Claire Jacqueline Calderwood

Chronic conditions both drive development of and are consequences of tuberculosis (TB). While there is growing awareness of chronic lung disease, data on other health conditions post-TB are limited. In this cross-sectional study in Zimbabwe, we offered adults with pulmonary TB an integrated health check at or after treatment completion, assessing uptake and yield. Members of the same households were also offered the intervention. Selecting household members without prior or current TB as a comparator, we calculated odds ratios (OR) for HIV, diabetes, hypertension, underweight, anaemia, symptoms of mental health disorders, self-reported memory difficulty, vision impairment, chronic lung disease and multimorbidity (two or more of the above); and compared health-related quality of life (HRQoL; EQ-5D value). Of 229 people with TB invited, 96 (42%) participated (median age 38 years, 54% men, median 356 days from diagnosis). Common reasons for non-participation were migration and work. Among people with TB, chronic conditions were common and, other than HIV, mostly undiagnosed. Ninety-one percent of people with recent TB had at least one chronic condition; almost two-thirds had two or more. Compared to 285 household comparators (median age 34 years, 71% female) and after adjustment for age and sex, people with recent TB were more likely to have at least one chronic condition (OR 2.30 [95% confidence interval 1.03–5.11]) but not multimorbidity (1.55 [0.86–2.78]). People with recent TB had greater odds of HIV (1.77 [1.03–3.04]), symptoms of mental health disorders (1.57 [0.96–2.56]), self-reported memory difficulty (2.13 [1.19–3.80]), impaired lung function (3.24 [1.46–7.20] among 39/92 people with TB and 155/285 household comparators with data available), and underweight (5.15 [2.28–11.61]) compared to household comparators without prior TB; hypertension was less common (0.40 [0.20–0.79]) and HRQoL was worse (p = 0.005). Uptake of chronic disease screening among people with recent TB was low, but prevalence of chronic conditions was high. Holistic approaches to treatment which identify and address these conditions are needed. The contribution of post-TB multimorbidity to morbidity and mortality among TB survivors should be included in global disease estimates. Whilst comparison to household controls aimed to reduce confounding by socio-economic status, a limitation of this approach is externality, whereby the health status of the person with TB influenced that of their household members.

Most tuberculosis diagnostic validation studies use microbiological or combination reference standards to define tuberculosis. We convened an Endpoint Review Committee (ERC) to define outcomes in ERASE-TB, a longitudinal cohort study across three high tuberculosis-burden countries, aimed at validating novel diagnostics for early detection. Herein, we describe processes and outcomes of the ERC. ERASE-TB enrolled 2,109 household contacts of people with tuberculosis who were followed up 6-monthly up to 24 months with clinical, microbiological, and radiological assessments at each visit. Any participants with a chest X-ray suggestive of tuberculosis or a positive Xpert MTB/Rif Ultra were investigated and eligible for endpoint review. For these, the clinical presentation, radiological, and microbiological results were reviewed independently by two study clinicians; any discordant endpoint categorisations were assessed by the ERC (first individually; if discordant, during a consensus meeting). Tuberculosis outcomes relied on predefined definitions (confirmed, likely, possible, unlikely). The ERC comprised four members: a tuberculosis programme manager, clinicians, and a radiologist. Semi-structured interviews (n = 4) with ERC members explored experiences and challenges in tuberculosis classification. A total of 96 clinical summaries underwent review, 55 were agreed internally, with the majority being categorised as confirmed tuberculosis (34/55, 61.8%). Among the remaining 41, the ERC members agreed on only 14 (34.1%) classifications, with the majority being classified as confirmed tuberculosis (10/14, 71.4%). The discordant 27 were discussed at the consensus meeting; 9/27 were classified as likely tuberculosis (33.3%), and 7/27 as possible and unlikely (25.9%). Qualitative interviews highlighted the complexity of tuberculosis diagnosis, value of longitudinal measurements, and tensions between decision making for research as compared to clinical purposes. Standardized tuberculosis classification frameworks, longitudinal data, and real-time expert review can improve diagnostic accuracy and comparability across studies. Future research should integrate structured ERC processes prospectively to refine tuberculosis case definitions and ensure robust clinical and research outcomes.

Tuberculosis predominates in communities with multiple health and socioeconomic vulnerabilities. Tuberculosis diagnosis presents an opportunity for expanded health services to tuberculosis-affected households. We conducted a modified Delphi process to ascertain if and how expanded services should be offered to people with tuberculosis and their households. Purposively invited panellists were identified through professional networks and included researchers, service providers, policymakers and members of tuberculosis-affected communities. Panellists completed two online survey rounds. Round one sought to establish consensus on the perceived value of integration and capture diverse views on service integration priorities through free-text responses. Round two explored broad consensus statements (consensus defined as ≥75% agreement) developed from round one responses using Likert scales and country-specific priorities. Free-text responses were analysed using inductive thematic analysis. The percentage of panellists agreeing with each statement was calculated as a proportion of all responses, overall and by pre-specified subgroups of professional categories and WHO region. In round one, 223 panellists from 44 countries indicated strong support for expanded and better integrated services for people with tuberculosis (98% agreement), and their household contacts (84%). In round two, 324 people from 68 countries reached consensus on key motivations for service integration. These included improved tuberculosis treatment and other health outcomes among people with tuberculosis, and increased tuberculosis screening and preventive treatment uptake among contacts. Almost all (>99%) panellists agreed that people with tuberculosis should be routinely screened for relevant non-tuberculosis conditions, but only 69% thought this was appropriate among household contacts. There was consensus (93%) that population-wide tuberculosis screening should be integrated with other disease screening. Multiple, often context-specific, considerations for implementation were highlighted. Integrated tuberculosis screening and care is highly valued by global tuberculosis experts. This international consensus provides a strong mandate for research evaluating the feasibility and effectiveness of integrated tuberculosis service delivery and further policy and guideline development.

Background: opulations in Africa are ageing, and people living with HIV (PLHIV) are surviving longer largely due to antiretroviral therapy (ART). Tuberculosis (TB) has traditionally been considered a disease of young adults; however, the impact of shifting demographics on the age distribution of people living with TB (PWTB) is poorly understood. Methods: We conducted a rapid review and individual participant data (IPD) meta-analysis of studies from Zimbabwe reporting age at TB diagnosis. We searched MEDLINE and Embase to 14th March 2025, screened studies for eligibility, and contacted authors to obtain IPD. Datasets were checked, cleaned and harmonised. We summarised age distributions across five-year periods to estimate crude median ages. We then fitted Bayesian regression models to estimate mean age at TB diagnosis over time, adjusting for sex, study (as a random effect) and underlying population structure (using WorldPop data). Findings: We analysed 12 datasets including 15,925 PWTB. On crude analysis the median age of PWTB increased from 32 years (interquartile range (IQR) 25.5–38.5) in 2000-2004 to 38 years (IQR 30.1–45.9) in 2020-2024. When modelled, with each passing calendar year between 2000-2024, age at TB diagnosis or notification increased by 0.52 years of age (95% credible interval [CrI] 0.17-0.91). Interpretation: Age at TB diagnosis in Zimbabwe increased between 2000 and 2024. As populations and PWTB age, TB programmes must adapt case-finding, clinical services and management for older adults taking account of multimorbidity, polypharmacy and frailty. TB notification data with greater granularity regarding age would improve understanding of this area.

Tuberculosis (TB) rarely occurs in isolation; most people with TB experience multiple coexisting conditions, including HIV, diabetes, undernutrition, depression, and substance use disorders, which worsen disease severity and compromise treatment outcomes. Although the World Health Organization has issued disease-specific guidance for managing key comorbidities, TB care remains largely siloed and poorly equipped to address the growing burden of multimorbidity, particularly in African health systems. In this perspective article, we propose a phased framework for multimorbidity-centered TB care. The first phase emphasizes systematic screening for common comorbidities and establishment of basic referral pathways. The second phase focuses on strengthening coordination between TB programs and existing health and social services, including task sharing and longitudinal follow-up. The third phase advances toward fully integrated, co-located, multidisciplinary models of care that embed TB services within broader multimorbidity platforms. Together, this framework offers a pragmatic roadmap for TB programs to deliver more person-centered, equitable, and efficient care, strengthen primary care systems, and accelerate progress toward ending TB as a public health threat in Africa.

Background: Screening for sensitive and stigmatized conditions such as mental health or experience of violence is challenging. Audio computer-assisted self-interviewing (ACASI), administered by using a tablet and headphones, may be more sensitive for this purpose than paper-based self-administered questionnaires (SAQ) handed in to project staff. We conducted a methodological cluster-randomized trial in Zimbabwe to compare two methods of screening for common mental disorders (CMD) and intimate partner violence (IPV): ACASI versus SAQ. Methods: Trial participants were health workers receiving occupational health checks at hospitals and primary health clinics. The unit of randomization was a working day. CMD was measured by using the Shona Symptom Questionnaire, anxiety by using the Generalised Anxiety Disorder-7 questionnaire, and IPV by using the World Health Organization screening questionnaire. The co-primary outcomes were CMD prevalence and the prevalence of any IPV, compared by arm at the cluster level, adjusting for gender and weekend. Secondary outcomes were the prevalence of anxiety and of physical, emotional, and severe physical and sexual IPV. Results: Between 20 February and 10 June 2022, 1240 participants were enrolled in 71 clusters (workdays), with 77.0% female and 66.4% in clinical-facing roles. The cluster-level geometric mean prevalence of CMD was 19.4% when using ACASI and 14.1% when using SAQ [adjusted risk ratio (aRR) 1.37, 95% confidence interval (CI) 0.99, 1.89; P = .056]. ACASI yielded a higher prevalence of overall IPV than the SAQ (cluster-level geometric mean prevalence 40.6% compared with 22.4%, aRR 1.81, 95% CI 1.40, 2.35; P < .001), of emotional IPV (aRR 1.66, 95% CI 1.27, 2.17; P < .001), and of physical IPV (aRR 1.61, 95% CI 1.16, 2.25; P = .005). No differences were seen in the prevalence of severe physical or sexual IPV or anxiety across the trial arms. Conclusion: Screening for CMD and IPV by using a confidential ACASI method identifies more people who may benefit from care than screening by using SAQ handed in to clinic staff. This may be explained by under-reporting on the SAQ. ACASI is a promising screening method for sensitive issues in healthcare settings.

Globally, tuberculosis incidence and mortality is driven by syndemic interactions of tuberculosis with other chronic conditions including HIV, diabetes and undernutrition in a deleterious social and structural context, often characterised by poverty. Systematic screening for tuberculosis among household contacts is a core element of the WHO tuberculosis strategy but is hampered in high-tuberculosis incidence settings by health system constraints and low participation by household members of people with tuberculosis. Reframing screening as a health check, informed by the syndemic framework, could improve uptake and address proximate determinants of tuberculosis. Within a larger research study aimed at evaluating new tuberculosis diagnostic tests we developed and, using mixed methods, evaluated an integrated health check in a prospective cohort of tuberculosis household contacts in Zimbabwe. This included screening for a range of health conditions, health education and counselling, and on-site treatment or referral. Of 836 identified household contacts, 700 (84%) participated in tuberculosis screening. Of those, 467 people (67% women, median age 28 years) were invited to the health check; all participated in the intervention. One percent (n = 5/459) were diagnosed with tuberculosis. Almost two thirds (n = 288) had at least one unmet health need (either undiagnosed or uncontrolled diabetes, hypertension, HIV, anaemia, undernutrition, common mental health disorders, vision impairment, or tuberculosis). Of those referred following the health check, 66% accessed care for at least one condition, with variation across conditions. In-depth interviews with participants (n = 28), informed development of a refined explanatory theory, illustrating the benefits of a syndemic theory-based approach to tuberculosis screening for household contacts. Members of tuberculosis affected households have multiple, intersecting and unmet health needs. A holistic approach to systematic screening of household contacts guided by the syndemic framework could improve the health of these vulnerable people, advancing progress towards both tuberculosis and sustainable development goals.