Models of service delivery for people with TB and comorbidities range from the least integrated, where stand-alone disease-specific providers refer patients to the relevant specialist services for comorbidities, to the most integrated, where all services across the cascade of care for TB and key comorbidities are provided in a “one-stop-shop” by one health-care worker (83, 84). 10 Services may be provided at different levels of the health system, depending on the availability of comprehensive primary care and the degree of decentralization of the respective services. In some settings, TB services may be decentralized to the primary care level, while services for comorbidities such as diabetes and mental disorders may be available only at the secondary care level. In this situation, the degree of integration can be increased only if diabetes and mental health services are also decentralized closer to the end-user (22). The provision of integrated care and comprehensive services for people with HIV-associated TB as close as possible to where they live has long been a focus of WHO policy documents. Such efforts should include integrating services for the prevention, diagnosis, treatment and care of TB and HIV into maternal and child health services, including the prevention of parentto-child transmission of HIV, and treatment centres for drug dependency where applicable (76).
Within these models, care may be provided by separate specialist health-care workers who refer patients to different services according to established pathways. Alternatively, multidisciplinary teams comprising professionals with a mix of skills, including medical and nonmedical, that are required to meet the needs of the end-user, may provide coordinated care (85). Care can also be provided by one health-care worker for both TB and comorbidities, where the expertise is available (e.g. for TB and HIV) (84). All models of care may be strengthened by the engagement of community health-care workers, outreach teams and peer supporters.
⁸ Atkins S et al., unpublished, 2022.
⁹ Nishikiori N et al., unpublished, 2022.
¹⁰ The models of care described here are categorized according to where a person first seeks care, and according to the degree of integration. They are not prescriptive; national programmes should define the models that best enable the provision of quality-assured comprehensive services as close as possible to the end-user.