Обратная связьGlobally, tuberculosis (TB) remains a significant cause of ill health and is a leading cause of death due to an infectious agent (1). Five main health-related risk factors, namely, diabetes mellitus (diabetes), HIV, smoking, undernutrition and disorders due to alcohol use, account collectively for just under half of all new TB episodes globally. The contribution of these risk factors to the global TB burden is reported annually in the WHO’s Global tuberculosis report (1). For the purpose of these consolidated guidelines, a health-related risk factor is defined as a condition or action that increases the risk of TB disease (2). Other significant health-related risk factors for TB disease include silicosis and disorders due to drug use. When they occur in people with TB, health-related risk factors are also considered comorbidities, and may lead to poor TB treatment outcomes, lower health-related quality of life, or other suboptimal health or social outcomes, such as increased out-of-pocket costs or TB-associated disabilities. The impact of these risk factors for TB differs between and even within countries.
People with TB also frequently experience other comorbidities, including pulmonary and mental health conditions, and viral hepatitis (2). Moreover, people with TB may develop chronic lung disease or other impairments (for example musculoskeletal or neurological impairments), all of which require specialized care or rehabilitation during TB treatment and after TB treatment completion. Health-related risk factors and TB comorbidities require holistic people-centred care in the context of universal health coverage.
Addressing individual comorbidities, multimorbidity, TB-associated disabilities and health-related risk factors for TB are key elements of the WHO End TB strategy, which focuses on integrated patient-centred care and prevention (3). The End TB strategy emphasizes that relevant comorbidities and health-related risk factors should be routinely assessed and managed for improved TB treatment and general health outcomes.
The political declaration of the 2023 United Nations (UN) High-Level Meeting on the fight against TB (4) reaffirmed the commitment to ending the TB epidemic globally by 2030, in line with the Sustainable Development Goals. In the declaration, Member States committed to integrating services for TB, HIV and other comorbidities within primary health care, and to strengthening coordination and collaboration between programmes, to ensure universal access to integrated prevention, diagnosis, treatment and care for TB, HIV and other comorbidities. Member States also committed to three key targets by 2027: a) at least 90% of the estimated number of people who develop TB are reached with quality assured diagnosis and treatment; b) at least 90% of all people at high-risk of developing TB are provided with preventive treatment, including approximately 15 million people living with HIV, and c) all people with TB have access to a health and social benefits package so they do not have to endure financial hardship because of their illness (4). In the latest UN High-Level Meeting declarations on HIV (5) and on Universal Health Coverage (6) in 2021 and 2023, respectively, Member States also committed to assuring integrated people-centred services for TB, HIV, noncommunicable diseases and mental health.
Although global guidance on interventions to address TB and key comorbidities exists in different publications, its uptake has been variable. The WHO consolidated guidelines on tuberculosis. Module 6: tuberculosis and comorbidities consolidate the latest evidence-based recommendations and provide a one-stop shop for countries to scale up people-centred care and prevention of TB and comorbidities. They include the latest recommendations developed by various guideline development groups (GDGs) convened by WHO, which used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to summarize the evidence and formulate recommendations (see Annex 1 for the current approach). The GRADE approach was used to rate the certainty in the estimate of effect (that is, the quality of evidence) as high, moderate, low or very low; it was also used to determine the strength of the recommendations, rating them as strong or conditional. The GDGs used the version of the WHO Handbook for guideline development that applied at the time. For more details, please refer to the original guidelines.
These guidelines are accompanied by an operational handbook (7) and are aligned with WHO’s Framework for collaborative action on tuberculosis and comorbidities (2). The consolidated guidelines summarize WHO recommendations on TB and comorbidities and the evidence and processes behind them, while the operational handbook provides practical guidance to aid in the implementation of these recommendations by country programmes. The Framework document provides a structure and mechanisms for establishing and strengthening collaborative action across disease programmes and with relevant sectors outside the health system for the delivery of people-centred care for TB and comorbidities. To further strengthen a comprehensive response to TB and comorbidities, it is critical to ensure linkages with the national coordination platforms and mechanisms for the Multisectoral accountability framework for TB (MAF-TB) (8).
Objectives
The objectives of the consolidated guidelines are to:
- consolidate existing recommendations to address TB and comorbidities;
- support Member States in implementing effective people-centred interventions to address TB and comorbidities and contribute to reducing disease burden, morbidity and mortality, as well as costs and financial hardship for people affected by TB and comorbidities; and
- contribute to reducing the disease burden of TB and comorbidities.
Structure and evolution
The consolidated guidelines are a living document and will include a separate section for each of the key TB comorbidities or health-related risk factors. The first edition of the consolidated guidelines on TB comorbidities focuses entirely on HIV-associated TB. In the second edition a section on nutrition will be added. Content for each section will be progressively updated and added.
