Strategies to detect and treat concurrent tuberculosis and diabetes mellitus in Indonesia, Peru and Romania: Costs, operational feasibility and impact on health-related quality of life

There is an established link between tuberculosis (TB) and diabetes mellitus (DM); active TB is two to three times more likely to develop in people with DM and TB outcomes are worsened in people with concurrent disease. The aim of this PhD thesis is to assess the costs, operational feasibility and health-related quality of life impact of alternative screening and management strategies for patients with concurrent TB and DM (TB-DM) in Indonesia, Peru and Romania. In these three countries with an increasing prevalence of DM and high country burdens of TB, this evidence is essential for establishing cost-effective and feasible diagnostic guidelines and treatment protocols. Primary data were obtained from a cross-sectional study where patients underwent bidirectional screening for TB-DM in Indonesia, Peru and Romania. However, since the overall study evolved differently in the three countries, analyses in the thesis are not always for all three countries. Indonesia is for instance the only country where patients with TB-DM were recruited to a randomised controlled trial (RCT) that compared standard DM care to intensive DM monitoring with education and counselling over six months. All patients in the RCT were monitored for TB and DM outcomes over the subsequent 12 months. In Indonesia and Romania, the cost per accurate diagnosis for various algorithms was lower when screening people with TB for DM compared to screening people with DM for TB. The testing algorithm with the lowest cost per accurate diagnosis was age and point of care random plasma glucose in Indonesia (US$ 1.49) and Romania (US$ 5.64). From the perspective of health care workers, the barriers, opportunities and the most favourable test characteristics for implementing each test into routine practice were identified in Indonesia and Peru, with POC HbA1c being the most operationally feasible. Preliminary findings from the RCT in Indonesia illustrate that patients with TB-DM in the intensive monitoring arm reported a better HRQoL, but incurred 2.5 times more costs (out of pocket payments and productivity losses) than those in the standard care arm. This comparative analysis is the first to assess and combine the costs, accuracy and feasibility of implementing bi-directional diagnostic testing, as well as patient treatment costs and health-related quality of life of concurrent TB-DM across several countries. It provides novel information needed for the cost-effective delivery of services for TB-DM, an emerging syndemic with an increasing burden in low- and middle-income countries.