135)
Nutrition – Nutritional care and support for patients with tuberculosis (41)
Tobacco – A WHO/the Union monograph on TB and tobacco control (36)
Tuberculosis – WHO consolidated guidelines on tuberculosis:
(relevant for – Module 1: Prevention – tuberculosis preventive treatment (7)
all comorbidities) – Module 2: Screening – systematic screening for tuberculosis
disease (20)
– Module 3: Diagnosis – rapid diagnostics for tuberculosis detection,
2021 update (136)
– Module 4: Treatment – drug-resistant tuberculosis treatment (21)
– Module 4: Treatment – tuberculosis care and support (69)
– Module 4: Treatment – drug-susceptible tuberculosis treatment (137)
– Module 5: Management of tuberculosis in children and adolescents
(138)
For the latest updated guidelines on tuberculosis please refer to
the WHO TB Knowledge Sharing Platform
Viral hepatitis – Guidelines for the care and treatment of persons diagnosed with
chronic hepatitis C virus infection (139)
– Guidelines for the prevention, care and treatment of persons with
chronic hepatitis B infection (140)
– Guidelines on hepatitis B and C testing (73)

56 Framework for collaborative action on tuberculosis and comorbidities

Table A1.2. Other relevant WHO documents and
frameworks
Comorbidity Relevant WHO documents and frameworks
Alcohol use – Global strategy to reduce the harmful use of alcohol (141)
Diabetes – HEARTS D: diagnosis and management of type 2 diabetes (142)
Drug use – International standards for the treatment of drug use disorders (63)
– Guidelines for the psychosocially assisted pharmacological
treatment of opioid dependence (143)
HIV – A guide to monitoring and evaluation for collaborative TB/HIV
activities (128)
Mental disorders – mhGAP Intervention Guide (144)
Nutrition – Essential nutrition actions: mainstreaming nutrition through the
life-course (145)
Tobacco – Be He@lthy, Be Mobile: a handbook on how to implement mTB-
Tobacco (146)
Tuberculosis – The End TB Strategy (9)
(relevant for – Multisectoral accountability framework to accelerate progress to
all comorbidities) end tuberculosis by 2030 (MAF-TB) (77)
– People-centred framework for tuberculosis programme planning
and prioritization: user guide (76)
Other: health – Framework on integrated people-centred health services: an
systems-related overview (4)
frameworks – Operational framework for primary health care: transforming vision
into action (5)

Annex 1. Relevant WHO documents 57

 Annex 2. Barriers to and enablers of
collaborative care

Table A2.1. Barriers to collaborative action on TB and comorbidities, elicited

during focus group discussions with 16 countries5 and from literature review
(105,111–120,147–159)

Focus group Literature

Aspect Barrier discussions review
Leadership Lack of political commitment to address
X X
and TB comorbidities (other than HIV)
governance Lack of national guidelines or policies for
O X
TB and comorbidities
Limited collaboration between health
programmes as well as with sectors X X
beyond the healthcare system
Limited engagement by related health
programmes in collaborative action (other X O
than the national TB programme)
Limited engagement of the private sector X O
Criminalization, which hinders access to
TB services by people who use drugs,
O X
due to fears of engagement with law
enforcement agents
Health Staff shortages for screening, treatment
workforce and referral, especially at the primary care X X
level, which may affect quality of care
Uneven distribution of healthcare workers,
potentially skewed towards urban areas X O
and tertiary centres
High staff turnover and rotation X X
Limited training on screening,
diagnosis and joint management of
X X
TB or comorbidities in the respective
programmes

5
Bangladesh, Belarus, Brazil, Georgia, India, Indonesia, Kenya, Mexico, Namibia, Pakistan, Peru, the Philippines, Sierra Leone,
United Republic of Tanzania, Zambia, Zimbabwe

58 Framework for collaborative action on tuberculosis and comorbidities

 Focus group Literature
Aspect Barrier discussions review
Limited skills on joint management of
TB and comorbidities among staff in the X X
respective programmes
Legislation that does not allow healthcare
workers to prescribe outside area of X X
expertise, e.g. for mental health
Fear of TB among healthcare workers and
resultant stigmatization of people with X X
presumed TB
Health Inadequate funding for health overall X O
systems Dependence on external donor funding,
financing X O
which can be unpredictable
Earmarked funding and inability to
redistribute funds between programmatic
X O
areas, which may impede implementation
of collaborative activities
Insufficient budgets for additional
screening and treatment services (e.g. O X
equipment, maintenance, personnel)
Limited data on cost-effectiveness
of TB screening among people with O X
comorbidities such as diabetes
Funding structures that incentivize
inpatient treatment, e.g. funding allocated X O
on the basis of bed occupancy
Inadequate funding for community-based
services, including community health X O
worker programmes
High out-of-pocket costs for services for
comorbidities for people with TB (who
may not have health insurance to cover X X
treatment for comorbidities) may deter
end user from accessing services

Annex 2. Barriers to and enablers of collaborative care 59

 Focus group Literature
Aspect Barrier discussions review
Access to Unavailability and stock-outs of supplies,
medicines including screening and diagnostic
and other equipment (e.g. blood glucometers, X X
supplies/ molecular WHO-recommended rapid
equipment diagnostic tests for TB), and medicines
Regulations prohibiting prescription of
certain medicines (e.g. insulin) outside of X O
specialist services
Healthcare workers in TB services,
including doctors and nurses who may
X O
not be able to prescribe medicines for
comorbidities
Lack of updated national Essential
X O
Medicines Lists
Suboptimal screening tools O X
Inadequate supply of therapeutic and
O X
supplementary foods
High out-of-pocket expenditure faced by
patients due to the cost of screening and
X X
diagnostic equipment (e.g. blood glucose
measurement strips), and treatment costs
Health Limited coordination between disease-
X X
service specific programmes
delivery Long waiting times for end user to receive
the required care from different healthcare
workers in less integrated models of X X
service delivery, even when services are
co-located
High out-of-pocket expenditure incurred
for appointments and referrals to
secondary or tertiary care, which prevents X X
access to and engagement with integrated
services
Lack of infrastructure for TB and
comorbidities (e.g. inappropriate
infection prevention and control O X
measures, no space to conduct screening
or counselling)
Difficulties in ensuring referrals and
linkage to quality care for comorbidities;
O X
referrals to relevant services not followed
through; long waiting times for referrals

60 Framework for collaborative action on tuberculosis and comorbidities

 Focus group Literature
Aspect Barrier discussions review
Poorly defined pathways for ongoing
management and continuity of care after O X
completion of TB treatment
Weak links with social services O X
Cultural beliefs and preconceptions about
disease; fear of stigma and discrimination O X
among end users
Limited awareness among people with
TB of the importance of screening for
O X
and co-management of comorbidities
throughout TB treatment
Side-effects of medications associated
with non-adherence, especially if end user O X
is not counselled on possible side-effects
Health Limited data on the burden of TB and
X O
information comorbidities
systems Lack of indicators to monitor and evaluate
the joint burden of, and collaborative X O
action on TB and comorbidities
Lack of standardized recording and
reporting structures for monitoring and O X
evaluation of collaborative action
Separate health information systems
(electronic and paper-based) for TB and
comorbidities, which impede sharing of X X
data between facilities and programmes,
with limited cross-checking
Inadequate feedback mechanisms (e.g.
X X
referral and counter-referral)

Annex 2. Barriers to and enablers of collaborative care 61

 Table A2.2. Enablers of collaborative action on TB and comorbidities, elicited
during focus group discussions with 16 countries6 and from literature review
(105,111–120,147–159)

Focus group Literature

Aspect Enabler discussions review
Leadership and Assessment of the joint burden and cost
X X
governance implications of TB and comorbidities
Development of a business case for
TB and comorbidities, based on the
epidemiological burden and financial X O
impact on health services and affected
individuals
Political buy-in by government X X
Strong collaborative mechanisms,
including for joint planning, budgeting, X O
coordination and accountability
Multisectoral collaboration to share
X O
technical expertise
Strong partnerships between
government, private sector,
X X
nongovernmental organizations, civil
society and the community
Development of guidelines and
standard operating procedures
through collaboration between
the national TB programme and X X
other health-related programmes,
to support operationalization and
institutionalization of recommendations

6
Bangladesh, Belarus, Brazil, Georgia, India, Indonesia, Kenya, Mexico, Namibia, Pakistan, Peru, the Philippines, Sierra Leone,
United Republic of Tanzania, Zambia, Zimbabwe

62 Framework for collaborative action on tuberculosis and comorbidities

 Focus group Literature
Aspect Enabler discussions review
Health Recruitment and deployment of
workforce healthcare workers guided by needs
assessment to ensure sufficient staffing, X O
including of outpatient services and in
rural areas
Sustained and adequate funding for
X O
training needs
Joint capacity building for TB and
comorbidities at the community
level, including in areas of knowledge
X O
and technical competence to screen
for, diagnose and treat TB and key
comorbidities
Motivation and incentivization of
O X
providers
Use of point-of-care tests that require
minimal training, e.g. screening for O X
diabetes mellitus
Training on stigma reduction and
communication skills during pre-service
X O
curricular training and continuing
professional education
Task shifting to empower lay providers to
conduct screening and referral activities,
X X
to facilitate the delivery of services for TB
and comorbidities

Annex 2. Barriers to and enablers of collaborative care 63

 Focus group Literature
Aspect Enabler discussions review
Health system Patient cost surveys for people with
financing TB and comorbidities to estimate the X O
financial impact
Sustainable domestic funding at the
X O
national and subnational levels
Use of inexpensive yet accurate point-
of-care screening tools, e.g. validated
O X
questionnaires administered by
healthcare workers
Coordinated planning and budgeting for
X O
TB and comorbidities
Inclusion of comorbidities in national
strategic plans for TB, and vice versa, as X O
well as in national health strategic plans
Results-based financing, e.g. payment
X O
per number of people screened/treated
Public–private mix, including strong
partnerships with the private sector for X O
delivering TB services
Point-of-care screening for comorbidities
O X
provided free of charge to end user
Removal of or subsidized user fees for
O X
diagnosis and treatment of comorbidities

64 Framework for collaborative action on tuberculosis and comorbidities

 Focus group Literature
Aspect Enabler discussions review
Access to Legislation permitting procurement of
X O
medicines and essential medicines according to need
other supplies/ Legislation that permits availability of
equipment drugs for key comorbidities within TB X O
services, and vice versa
Legislation and qualification that allow
healthcare workers in TB services to
X O
prescribe for comorbidities, and vice
versa
Availability of essential medicines
and diagnostic tools for TB and key
comorbidities (e.g. point-of-care tests, X X
equipment for anthropometry), in the
relevant services
Strong systems for procurement, supply
and dispensation of medicines and other O X
products
Inclusion of medications for
comorbidities in established integrated O X
drug supply management systems
Development of new tools and
technologies for diagnosis and
X O
treatment, e.g. use of digital
technologies

Annex 2. Barriers to and enablers of collaborative care 65

 Focus group Literature
Aspect Enabler discussions review
Health service Sustainable funding for community-
X O
delivery based services
Building on decentralized TB services can
be a good entry point for integrating O X
comorbidity services
Decentralization of the different
specialist services, which facilitates
X O
delivery of integrated services, especially
at the community level
Availability and dissemination of
guidance and normative documents, X O
which facilitate collaborative action
Expansion of social protection initiatives
X O
to facilitate equitable access to services
Co-location of screening and treatment
O X
services for TB and comorbidities
Mobile clinics providing care in or close
O X
to end user’s home
Training of community health workers to
X O
screen for both TB and comorbidities
Leveraging the skillset and contact
networks of community health workers X O
to expand access
Community health workers delivering
O X
medicines to end users in the community
Availability of psychosocial and family
O X
support
End user motivation to know their health
O X
status
Counselling and education of end user
O X
on TB and comorbidities
Community education to improve
health-seeking behaviour for TB and X O
comorbidities

66 Framework for collaborative action on tuberculosis and comorbidities

 Focus group Literature
Aspect Enabler discussions review
Health Establishment of indicators on the joint
information burden and collaborative action for TB
systems and key comorbidities, which can be
X X
captured during surveillance activities,
and incorporation of these within the TB
reporting system
Baseline surveys to establish the joint
burden of TB and key comorbidities and X O
health-related risk factors
Regular joint review and analysis of data
by the national TB programme and other
X O
relevant health programmes, which feed
back into programming
Use of existing data to identify those at
O X
highest risk for comorbidities
Evaluation of effectiveness and cost-
effectiveness through randomized
O X
controlled trials and implementation
science
Strengthened data collection
and reporting systems (including O X
referral systems)
Interoperability of electronic health
records to allow sharing of data between
X O
TB services, primary care, hospitals and
specialist services

Annex 2. Barriers to and enablers of collaborative care 67

 Table A2.3. Summary of experiences of care for TB and comorbidities, elicited
from interviews with TB survivors with one or several comorbidities, during the
development of the Framework for collaborative action on TB and comorbidities

Negative experiences Positive experiences

Diabetes – Limited and ad hoc access to insulin – Easy to disclose diabetes
therapy comorbidity to TB provider
– Nutritional counselling or – Early screening for diabetes
supplementation not tailored to the – Early referral for management
combined requirements of people of diabetes helped improve
with TB and diabetes glycaemic control during TB
– Limited awareness among end treatment
users of the connection between TB – Co-management (diagnosis
and diabetes, and the importance and treatment) of TB and
of glycaemic control during TB diabetes by the same primary
treatment care doctor
– Disclosure of diagnosis of diabetes
to TB provider did not facilitate
access to further treatment
– Late referrals to diabetes services
(e.g. referred only when blood
sugar was excessively high)
HIV7 – High pill burden – Knowledge of the curability of
(118,160) – Side-effects of treatment TB
– Insufficient funds for transport, – Understanding of the severity
which precluded attendance of TB in the presence of HIV
at daily TB treatment support infection
appointments – Support from family and
– Fear of stigma and discrimination healthcare workers
related to both TB and HIV
– Inadequate food intake to mitigate
side-effects of the combined
treatment regimen for TB and HIV,
leading to poor adherence

7
Interviews did not pursue detailed enquiry into needs and expectations for HIV care as these have been extensively researched
in previous work. This table summarizes findings on HIV care from Daftary et al. (2012) (157) and Gebremariam et al. (2010) (118)

68 Framework for collaborative action on tuberculosis and comorbidities

 Negative experiences Positive experiences
Mental – Difficulty in disclosing mental – Routine enquiry into end
health health issues to TB provider user’s mental and emotional
due to fear of mental health well-being
labelling, stigma or forcible – Counselling provided by
institutionalization trusted community health
– Lack of provider-initiated screening workers, social workers or peer
for mental health issues supporters
– Perception that TB providers do not – Referral/linkage to peer/
have the time or skillset/expertise support
to address mental health issues – Referral to psychologist or
– Poor understanding of TB other specialized care in the
treatment hardships among case of severe mental health
psychiatrists issues
– Poor appreciation for the range – Positive relationships with
of potential mental health issues psychiatrists or psychologists
(e.g. mild depressive symptoms to among people with pre-
severe anxiety or suicidal ideations) existing mental health
– Mental health issues exacerbated problems
by multimorbidity (e.g. diabetes,
substance use)
Substance – Difficulty in disclosing drug or – Access to specialized
use alcohol use to TB provider due to treatment and care for drug
fear of discrimination, disrespect or use disorders/ harm reduction
forcible institutionalization services
– Lack of routine screening for drug – Routine provider-initiated
use queries on alcohol use
– Lack of support to discontinue – Home visits by peer
alcohol or drug use, beyond verbal supporters or community
recommendation to quit health workers
– Difficulty in engaging with
additional support, especially if
experiencing multimorbidity (e.g.
mental illness, viral hepatitis)
– Reluctance to discontinue
substance use during TB treatment
due to fear of experiencing
withdrawal
Tobacco – Tobacco cessation support limited – Easy to disclose tobacco use
to verbal recommendation to quit to TB provider
– Quitting considered a low priority
by end user compared with life-
threatening disease

Annex 2. Barriers to and enablers of collaborative care 69

 Negative experiences Positive experiences
Viral – Viral hepatitis identified only after – Liver function tests available
hepatitis TB treatment initiation, during as part of TB treatment
(hepatitis C) monitoring monitoring
– Difficulty in disclosing viral hepatitis – TB treatment dose
to TB provider due to fear of being alterations to accommodate
perceived as drug users, judged compromised liver function
and stigmatized
– Limited availability of HCV
treatment

General preferences for care

■ Healthcare workers showing kindness, empathy, openness and encouragement
■ Healthcare workers querying on comorbidities regularly and repeatedly
■ Single provider with multidisciplinary training or multidisciplinary teams including doctors,
nurses, social or community health workers, specialist physicians and peer supporters
■ Material support to cover the cost of treatment of comorbidities not covered by the
government (e.g. insulin, nutrition, etc.)

70 Framework for collaborative action on tuberculosis and comorbidities

Annex 3. Declaration of interests

All experts consulted during the stakeholder consultation and external review process for the
Framework for collaborative action on TB and comorbidities completed a WHO declaration
of interests form. All declarations were evaluated by the WHO secretariat for any conflict of
interests, and were presented at the beginning of the stakeholder consultation. The following
experts declared interests, none of which were judged as a conflict of interest in relation to the
development of the framework.

■ Aneeta Pasha: Research funding of $187 000 from Harvard Medical School Center for
Global Health Delivery, Dubai, between 2015-2017.
■ Harry Hausler: Currently employed as CEO of TB HIV Care, a non-profit company that
provides TB and HIV services for the general population and key populations including
people who inject drugs, sex workers and inmates in correctional services. Chair of the TB
Prevention Task Team of the National TB Think Tank, responsible for advising government
on TB prevention in South Africa.
■ Jeremy Ross: Employed by the non-governmental organization TreatAsia, who have
received research grant funding from the United States National Institutes of Health
(NIH) for HIV-related research that includes impact and outcomes related to various
comorbidities and coinfections.
■ Mary Rosary Santiago: Currently employed by the organization FHI360, which has a
primary mandate to provide technical assistance to the NTP in the Philippines in identifying
and introducing innovative approaches across the TB cascade of care which may involve
clinical and system integration of TB with other diseases such as HIV, diabetes, etc.
■ Phangisile Mtshali: Chairperson of the Non-Executive Board of Directors of the Aurum
Institute, remuneration of ZAR 20 000 per quarter for board meetings.
■ Zahedul Islam: Member of the Community Advisory Panel (UCAP) of the International
Union Against TB and Lung Disease. Voluntary role.

71
For further information, please contact:
Global Tuberculosis Programme
World Health Organization
20, Avenue Appia CH-1211 Geneva 27 Switzerland
Web site: www.who.int/tb