Characteristics and Comorbidities at Start of Tuberculosis Treatment in Three Regions of the Philippines: The St-ATT Cohort

Background: Diabetes and undernutrition are common risk factors for tuberculosis (TB), associated with poor treatment outcomes and exacerbated by TB. Here we describe the characteristics and non-communicable multimorbidity (co-occurrence of 2 or more medical conditions) in Filipino adults at the time of initiating a new TB treatment regimen enrolled into the Starting Anti-TB Treatment (St-ATT) Cohort. Methods and Findings: Nine-hundred participants (69.6% male) were enrolled from 13 public health facilities in Metro Manila (N=184), Negros Occidental (N=372) and Cebu (N=344) within 5 days of starting treatment including 133 (14.8%) initiating the 9 month WHO shorter treatment regimen for multi-drug resistant TB (MDR-TB). Diabetes was defined as HbA1c ≥6.5% and/or current diabetes medication; hypertension as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg and/or current anti-hypertensive medication, anaemia as haemoglobin <11 g/dl and moderate/severe undernutrition as body-mass-index <17 kg/m2. The most common comorbidities were moderate/severe undernutrition 23.4% (210/899), diabetes 22.5% (199/881), hypertension 19.0% (164/864) and moderate/severe anaemia 13.5% (121/899). Fifty-eight percent had ≥1 of these comorbid conditions (496/847), with 17.1% having ≥2; the most common combination being diabetes and hypertension (N=57, 6.7%). Just over half of diabetes (54.8%) and hypertension (54.9%) was previously undiagnosed, and lack of glycemic control (HbA1c<8.0%) was common in those already on medication (N=50/73, 68.5%). MDR-TB treatment was associated with increased odds of diabetes (Adjusted odds ratio (AOR) = 2.48, 95% CI: 1.55-3.95); but decreased odds of hypertension (AOR=0.55, 95% CI: 0.39-0.78). HIV infection was only associated with anaemia (AOR=4.51, 95% CI: 1.01-20.1). Previous TB treatment was associated with moderate/severe undernutrition (AOR = 1.98, 95% CI: 1.40-2.80), as was increased duration of TB-symptoms before starting treatment and household food insecurity. No associations for sex, alcohol or tobacco use were observed. MDR-TB treatment was marginally associated with having ≥2 comorbidities (OR = 1.52, 95% CI: 0.97-2.39). Conclusions: TB treatment programmes need to consider planning for a large proportion of persons requiring diagnosis and management of comorbidities with the potential to adversely affect TB treatment outcomes and quality of life. Of the conditions examined here, dietary advice and nutritional management are considered usual components of comprehensive care.