Addressing the Triple Burden: High Rates of HIV, Malnutrition, and NCDs in TB-Affected African Households Highlight Need for Integrated Care

Introduction

The co-occurrence of infectious diseases, malnutrition, and non-communicable diseases (NCDs) has created a “double burden” of health challenges in resource-limited regions. Tuberculosis (TB) is a major public health issue in Africa, with significant impacts on households due to shared environmental, structural, and social determinants. TB-affected households often encounter additional health risks, including HIV and conditions like diabetes, hypertension, and chronic lung disease, creating complex health needs.

A recent article published in PLOS Medicine by Calderwood et al.  explores findings from the ERASE-TB study, a cross-sectional analysis of tuberculosis-affected households in Mozambique, Tanzania, and Zimbabwe. The study investigates the prevalence of HIV, malnutrition, and NCDs among individuals residing in households affected by tuberculosis. By identifying the prevalence and distribution of these conditions, the ERASE-TB study aims to inform integrated health interventions that could alleviate health burdens in these communities.

Study Design and Methodology

The ERASE-TB study screened 1,958 individuals aged 10 years and older from TB-affected households for tuberculosis, HIV, malnutrition, and NCDs, including diabetes, hypertension, and chronic lung disease. Household members were recruited from three sites: Maputo in Mozambique, Mbeya in Tanzania, and Harare in Zimbabwe. In addition to TB symptom screening, HIV status, body mass index (BMI), blood pressure, and glycated hemoglobin (HbA1c) were recorded to assess these health conditions.

The study examined multimorbidity within individuals (the co-occurrence of two or more chronic conditions) and explored clustering at the household level. This study design allowed researchers to assess both individual and household-level health profiles, providing insights into shared risk factors and potential interventions.

Defining Chronic Conditions

• HIV Status: Confirmed using standard HIV tests based on national guidelines.
• Nutritional Disorders: Measured through BMI, categorizing individuals as underweight, healthy weight, overweight, or obese. Anemia was assessed through hemoglobin levels.
• Non-communicable Diseases: Chronic lung disease was identified through spirometry, and diabetes and hypertension were assessed using point-of-care HbA1c tests and single-day blood pressure measurements, respectively.

The prevalence and clustering of these conditions were analyzed using statistical models to account for household-level factors. This approach aimed to determine if certain health conditions are more likely to occur within specific household environments.

Primary Findings

High Prevalence of HIV and Malnutrition

HIV prevalence was notably high within the cohort, with 15% of household contacts testing positive. Among women, the prevalence was even higher at 19.1%, compared to 8.4% in men. Adolescent HIV prevalence was lower at 2.7%, but a concerning 44% of HIV-positive adolescents were unaware of their status. Most adults with HIV were aware of their status and were receiving treatment, yet these figures emphasize the ongoing need for targeted HIV interventions within TB-affected households.

Malnutrition was also prevalent, with 18% of individuals classified as underweight. The issue of undernutrition was especially prominent among adolescents, of whom one in four showed signs of stunting. Contrastingly, overweight and obesity affected nearly 30% of the study population, primarily among adult women. This dual burden of malnutrition highlights the complex nutritional needs within these communities.

Prevalence of Non-Communicable Diseases

The prevalence of NCDs within TB-affected households included:

• Hypertension: Affecting 32% of adults, with higher rates among older participants.
• Diabetes: Present in 9.4% of adults, with prevalence increasing with age.
• Chronic Lung Disease: Identified in 10.3% of household contacts, showing no significant sex differences.

While HIV treatment access was robust, significant gaps existed in the diagnosis and management of NCDs. Only 33% of adults with hypertension and 20.5% of adults with diabetes were aware of their conditions, and fewer were on treatment. These findings underscore the lack of NCD care resources within tuberculosis-affected households and the need for comprehensive health services that address both infectious and chronic conditions.

Multimorbidity and Clustering of Health Conditions

The study found that 61% of adults in TB-affected households had at least one chronic condition, and 24% experienced multimorbidity. The most common multimorbidity combination was HIV and hypertension, emphasizing the overlapping health challenges faced by these households. Additionally, clustering analyses showed that certain conditions, such as HIV, anemia, and underweight, tend to cluster within households, whereas NCDs like diabetes and hypertension were more dispersed. This pattern suggests that infectious diseases and nutritional disorders may be influenced by shared household factors, while NCDs might result from broader environmental influences.

Challenges in Access to Care and Potential Solutions

While most individuals with HIV were aware of their status and receiving treatment, large treatment gaps persisted for NCDs. Among those with hypertension, only 33% were aware of their condition, and just 18% had controlled blood pressure levels. Diabetes awareness and management also lagged, with less than a third of diagnosed individuals on treatment and achieving controlled blood sugar levels. The treatment gap for NCDs is concerning, particularly as many household members live in extreme poverty, limiting their ability to access regular healthcare.

This limited access to care calls for a shift towards integrated healthcare solutions. Screening for NCDs within tuberculosis programs, particularly in high-burden areas, could provide an efficient way to identify and manage chronic conditions early. The study suggests that healthcare interventions should not only target TB but also address the broader health challenges within these vulnerable communities.

Implications for Public Health Policy and Integrated Health Programs

The findings from the ERASE-TB study emphasize the need for an integrated health approach in tuberculosis-affected communities. Key recommendations include:

• Integration of Screening Programs: Systematic screening for both infectious and chronic diseases during TB contact tracing could help address overlapping health burdens. By integrating screening for HIV, malnutrition, and NCDs within tuberculosis programs, health systems could deliver more comprehensive care.
• Nutritional and Lifestyle Support: Given the dual burden of malnutrition (both undernutrition and obesity), targeted nutritional support could benefit these communities. Nutritional counseling, access to affordable healthy foods, and interventions to address stunting in adolescents could improve outcomes for at-risk households.
• Strengthening NCD Care Access: Improved diagnostic facilities and affordable treatment options for diabetes, hypertension, and chronic lung disease are essential. The study’s findings highlight that many individuals with NCDs remain undiagnosed, indicating the need for greater investment in NCD care.
• Household-Level Health Education: Educational initiatives focusing on the prevention of NCDs, nutrition, and HIV management could empower household members to make healthier lifestyle choices. Household-level interventions can build awareness of shared risk factors and encourage positive health behaviors.

Conclusion

The ERASE-TB study provides a comprehensive look at the health conditions affecting tuberculosis-affected households in east and southern Africa. High rates of HIV, malnutrition, and NCDs, compounded by socioeconomic barriers, create a substantial health burden for these communities. Multimorbidity is prevalent, with many households experiencing coexisting conditions that further strain limited resources.

This research highlights the importance of integrated health services that address both infectious and non-communicable diseases. By embedding NCD and nutritional screening within tuberculosis programs (or other programs for communicable diseases with complex health effects), health systems could identify and manage multiple conditions simultaneously, improving outcomes for individuals and households alike. Such an approach could reduce tuberculosis incidence and support the long-term health of vulnerable populations globally.