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Hayward SE, Vanqa N, Makanda G, Tisile P, Ngwatyu L, Foster I, Mcinziba AA, Biewer A, Mbuyamba R, Galloway M, Bunyula S, van der Westhuizen HM, Friedland JS, Medina-Marino A, Viljoen L, Schoeman I, Hoddinott G, Nathavitharana RR. "As a patient I do not belong to the clinic, I belong to the community": co-developing multi-level, person-centred tuberculosis stigma interventions in Cape Town, South Africa. BMC GLOBAL AND PUBLIC HEALTH 2024; 2:55. [PMID: 39157720 PMCID: PMC11324783 DOI: 10.1186/s44263-024-00084-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/17/2024] [Indexed: 08/20/2024]
Abstract
Background Anticipated, internal, and enacted stigma are major barriers to tuberculosis (TB) care engagement and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa. Methods Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n = 87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed, and then further interpreted using the socio-ecological model and behaviour change wheel framework. Results Intervention components across socio-ecological levels shared common functions linked to effective behaviour change, namely education, training, enablement, persuasion, modelling, and environmental restructuring. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal and anticipated stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended to decrease enacted stigma. Participants discussed how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers. Conclusions Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-led multi-level intervention components should be prioritised by TB programs, including integrated TB/HIV care services. Supplementary Information The online version contains supplementary material available at 10.1186/s44263-024-00084-z.
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Affiliation(s)
- Sally E. Hayward
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- TB Proof, Cape Town, South Africa
| | - Nosivuyile Vanqa
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | | | | | | | - Abenathi A. Mcinziba
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Amanda Biewer
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | | | | | | | | | - Jon S. Friedland
- Institute for Infection and Immunity, St George’s, University of London, London, UK
| | - Andrew Medina-Marino
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Desmond Tutu Health Foundation, Cape Town, South Africa
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Lario Viljoen
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | - Graeme Hoddinott
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, Australia
| | - Ruvandhi R. Nathavitharana
- TB Proof, Cape Town, South Africa
- Beth Israel Deaconess Medical Center, Boston, MA USA
- Harvard Medical School, Boston, MA USA
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Sparg T, Petersen L, Mayers P, Rogers C. South African adolescents' lived experiences of acquired hearing loss following multidrug-resistant tuberculosis treatment. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1336346. [PMID: 38469378 PMCID: PMC10925655 DOI: 10.3389/fresc.2024.1336346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/10/2024] [Indexed: 03/13/2024]
Abstract
Objective The impact of acquiring hearing loss might be exacerbated during adolescence, as this normal transition from childhood to adulthood is characterised by identity construction and social intensity. This study aimed to describe the lived experiences of South African adolescents with acquired hearing loss following aminoglycoside treatment for multidrug resistant tuberculosis. Design The study adopted a descriptive phenomenological design and in-depth, semi-structured interviews were conducted in English, isiZulu and Afrikaans. The data was managed and analysed according to a modified version of Hycner's framework. Study sample Six participants aged 16-24 years with bilateral, mild to profound hearing loss acquired from aminoglycoside treatment were recruited from two South African provinces. Results Three themes emerged which created a triple burden for participants. They endured socio-economic hardship encompassing limited economic and emotional support. Participants battled the consequences of life-threatening MDR-TB including illness, hospitalisation, stigma, and other challenges. Finally, participants were left with life-changing hearing loss. Conclusion The findings indicate the necessity of holistic management of adolescents with aminoglycoside-related acquired hearing loss and serves as motivation to improve ototoxic monitoring practices and patient uptake of monitoring services and calls for the cessation, or at least cautious use, of aminoglycosides.
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Affiliation(s)
- Tarryn Sparg
- Division of Communication Sciences and Disorders, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lucretia Petersen
- Division of Communication Sciences and Disorders, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Pat Mayers
- Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Christine Rogers
- Division of Communication Sciences and Disorders, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Hayward SE, Vanqa N, Makanda G, Tisile P, Ngwatyu L, Foster I, Mcinziba A, Biewer A, Mbuyamba R, Galloway M, Bunyula S, Westhuizen HM, Friedland JS, Marino-Medina A, Viljoen L, Schoeman I, Hoddinott G, Nathavitharana RR. "As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa. RESEARCH SQUARE 2024:rs.3.rs-3921970. [PMID: 38405783 PMCID: PMC10889064 DOI: 10.21203/rs.3.rs-3921970/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa. Methods Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model. Results Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers. Conclusions Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.
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Affiliation(s)
| | | | | | | | | | | | | | - Amanda Biewer
- Beth Israel Deaconess Medical Center, Harvard Medical School
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Ross J, Perumal R, Wolf A, Zulu M, Guzman K, Seepamore B, Reis K, Nyilana H, Hlathi S, Narasimmulu R, Cheung YKK, Amico KR, Friedland G, Daftary A, Zelnick JR, Naidoo K, O'Donnell MR. Adaptive evaluation of mHealth and conventional adherence support interventions to optimize outcomes with new treatment regimens for drug-resistant tuberculosis and HIV in South Africa (ADAP-TIV): study protocol for an adaptive randomized controlled trial. Trials 2023; 24:776. [PMID: 38037105 PMCID: PMC10691086 DOI: 10.1186/s13063-023-07520-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/17/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Highly effective, short-course, bedaquiline-containing treatment regimens for multidrug-resistant tuberculosis (MDR-TB) and integrase strand transfer inhibitor (INSTI)-containing fixed dose combination antiretroviral therapy (ART) have radically transformed treatment for MDR-TB and HIV. However, without advances in adherence support, we may not realize the full potential of these therapeutics. The primary objective of this study is to compare the effect of adherence support interventions on clinical and biological endpoints using an adaptive randomized platform. METHODS This is a prospective, adaptive, randomized controlled trial comparing the effectiveness of four adherence support strategies on a composite clinical outcome in adults with MDR-TB and HIV initiating bedaquiline-containing MDR-TB treatment regimens and receiving ART in KwaZulu-Natal, South Africa. Trial arms include (1) enhanced standard of care, (2) psychosocial support, (3) mHealth using cellular-enabled electronic dose monitoring, and (4) combined mHealth and psychosocial support. The level of support will be titrated using a differentiated service delivery (DSD)-informed assessment of treatment support needs. The composite primary outcome will include survival, negative TB culture, retention in care, and undetectable HIV viral load at month 12. Secondary outcomes will include individual components of the primary outcome and quantitative evaluation of adherence on TB and HIV treatment outcomes. DISCUSSION This trial will evaluate the contribution of different modes of adherence support on MDR-TB and HIV outcomes with WHO-recommended all-oral MDR-TB regimens and ART in a high-burden operational setting. We will also assess the utility of a DSD framework to pragmatically adjust levels of MDR-TB and HIV treatment support. TRIAL REGISTRATION ClinicalTrials.gov NCT05633056. Registered on 1 December 2022.
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Affiliation(s)
- Jesse Ross
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA
| | - Rubeshan Perumal
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Allison Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA
| | - Mbali Zulu
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Kevin Guzman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA
| | - Boitumelo Seepamore
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- School of Applied Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Karl Reis
- Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA
| | - Hlengiwe Nyilana
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Senzo Hlathi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | | | - Ying Kuen K Cheung
- Department of Biostatistics, Columbia University Irving Medical Center, New York City, NY, USA
| | - K Rivet Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Amrita Daftary
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, Canada
| | - Jennifer R Zelnick
- Graduate School of Social Work, Touro University, New York City, NY, USA
| | - Kogieleum Naidoo
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Max R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Suite E101, 8th Floor, PH Building, 622 W. 168th Street, New York City, NY, 10032, USA.
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.
- Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY, USA.
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Nightingale R, Carlin F, Meghji J, McMullen K, Evans D, van der Zalm MM, Anthony MG, Bittencourt M, Byrne A, du Preez K, Coetzee M, Feris C, Goussard P, Hirasen K, Bouwer J, Hoddinott G, Huaman MA, Inglis-Jassiem G, Ivanova O, Karmadwala F, Schaaf HS, Schoeman I, Seddon JA, Sineke T, Solomons R, Thiart M, van Toorn R, Fujiwara PI, Romanowski K, Marais S, Hesseling AC, Johnston J, Allwood B, Muhwa JC, Mortimer K. Post-TB health and wellbeing. Int J Tuberc Lung Dis 2023; 27:248-283. [PMID: 37035971 PMCID: PMC10094053 DOI: 10.5588/ijtld.22.0514] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/02/2022] [Indexed: 04/11/2023] Open
Abstract
TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.
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Affiliation(s)
- R Nightingale
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, Department of Respiratory Medicine, Liverpool University Hospitals NHS foundation Trust, Liverpool, UK
| | - F Carlin
- Department of Infectious Diseases, Liverpool University Hospitals NHS foundation Trust, Liverpool, UK
| | - J Meghji
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, Department of Respiratory Medicine, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - K McMullen
- Division of Neurology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D Evans
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M G Anthony
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M Bittencourt
- University Hospital, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | - A Byrne
- Department of Thoracic Medicine, St Vincent´s Hospital Clinical School University of New South Wales, Sydney, NSW, Australia
| | - K du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M Coetzee
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - C Feris
- Occupational Therapy Department, Windhoek Central Hospital, Ministry of Health and Social Services, Windhoek, Namibia, Division of Occupational Therapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Tygerberg, South Africa
| | - P Goussard
- Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - K Hirasen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, Paediatric Pulmonology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - J Bouwer
- Department of Psychiatry, University of the Witwatersrand, Johannesburg, South Africa
| | - G Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M A Huaman
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - G Inglis-Jassiem
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - O Ivanova
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, German Centre for Infection Research, Partner Site Munich, Munich, Germany
| | - F Karmadwala
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - H S Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | | | - J A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa, Department of Infectious Diseases, Imperial College London, London, UK
| | - T Sineke
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg, South Africa
| | - M Thiart
- Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - R van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg, South Africa
| | - P I Fujiwara
- Task Force, Global Plan to End TB, 2023-2030, Stop TB Partnership, Geneva, Switzerland
| | - K Romanowski
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada, Provincial TB Services, BC Centre for Disease Control, Vancouver, BC, Canada
| | - S Marais
- Division of Neurology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa, Neurology Research Group, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - J Johnston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada, Provincial TB Services, BC Centre for Disease Control, Vancouver, BC, Canada
| | - B Allwood
- Division of Pulmonology, Department of Medicine, Faculty of Medicine, Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J C Muhwa
- Department of Medicine, Therapeutics, Dermatology and Psychiatry, Kenyatta University, Nairobi, Kenya
| | - K Mortimer
- Department of Respiratory Medicine, Liverpool University Hospitals NHS foundation Trust, Liverpool, UK, Department of Medicine, University of Cambridge, Cambridge, UK, Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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DeSanto D, Velen K, Lessells R, Makgopa S, Gumede D, Fielding K, Grant AD, Charalambous S, Chetty-Makkan CM. A qualitative exploration into the presence of TB stigmatization across three districts in South Africa. BMC Public Health 2023; 23:504. [PMID: 36922792 PMCID: PMC10017062 DOI: 10.1186/s12889-023-15407-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 03/08/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) stigma is a barrier to active case finding and delivery of care in fighting the TB epidemic. As part of a project exploring different models for delivery of TB contact tracing, we conducted a qualitative analysis to explore the presence of TB stigma within communities across South Africa. METHODS We conducted 43 in-depth interviews with 31 people with TB and 12 household contacts as well as five focus group discussions with 40 ward-based team members and 11 community stakeholders across three South African districts. RESULTS TB stigma is driven and facilitated by fear of disease coupled with an understanding of TB/HIV duality and manifests as anticipated and internalized stigma. Individuals are marked with TB stigma verbally through gossip and visually through symptomatic identification or when accessing care in either TB-specific areas in health clinics or though ward-based outreach teams. Individuals' unique understanding of stigma influences how they seek care. CONCLUSION TB stigma contributes to suboptimal case finding and care at the community level in South Africa. Interventions to combat stigma, such as community and individual education campaigns on TB treatment and transmission as well as the training of health care workers on stigma and stigmatization are needed to prevent discrimination and protect patient confidentiality.
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Affiliation(s)
- Daniel DeSanto
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Richard Lessells
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, London, UK
- KwaZulu-Natal Research Innovation & Sequencing Platform, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Dumile Gumede
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Centre for General Education, Durban University of Technology, Durban, South Africa
| | - Katherine Fielding
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, London, UK
| | - Alison D Grant
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, London, UK
- School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Candice M Chetty-Makkan
- The Aurum Institute, Johannesburg, South Africa
- Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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7
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Bergman AJ, McNabb KC, Mlandu K, Akumbom A, Flores DD. Identity management in the face of HIV and intersecting stigmas: A metasynthesis of qualitative reports from sub-Saharan Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000706. [PMID: 36962951 PMCID: PMC10022386 DOI: 10.1371/journal.pgph.0000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 12/06/2022] [Indexed: 02/04/2023]
Abstract
While stigma experienced by people living with HIV (PLWH) is well documented, intersectional stigma and additional stigmatized identities have not received similar attention. The purpose of this metasynthesis is to identify salient stigmatized intersections and their impact on health outcomes in PLWH in sub-Saharan Africa. Using Sandelowski and Barroso's metasynthesis method, we searched four databases for peer-reviewed qualitative literature. Included studies (1) explored personal experiences with intersecting stigmas, (2) included ≥1 element of infectious disease stigma, and (3) were conducted in sub-Saharan Africa. Our multinational team extracted, aggregated, interpreted, and synthesized the findings. From 454 screened abstracts, the 34 studies included in this metasynthesis reported perspectives of at least 1258 participants (282 men, 557 women, and 109 unspecified gender) and key informants. From these studies, gender and HIV was the most salient stigmatized intersection, with HIV testing avoidance and HIV-status denial seemingly more common among men to preserve traditional masculine identity. HIV did not threaten female identity in the same way with women more willing to test for HIV, but at the risk of abandonment and withdrawal of financial support. To guard against status loss, men and women used performative behaviors to highlight positive qualities or minimize perceived negative attributes. These identity management practices ultimately shaped health behaviors and outcomes. From this metasynthesis, the Stigma Identity Framework was devised for framing identity and stigma management, focusing on role expectation and fulfillment. This framework illustrates how PLWH create, minimize, or emphasize other identity traits to safeguard against status loss and discrimination. Providers must acknowledge how stigmatization disrupts PLWH's ability to fit into social schemas and tailor care to individuals' unique intersecting identities. Economic security and safety should be considered in women's HIV care, while highlighting antiretrovirals' role in preserving strength and virility may improve care engagement among men.
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Affiliation(s)
- Alanna J Bergman
- Center for Infectious Disease and Nursing Innovation, School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Katherine C McNabb
- Center for Infectious Disease and Nursing Innovation, School of Nursing, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Khaya Mlandu
- Izikhuba Unjani Clinic, Mngungundlovu, South Africa
| | - Alvine Akumbom
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
| | - Dalmacio Dennis Flores
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States of America
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8
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Kallon II, Colvin CJ. A qualitative exploration of continuity of TB care in clinics after discharge from hospitals in Cape Town, South Africa. BMC Health Serv Res 2022; 22:1489. [PMID: 36474237 PMCID: PMC9727991 DOI: 10.1186/s12913-022-08880-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Continuity of care remains a challenge for TB patients who are discharged from hospital and referred to primary health care clinics in South Africa. The aim of this study was to explore the experiences and perceptions of patients, health care workers and family members regarding continuity of TB care in a Cape Town health district. METHODS We conducted one-on-one interviews, using semi-structured interview guides, with TB patients and their families and health care workers. We also conducted focus group interviews with other health care workers who performed similar duties. Field notes were kept and patients' home circumstances were also physically observed. Data saturation was achieved after 31 interviews. We used Miles and Huberman's qualitative data analysis framework to interpret the data. RESULTS Themes identified in the interviews were grouped into two categories: (1) patients' socio-economic circumstances including complex family relationships, good or lack of family support, inadequate income, and agency; and (2) health system challenges, including inadequate referral links between the clinic and the hospital and negative emotions as a result of poor service delivery experienced by patients. CONCLUSION Some TB Patients experienced poor continuity of care on discharge from hospitals to primary health clinics and perceived that this resulted from socio-economic conditions and health system-related problems that triggered negative emotions. Proper communication between the hospital and clinic regarding patients' care, adequate counselling, and patient-centred treatment are required to address poor continuity of care among patients with TB down-referred to clinics.
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Affiliation(s)
- Idriss Ibrahim Kallon
- grid.7836.a0000 0004 1937 1151Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa ,grid.11956.3a0000 0001 2214 904XCentre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Christopher J Colvin
- grid.7836.a0000 0004 1937 1151Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa ,grid.27755.320000 0000 9136 933XDepartment of Public Health Sciences, University of Virginia, Virginia, USA ,grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University, Providence, USA
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9
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Tornu E, Quarcoopome L. Correlates of quality of life among persons living with tuberculosis: A cross-sectional study. PLoS One 2022; 17:e0277192. [PMID: 36331938 PMCID: PMC9635747 DOI: 10.1371/journal.pone.0277192] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction The correlates of quality of life originating from the demographic characteristics, comorbidities and sources of social support among persons living with tuberculosis remain underreported. The aim of this study was to examine the correlates of quality of life among persons living with tuberculosis within Greater Accra, Ghana. Methods A cross-sectional survey design was used to assess the correlates of quality of life among 250 randomly sampled persons living with tuberculosis. Quality of life was assessed with the Quality of Life Brief Version (WHOQOL-BREF) questionnaire and correlates were derived using Spearman rho correlations. Chi-square analyses assessed associations among respondent characteristics. Results All four quality of life domains (physical, psychological, social relationship and environmental) of persons living with tuberculosis were positively correlated. Furthermore, receiving social support from family or friends correlated positively with respondents’ quality of life. Human Immunodeficiency Virus (HIV) infection and receiving social support mainly from work colleagues or religious institutions correlated negatively with respondents’ quality of life domains. Other correlates of quality of life included age, pleuritis with pleural effusion, number of dependants and distance to tuberculosis treatment centres. Social support from family and friends corresponded with better quality of life among persons living with tuberculosis. Conclusion The quality of life domains of persons living with tuberculosis are interrelated and can be enhanced by social support. Healthcare providers should involve the significant others of persons living with tuberculosis, human immunodeficiency virus and pleuritis with pleural effusion in their care to promote patients’ quality of life.
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Affiliation(s)
- Eric Tornu
- Department of Adult Health, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Louisa Quarcoopome
- Department of Internal Medicine and Therapeutics, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
- * E-mail:
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10
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Wouters E, van Rensburg AJ, Engelbrecht M, Buffel V, Campbell L, Sommerland N, Rau A, Kigozi G, van Olmen J, Masquillier C. How the 'HIV/TB co-epidemic-HIV stigma-TB stigma' syndemic impacts on the use of occupational health services for TB in South African hospitals: a structural equation modelling analysis of the baseline data from the HaTSaH Study (cluster RCT). BMJ Open 2022; 12:e045477. [PMID: 35383052 PMCID: PMC8984004 DOI: 10.1136/bmjopen-2020-045477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) has become an occupational health hazard in South African hospitals where healthcare workers (HCWs) are additionally confronted daily with HIV and its associated stigma, causing a syndemic. Early TB diagnosis and treatment are vital, but the uptake of these services through occupational healthcare units (OHUs) is low. The current study hypothesises that (1) the link between HIV and TB and (2) the perceived HIV stigmatisation by colleagues create (3) a double HIV-TB stigma which increases (4) internalised TB stigma and leads to (5) a lower willingness to use OHU services for TB screening and treatment. DESIGN A cross-sectional study using the baseline data from the HIV and TB Stigma among Healthcare workers Study (HaTSaH Study). SETTING Six hospitals in the Free State province of South Africa. PARTICIPANTS 820 HCWs of the six selected hospitals. RESULTS The study results demonstrate that the co-epidemic (β=0.399 (screening model) and β=0.345 (treatment model)) combined (interaction effect: β=0.133 (screening) and β=0.132 (treatment)) with the persistent stigmatisation of HIV is altering the attitudes towards TB (β=0.345 (screening) and β=0.400 (treatment)), where the stigmatising views of HIV are transferred to TB-illustrating the syndemic impact. Our model demonstrated that this syndemic not only leads to higher levels of internal TB stigma (β=0.421 (screening) and β=0.426 (treatment)), but also to a lower willingness to use the OHU for TB screening (probit coefficient=-0.216) and treatment (probit coefficient=-0.160). Confidentiality consistently emerged as a contextual correlate of OHU use. CONCLUSIONS Theoretically, our results confirm HIV as a 'syndemic generator' which changes the social meaning of TB in the hospital context. Practically, the study demonstrated that the syndemic of TB and HIV in a highly endemic context with stigma impacts the intended use of occupational TB services. TRIAL REGISTRATION NUMBER Pre-results of the trial registered at the South African National Clinical Trials Register, registration ID: DOH-27-1115-5204.
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Affiliation(s)
- Edwin Wouters
- Centre for Population, Family & Health, University of Antwerp, Antwerp, Belgium
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, Free State, South Africa
| | | | - Michelle Engelbrecht
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, Free State, South Africa
| | - Veerle Buffel
- Centre for Population, Family & Health, University of Antwerp, Antwerp, Belgium
| | - Linda Campbell
- Centre for Population, Family & Health, University of Antwerp, Antwerp, Belgium
| | | | - Asta Rau
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, Free State, South Africa
| | - G Kigozi
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, Free State, South Africa
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11
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Nsubuga R, Adrawa N, Okoboi S, Komuhangi A, Izudi J. Complete sputum smear monitoring among adults with pulmonary tuberculosis in central Uganda: evidence from a retrospective cohort study. BMC Infect Dis 2022; 22:191. [PMID: 35216577 PMCID: PMC8876256 DOI: 10.1186/s12879-022-07178-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 02/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background People with bacteriologically confirmed pulmonary tuberculosis require sputum smear monitoring at 2, 5, and 6 months to establish treatment outcomes. However, there is limited information about sputum smear monitoring in Uganda, similar to other developing countries. We examined factors associated with complete sputum smear monitoring among persons with bacteriologically confirmed pulmonary TB aged ≥ 15 years in central Uganda. Methods We retrospectively reviewed and abstracted data for persons with bacteriologically confirmed pulmonary TB initiated on treatment between January 2017 and December 2019 across 11 large TB units in Masaka district in central Uganda. Complete sputum smear monitoring was measured as the receipt of three sputum smear microscopy tests at 2, 5, and 6 months of TB treatment. The data were summarized descriptively and the differences in the outcome with independent variables were examined using tests of statistical significance, namely the Chi-square or Fisher’s exact test and the student’s t-test. The factors independently associated with the outcome were established using the modified Poisson regression analysis with robust standard errors, reported as adjusted risk ratio (aRR) along with the 95% confidence interval (CI). Results A total of 416 participants were enrolled, with a mean age of 37.3 ± 12.9 years. Of the participants, 290 (69.7) were males, 269 (64.7) were rural residents, and 128 (30.8%) had complete sputum smear monitoring. Urban residence (aRR, 1.45; 95% CI 1.12–1.90) and treatment under the community-based directly observed therapy short-course strategy (DOTS) (aRR, 1.91; 95% CI 1.25–2.92) were associated with a higher likelihood of complete sputum smear monitoring while TB and human immunodeficiency virus (TB/HIV) comorbidity (aRR 0.45, 95% CI 0.30–0.68) was associated with a lower likelihood of complete sputum smear monitoring. Conclusions We found a low magnitude of complete sputum smear monitoring among persons with bacteriologically confirmed pulmonary TB aged ≥ 15 years in central Uganda. Strategies to enhance the performance of sputum smear monitoring should target rural health facilities, strengthen TB/HIV collaboration and the implementation of community-based DOTS.
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Affiliation(s)
- Ronald Nsubuga
- Institute of Public Health and Management, Clarke International University, Kampala, Uganda
| | - Norbert Adrawa
- The AIDS Support Organization (TASO), Soroti Center of Clinical Excellence, Soroti, Uganda
| | - Stephen Okoboi
- Institute of Public Health and Management, Clarke International University, Kampala, Uganda.,Infectious Diseases Institute (IDI), Makerere University College of Health Sciences, Kampala, Uganda
| | - Alimah Komuhangi
- Institute of Public Health and Management, Clarke International University, Kampala, Uganda
| | - Jonathan Izudi
- Institute of Public Health and Management, Clarke International University, Kampala, Uganda. .,Infectious Diseases Institute (IDI), Makerere University College of Health Sciences, Kampala, Uganda. .,Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
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12
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Naidu T, Pillay SR, Ramlall S, Mthembu SS, Padayatchi N, Burns JK, Tomita A. Major Depression and Stigma among Individuals with Multidrug-Resistant Tuberculosis in South Africa. Am J Trop Med Hyg 2020; 103:1067-1071. [PMID: 32700662 DOI: 10.4269/ajtmh.19-0426] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Stigma is an important social determinant of health-seeking behavior; however, the nature and extent of its association with depression among people living with multidrug-resistant tuberculosis (MDR-TB) are not well-understood. We enrolled 200 microbiologically confirmed MDR-TB inpatients at a TB specialist hospital in KwaZulu-Natal Province, an area considered the epicenter for MDR-TB coinfection in South Africa. Four aspects of stigma and their association with major depression were assessed through individual interviews: 1) community and 2) patient perspectives toward TB, and 3) community and 4) patient perspectives toward HIV. A major depressive episode (MDE), HIV coinfection, and low income were significantly associated with greater stigma subscales. Based on an adjusted regression model, the MDE was the only factor independently associated with (all aspects of) stigma. These results indicate the potential utility of addressing stigma associated with the MDE as an important step in improving health-seeking behavior to promote adherence and retention in care.
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Affiliation(s)
- Thirusha Naidu
- Behavioural Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Suntosh R Pillay
- King DinuZulu Hospital, KwaZulu-Natal Department of Health, Durban, South Africa.,Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | - Suvira Ramlall
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nesri Padayatchi
- MRC HIV-TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Jonathan K Burns
- Institute of Health Research, University of Exeter, Exeter, United Kingdom.,Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa
| | - Andrew Tomita
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
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13
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Bresenham D, Kipp AM, Medina-Marino A. Quantification and correlates of tuberculosis stigma along the tuberculosis testing and treatment cascades in South Africa: a cross-sectional study. Infect Dis Poverty 2020; 9:145. [PMID: 33092636 PMCID: PMC7579945 DOI: 10.1186/s40249-020-00762-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/12/2020] [Indexed: 11/14/2022] Open
Abstract
Background South Africa has one of the world’s worst tuberculosis (TB) (520 per 100 000 population) and TB-human immunodeficiency virus (HIV) epidemics (~ 56% TB/HIV co-infected). While individual- and system-level factors influencing progression along the TB cascade have been identified, the impact of stigma is underexplored and underappreciated. We conducted an exploratory study to 1) describe differences in perceived community-level TB stigma among community members, TB presumptives, and TB patients, and 2) identify factors associated with TB stigma levels among these groups. Methods A cross sectional study was conducted in November 2017 at public health care facilities in Buffalo City Metro (BCM) and Zululand health districts, South Africa. Community members, TB presumptives, and TB patients were recruited. Data were collected on sociodemographic characteristics, TB knowledge, health and clinical history, social support, and both HIV and TB stigma. A validated scale assessing perceived community TB stigma was used. Univariate and multivariate linear regression models were used to describe differences in perceived community TB stigma by participant type and to identify factors associated with TB stigma. Results We enrolled 397 participants. On a scale of zero to 24, the mean stigma score for TB presumptives (14.7 ± 4.4) was statistically higher than community members (13.6 ± 4.8) and TB patients (13.3 ± 5.1). Community members from Zululand (β = 5.73; 95% CI 2.19, 9.72) had higher TB stigma compared to those from BCM. Previously having TB (β = − 2.19; 95% CI − 4.37, 0.0064) was associated with reduced TB stigma among community members. Understanding the relationship between HIV and TB disease (β = 2.48; 95% CI 0.020, 4.94), and having low social support (β = − 0.077; 95% CI − 0.14, 0.010) were associated with increased TB stigma among TB presumptives. Among TB Patients, identifying as Black African (β = − 2.90; 95% CI − 4.74, − 1.04) and knowing the correct causes of TB (β = − 2.93; 95% CI − 4.92, − 0.94) were associated with decreased TB stigma, while understanding the relationship between HIV and TB disease (β = 2.48; 95% CI 1.05, 3.90) and higher HIV stigma (β = 0.32; 95% CI 0.21, 0.42) were associated with increased TB stigma. Conclusions TB stigma interventions should be developed for TB presumptives, as stigma may increase initial-loss-to-follow up. Given that stigma may be driven by numerous factors throughout the TB cascade, adaptive stigma reduction interventions may be required.
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Affiliation(s)
- Dana Bresenham
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, South Africa
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, USA. .,Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Public Health, East Carolina University, 115 Heart Drive, Ste #2219, Greenville, NC, 27858-4353, USA.
| | - Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, 10 Rochester Rd, Vincent, East London, South Africa. .,Desmond Tutu HIV Centre, Men's Health Division, University of Cape Town, Cape Town, South Africa.
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14
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Daniels J, De Vos L, Mogos W, Olivier D, Shamu S, Mudau M, Klausner J, Medina-Marino A. Factors influencing sexually transmissible infection disclosure to male partners by HIV-positive pregnant women in Pretoria townships, South Africa: a qualitative study. Sex Health 2020; 16:274-281. [PMID: 31072453 DOI: 10.1071/sh18177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/19/2019] [Indexed: 11/23/2022]
Abstract
Background Sexually transmissible infections (STI) may increase the risk of mother-to-child transmission (MTCT) of HIV. However, diagnostic testing and targeted treatment of STI (STI-TT) during pregnancy is not standard care in South Africa. METHODS A qualitative study was nested in a STI-TT intervention to investigate motivating and enabling factors associated with STI test results disclosure to sexual partners. A semi-structured interview protocol covered partner communication, HIV and STI disclosure, financial security and relationships dynamics. Interviews were conducted in participants' preferred language, audio-recorded, transcribed into English and analysed using a constant comparison approach. The study was conducted in two townships in Pretoria, South Africa. RESULTS Twenty-eight HIV-positive pregnant women were interviewed. Based on the interviews, two disclosure experiences for women were identified - those with vulnerable experiences and those with self-enabling experiences within their partnerships. Vulnerable women discussed intimate partner violence (IPV) and fear of relationship dissolution as factors influencing their test result disclosure. Self-enabled women discussed their ability to talk with their partners about STI and HIV infections and the influence of multiple concurrent partnerships in the acquisition of HIV/STIs. Both groups of women were concerned about men's health behaviours, and all cited the health and development of their unborn child as a key motivator for test result disclosure. CONCLUSIONS Improved counselling and support for pregnant women to disclose their STI test results to their partners may improve the impact of STI diagnostic testing during pregnancy by improving partner treatment uptake and thus reducing the risk of re-infection.
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Affiliation(s)
- Joseph Daniels
- Charles Drew University, 1731 E. 120th Street, Los Angeles, CA 90059, USA; and Corresponding author.
| | - Lindsey De Vos
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Winta Mogos
- Program in Public Health, 653 E. Peltason Drive, University of California Irvine, Irvine, CA 92617, USA
| | - Dawie Olivier
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Simukai Shamu
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Maanda Mudau
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
| | - Jeffrey Klausner
- UCLA CARE Center, 1399 S. Roxbury Drive, Suite 100, Los Angeles, CA 90035, USA
| | - Andrew Medina-Marino
- Foundation for Professional Development, 173 Mary Road, Die Wilgers, Pretoria, 0184, South Africa
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Medina-Marino A, Glockner K, Grew E, De Vos L, Olivier D, Klausner J, Daniels J. The role of trust and health literacy in nurse-delivered point-of-care STI testing for pregnant women living with HIV, Tshwane District, South Africa. BMC Public Health 2020; 20:577. [PMID: 32345293 PMCID: PMC7189538 DOI: 10.1186/s12889-020-08689-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/13/2020] [Indexed: 01/28/2023] Open
Abstract
Background Sexually transmitted infections (STIs) during pregnancy result in neonatal morbidity and mortality, and may increase mother-to-child-transmission of HIV. Yet the World Health Organization’s current syndromic management guidelines for STIs leaves most pregnant women undiagnosed and untreated. Point-of-care (POC) diagnostic tests for STIs can drastically improve detection and treatment. Though acceptable and feasible, poor medication adherence and re-infection due to lack of partner treatment threaten the programmatic effectiveness of POC diagnostic programmes. Methods To engender patient-provider trust, and improve medication adherence and disclosure of STI status to sexual partners, we trained study nurses in compassionate care, good clinical practices and motivational interviewing. Using qualitative methods, we explored the role patient-provider communications may play in supporting treatment adherence and STI disclosure to sexual partners. Nurses were provided training in motivational interviewing, compassionate care and good clinical practices. Participants were interviewed using a semi-structured protocol, with domains including STI testing experience, patient-provider communication, and HIV and STI disclosure. Interviews were audio-recorded, transcribed and analyzed using a constant comparison approach. Results Twenty-eight participants treated for Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), and/or Neisseria gonorrhea (NG) were interviewed. Participants described strong communications and trusting relationships with nurses trained in patient-centered care training and implementing POC STI diagnostic testing. However, women described a delayed trust in treatment until their symptoms resolved. Women expressed a limited recall of their exact diagnosis, which impacted their ability to fully disclose their STI status to sexual partners. Conclusions We recommend implementing patient health literacy programmes as part of POC services to support women in remembering and disclosing their specific STI diagnosis to sexual partners, which may facilitate partner treatment uptake and thus decrease the risk of re-infection.
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Affiliation(s)
- Andrew Medina-Marino
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa. .,The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.
| | - Katherine Glockner
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa.,Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Emily Grew
- Northeastern University, Boston, MA, USA
| | - Lindsey De Vos
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa
| | - Dawie Olivier
- Fundation for Professional Development, 10 Rochester Road, East London, 5217, South Africa
| | - Jeffrey Klausner
- David Geffen School of Medicine and Fielding School of Public Health, UCLA, Los Angeles, CA, USA
| | - Joseph Daniels
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
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Wouters E, Sommerland N, Masquillier C, Rau A, Engelbrecht M, Van Rensburg AJ, Kigozi G, Ponnet K, Van Damme W. Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers. BMC Infect Dis 2020; 20:106. [PMID: 32028895 PMCID: PMC7006097 DOI: 10.1186/s12879-020-4816-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma. METHODS Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group. RESULTS The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy. CONCLUSIONS This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences. TRIAL REGISTRATION South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.
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Affiliation(s)
- Edwin Wouters
- Department of Sociology and Centre for Population, Family and Health, University of Antwerp, Sint-Jacobstraat 2, BE-2000, Antwerp, Belgium.
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, Republic of South Africa.
| | - Nina Sommerland
- Department of Sociology and Centre for Population, Family and Health, University of Antwerp, Sint-Jacobstraat 2, BE-2000, Antwerp, Belgium
| | - Caroline Masquillier
- Department of Sociology and Centre for Population, Family and Health, University of Antwerp, Sint-Jacobstraat 2, BE-2000, Antwerp, Belgium
| | - Asta Rau
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, Republic of South Africa
| | - Michelle Engelbrecht
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, Republic of South Africa
| | | | - Gladys Kigozi
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, Republic of South Africa
| | - Koen Ponnet
- Department of Communication Sciences, Media, Innovation and Communication Technologies, Ghent University, Ghent, Belgium
| | - Wim Van Damme
- International Health Policy, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Time Interval for Diagnosis of Tuberculosis and Related Expenditure in Selected Health Centers in Addis Ababa, Ethiopia. ADVANCES IN PUBLIC HEALTH 2019. [DOI: 10.1155/2019/4705139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. Tuberculosis (TB) has continued to be a major health problem globally, in spite of the efforts to improve the diagnosis, treatment, and prevention. It affects millions of people each year and stands as the second cause of death due to infectious disease in the world. Early case finding and timely initiation of treatment is essential to ensure effective control of the disease as late diagnosis and treatment can aggravate the disease and result in poor outcomes and increase chances of transmission. Although TB services are supposed to be provided free of charge, TB affected families incur different types of costs in the process of seeking care, which might include health and nonhealth related costs. TB programs need to identify the underlying factors for delay and related expenditure for TB related services, in order to devise an effective strategy to reduce them. Therefore, the study aimed to assess the time interval between developing TB symptom until patients start anti-TB treatment and associated cost incurred by patients and families. Methods. This cross-sectional study was conducted among pulmonary TB patients who are bacteriologically confirmed, whose age is above 15 years and diagnosed at health centres in Addis Ababa. Results. The median time interval between onset of symptom and commencement of treatment was 4 weeks (IQR: 3, 6). Most patients with TB symptoms visited several health facilities before the final diagnosis was confirmed, the median number of visits being two, and only 48.8% were diagnosed on their first visit. Hence, they spent a lot of their limited resource in search of getting the right diagnosis. The total combined expenditure for all the visits was estimated to be median (IQR) 172.65 birrs (12, 671). Two variables were found to show statistically significant association with higher expenditure. Respondents who have good level of knowledge about TB are less likely to spend more than the median expenditure almost by a fifth compared to those with limited knowledge on TB, (adjusted odds ratio (AOR) = 0.2, with 95% confidence interval (CI): 0.06, 0.84). Patients who visited public hospitals were almost three times and those who visited private health facilities almost four times more likely to pay more than the median total expenditure, compared to those who visited health centre, AOR (95% CI) = 2.8 (1.53, 5.19) and AOR (CI) of 3.86 (1.06, 14.03), respectively. Conclusion. Patients with TB symptoms visit several health facilities till they are diagnosed, the median duration from onset of symptom till commencement of TB treatment being 4 weeks. It was noted that they face major expenses in the process of navigation to the right care. Two variables had statistically significant association with high pre-diagnosis expenditure, where patients with good level of knowledge about TB are less likely to spend more than the median, while patients who visited public hospitals or private health facilities had very high expenses. Improved public awareness about TB, minimizing service charges and other related fees, and further improvement in increasing access to services could reduce the length of time and expense for TB patients and their families. It is recommended to build capacity of health service providers to update them on programmatic approaches and latest diagnostic algorithm. It is important to strengthen public private partnership for TB services.
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Datiko DG, Habte D, Jerene D, Suarez P. Knowledge, attitudes, and practices related to TB among the general population of Ethiopia: Findings from a national cross-sectional survey. PLoS One 2019; 14:e0224196. [PMID: 31658300 PMCID: PMC6816561 DOI: 10.1371/journal.pone.0224196] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 10/08/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Ethiopia is among the high-burden countries for tuberculosis (TB), TB/HIV, and drug-resistant TB. The aim of this nationwide study was to better understand TB-related knowledge, attitudes, and practices (KAPs) and generate evidence for policy and decision-making. MATERIALS AND METHODS We conducted a cross-sectional TB KAP survey in seven regions and two city administrations of Ethiopia. Eighty kebeles (wards) and 40 health centers were randomly selected for the study. Using systematic sampling, 22 households and 11 TB patients were enrolled from each selected village and health center, respectively. Variables with a value of p = < 0.25 were included in the model for logistic regression analysis. RESULTS Of 3,503 participants, 884 (24.4%), 836 (24.1%), and 1,783 (51.5%) were TB patients, families of TB patients, and the general population, respectively. The mean age was 34.3 years, and 50% were women. Forty-six percent were heads of households, 32.1% were illiterate, 20.3% were farmers, and 19.8% were from the lowest quintile. The majority (95.5%) had heard about TB, but only 25.8% knew that TB is caused by bacteria. Cough or sneezing was reported as the commonest means of TB transmission. The majority (85.3%) knew that TB could be cured. Men, better-educated people, and TB patients and their families have higher knowledge scores. Of 2,483 participants, 96% reported that they would go to public health facilities if they developed TB symptoms. DISCUSSION Most Ethiopians have a high level of awareness about TB and seek care in public health facilities, and communities are generally supportive. Inadequate knowledge about TB transmission, limited engagement of community health workers, and low preference for using community health workers were the key challenges. CONCLUSIONS Given misconceptions about TB's causes, low preference for use of community health workers, and inadequate engagement, targeted health education interventions are required to improve TB services.
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Affiliation(s)
- Daniel G Datiko
- Challenge TB and Management Sciences for Health, Addis Ababa, Ethiopia
| | - Dereje Habte
- Challenge TB and Management Sciences for Health, Addis Ababa, Ethiopia
| | - Degu Jerene
- Challenge TB and Management Sciences for Health, Addis Ababa, Ethiopia
| | - Pedro Suarez
- Management Sciences for Health, Infectious Diseases Cluster, Arlington, Virginia, United States of America
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Mahasha PW, Ndwandwe DE, Mavundza EJ, Shey M, Wiysonge CS. Systematic review protocol on Bacillus Calmette-Guerin (BCG) revaccination and protection against tuberculosis. BMJ Open 2019; 9:e027033. [PMID: 31619416 PMCID: PMC6797475 DOI: 10.1136/bmjopen-2018-027033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 09/04/2019] [Accepted: 09/17/2019] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis (M.TB) and other species of the Mycobacterium tuberculosis complex. Globally, TB is ranked as the ninth leading cause of death and the leading cause of death from a single infectious agent. The bacille Calmette-Guerin (BCG) vaccine has been used globally since 1921 for the prevention of TB in humans, and was derived from an attenuated strain of Mycobacterium bovis. Evidence from previous randomised trials show that the efficacy of primary BCG vaccination against pulmonary TB ranged from no protection to very high protection. In addition, some studies suggest a benefit of BCG revaccination. For example, a recent trial conducted in South Africa showed that BCG revaccination of adolescents could reduce the risk of TB infection by half. However, we are not aware of any recent systematic reviews of the effects of BCG revaccination. Thus, the need for this systematic review of the effects of BCG revaccination on protection against TB infection and disease. METHOD AND ANALYSIS We will search PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, WHO International Clinical Trials Registry Platform and reference lists of relevant publications for potentially eligible studies. We will screen search outputs, select eligible studies, extract data and assess risk of bias in duplicate. Discrepancies will be resolved by discussion and consensus or arbitration. We will use the Grading of Recommendations Assessment, Development and Evaluation method to assess the certainty of the evidence. The planned systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) in August 2018. ETHICS AND DISSEMINATION Publicly available data will be used, hence no formal ethical approval will be required for this review. The findings of the review will be disseminated through conference presentations and publication in an open-access peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018105916.
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Affiliation(s)
| | | | | | - Muki Shey
- Wellcome Centre for Infectious Disease Research in Africa (CIDRI-Africa) & Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Charles Shey Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Asres A, Jerene D, Deressa W. Delays to anti-tuberculosis treatment intiation among cases on directly observed treatment short course in districts of southwestern Ethiopia: a cross sectional study. BMC Infect Dis 2019; 19:481. [PMID: 31142288 PMCID: PMC6542087 DOI: 10.1186/s12879-019-4089-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 05/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed tuberculosis (TB) diagnosis and treatment increase morbidity, mortality, expenditure, and transmission in the community. This study assessed patient and provider related delays to diagnosis and treatment of TB. METHODS A cross-sectional study was conducted among 735 new adult TB cases registered between January to December 2015 in 10 woredas equivalent to districts of southwestern Ethiopia. Data were collected through face-to-face interview of patients within the first 2 months of treatment initiation. Delay in days was tracked at three intervals: between onset of symptoms and self-presentation (Patient delay), Self-presentation to treatment initiation (Provider delay) and total delay. Days elapsed beyond median were used to define the delays. Bivariate and multiple logistic regression models were fit to identify predictors of delays and statistical significance was judged at p < 0.05. RESULT The median (inter-quartile range) of patient, provider and total delays were 25 (IQR;15-36), 22 (IQR:9-48) and 55 (IQR:32-100) days, respectively. More than half (54.6%) of the total delay was attributed to health system. Prior self-treatment [adjusted Odds Ratio (aOR)]: 1.72, 95% confidence interval [CI]:1.07-2.75), HIV co-infection (aOR:1.8, 95% CI: 1.05-3.10) and extra-pulmonary TB (aOR: 1.54,95% CI:1.03-2.29) were independently associated with increased odds of patient delay. On the other hand initial presentation to health posts or private clinics (aOR: 1.42, 95% CI: 1.01, 2.0) and patient delay (aOR: 1.81, 95% CI: 1.33-2.50) significantly predicted longer provider delay. Finally, having extra pulmonary TB (aOR: 1.6, 95% CI: 1.07-2.38), prior consultation of traditional healer (aOR: 3.72, 95% CI: 1.01-13.77) and use of holy water (aOR: 2.73, 95% CI: 1.11, 6.70) independently predicted longer total delay. CONCLUSION Tuberculosis patients waited too long time to initiate anti-TB treatment reflecting longer periods of morbidity and disease transmission. The delays are attributed to the patient, disease and health system related factors. Hence, improving community awareness, involving informal providers, health extension workers and TB treatment supporters can reduce the patient delay. Similarly, cough screening and improving diagnostic efficiencies of healthcare facilities should be in place to reduce the provider delays.
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Affiliation(s)
- Abyot Asres
- Department of Public Health, College of Health Sciences, Mizan Tepi University, Mizan Aman, Ethiopia. .,Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Degu Jerene
- Management Science for Health, Addis Ababa, Ethiopia
| | - Wakgari Deressa
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Abstract
BACKGROUND Tuberculosis causes more deaths than any other infectious disease globally. Bacillus Calmette-Guérin (BCG) is the only available vaccine, but protection is incomplete and variable. The modified Vaccinia Ankara virus expressing antigen 85A (MVA85A) is a viral vector vaccine produced to prevent tuberculosis. OBJECTIVES To assess and summarize the effects of the MVA85A vaccine boosting BCG in humans. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (Ovid); and four other databases. We searched the WHO ICTRP and ClinicalTrials.gov. All searches were run up to 10 May 2018. SELECTION CRITERIA We evaluated randomized controlled trials of MVA85A vaccine given with BCG in people regardless of age or HIV status. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility and risk of bias of trials, and extracted and analyzed data. The primary outcome was active tuberculosis disease. We summarized dichotomous outcomes using risk ratios (RR) and risk differences (RD), with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses. Where meta-analysis was inappropriate, we summarized results narratively. MAIN RESULTS The search identified six studies relating to four Phase 2 randomized controlled trials enrolling 3838 participants. Funding was by government bodies, charities, and philanthropic donors. Five studies included infants, one of them infants born to HIV-positive mothers. One study included adults living with HIV. All trials included authors from Oxford University who led the laboratory development of the vaccine. Participants received intradermal MVA85A after BCG in some studies, and before selective deferred BCG in HIV-exposed infants.The largest trial in 2797 African children was well conducted with low risk of bias for most parameters. Risk of bias was uncertain for selective reporting because there were no precise case definition endpoints for active tuberculosis published prior to the trial analysis.MVA85A added to BCG compared to BCG alone probably has no effect on the risk of developing microbiologically confirmed tuberculosis (RR 0.97, 95% CI 0.58 to 1.62; 3439 participants, 2 trials; moderate-certainty evidence), or the risk of starting on tuberculosis treatment (RR 1.10, 95% CI 0.92 to 1.33; 3687 participants, 3 trials; moderate-certainty evidence). MVA85A probably has no effect on the risk of developing latent tuberculosis (RR 1.01, 95% CI 0.85 to 1.21; 3831 participants, 4 trials; moderate-certainty evidence). Vaccinating people with MVA85A in addition to BCG did not cause life-threatening serious adverse effects (RD 0.00, 95% CI -0.00 to 0.00; 3692 participants, 3 trials; high-certainty evidence). Vaccination with MVA85A is probably associated with an increased risk of local skin adverse effects (3187 participants, 3 trials; moderate-certainty evidence), but not systemic adverse effect related to vaccination (144 participants, 1 trial; low-certainty evidence). This safety profile is consistent with Phase 1 studies which outlined a transient, superficial reaction local to the injection site and mild short-lived symptoms such as malaise and fever. AUTHORS' CONCLUSIONS MVA85A delivered by intradermal injection in addition to BCG is safe but not effective in reducing the risk of developing tuberculosis.
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Affiliation(s)
| | - Sophie Jullien
- Jigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | - Samuel Johnson
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
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TOMITA A, VANDORMAEL A, BÄRNIGHAUSEN T, PHILLIPS A, PILLAY D, DE OLIVEIRA T, TANSER F. Sociobehavioral and community predictors of unsuppressed HIV viral load: multilevel results from a hyperendemic rural South African population. AIDS 2019; 33:559-569. [PMID: 30702520 PMCID: PMC6547375 DOI: 10.1097/qad.0000000000002100] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extensive antiretroviral therapy scale-up is expected to prevent onward transmission of HIV by reducing the overall community viral load. Despite multiple studies about predictors of detectable viral load derived from clinical setting, to date, no study has established such predictors using a population-based viral load survey in a sub-Saharan African hyperendemic setting to inform interventions designed to halt HIV transmission. We used one of Africa's largest prospective cohorts in rural KwaZulu-Natal Province, South Africa, to establish the key sociodemographic, behavioral and community predictors of unsuppressed viral load at the population level. METHODS We collected 5454 viral load measurements from a population-based viral load survey of 3892 women living with HIV from a rural population during 2011, 2013 and 2014. Multilevel logistic regression models were fitted to examine the risk predictors of unsuppressed viral load. RESULTS Among women living with HIV in this population, the prevalence of unsuppressed viral load was 69% in 2011, 58% in 2013 and 53% in 2014. Although time since HIV infection was associated with lower risk for virologic detection [adjusted odds ratio (aOR) = 0.91,0.87-0.94], young women (aOR = 2.59,1.47-4.55) with extensive external migration history (aOR = 1.25,1.02-1.54), greater number of sexual partners (aOR = 1.30,1.02-1.67), and longer history of residing in an HIV incidence hotspot community were more likely to experience unsuppressed viral load (aOR = 1.12,1.06-1.19). CONCLUSION Young women, number of sexual partners, transiency and longer residence in an HIV hotspot community are important determinants of unsuppressed viral load in a hyperendemic rural African setting. To substantially reduce the persistently high transmission potential in these settings, targeted interventions to address these risk factors will be essential for both individual and population health gains.
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Affiliation(s)
- Andrew TOMITA
- Africa Health Research Institute, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing (KRISP), Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Alain VANDORMAEL
- Africa Health Research Institute, Durban, South Africa
- KwaZulu-Natal Research Innovation and Sequencing (KRISP), Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Till BÄRNIGHAUSEN
- Africa Health Research Institute, Durban, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
- Heidelberg Institute for Public Health, University of Heidelberg, Heidelberg, Germany
| | - Andrew PHILLIPS
- Institute for Global Health, University College London, London, UK
| | - Deenan PILLAY
- Africa Health Research Institute, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Tulio DE OLIVEIRA
- KwaZulu-Natal Research Innovation and Sequencing (KRISP), Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Frank TANSER
- Africa Health Research Institute, Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection & Population Health, University College London, London, UK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
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Fuady A, Houweling TAJ, Mansyur M, Burhan E, Richardus JH. Effect of financial support on reducing the incidence of catastrophic costs among tuberculosis-affected households in Indonesia: eight simulated scenarios. Infect Dis Poverty 2019; 8:10. [PMID: 30709415 PMCID: PMC6359783 DOI: 10.1186/s40249-019-0519-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/13/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The World Health Organization's End Tuberculosis Strategy states that no tuberculosis (TB)-affected households should endure catastrophic costs due to TB. To achieve this target, it is essential to provide adequate social protection. As only a few studies in many countries have evaluated social-protection programs to determine whether the target is being reached, we assessed the effect of financial support on reducing the incidence of catastrophic costs due to TB in Indonesia. METHODS From July to September 2016, we interviewed adult patients receiving treatment for TB in 19 primary health centres in urban, sub-urban and rural area of Indonesia, and those receiving multidrug-resistant (MDR) TB treatment in an Indonesian national referral hospital. Based on the needs assessment, we developed eight scenarios for financial support. We assessed the effect of each simulated scenario by measuring reductions in the incidence of catastrophic costs. RESULTS We analysed data of 282 TB and 64 MDR-TB patients. The incidences of catastrophic costs in affected households were 36 and 83%, respectively. Patients' primary needs for social protection were financial support to cover costs related to income loss, transportation, and food supplements. The optimum scenario, in which financial support would be provided for these three items, would reduce the respective incidences of catastrophic costs in TB and MDR-TB-affected households to 11 and 23%. The patients experiencing catastrophic costs in this scenario would, however, have to pay high remaining costs (median of USD 910; [interquartile range (IQR) 662] in the TB group, and USD 2613; [IQR 3442] in the MDR-TB group). CONCLUSIONS Indonesia's current level of social protection is not sufficient to mitigate the socioeconomic impact of TB. Financial support for income loss, transportation costs, and food-supplement costs will substantially reduce the incidence of catastrophic costs, but financial support alone will not be sufficient to achieve the target of 0% TB-affected households facing catastrophic costs. This would require innovative social-protection policies and higher levels of domestic and external funding.
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Affiliation(s)
- Ahmad Fuady
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands. .,Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
| | - Tanja A J Houweling
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
| | - Muchtaruddin Mansyur
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Erlina Burhan
- Department of Respiratory and Pulmonology, Persahabatan Hospital - Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 2040, 3000CA, Rotterdam, the Netherlands
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Masuku B, Mkhwanazi N, Young E, Koch A, Warner D. Beyond the lab: Eh!woza and knowing tuberculosis. MEDICAL HUMANITIES 2018; 44:285-292. [PMID: 30482821 PMCID: PMC6288688 DOI: 10.1136/medhum-2018-011479] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2018] [Indexed: 05/08/2023]
Abstract
Eh!woza is a public engagement initiative that explores the biomedical and social aspects of tuberculosis (TB) in South Africa. The project is a collaboration between scientists based in an infectious disease research institute, a local conceptual/visual artist, a youth-based educational non-governmental organization (NGO) and young learners from a high-burden TB community. The learners participate in a series of interactive science and media production workshops: initially presented with biomedical knowledge about TB and, in later sessions, are trained in creating documentary films and engage with ideas around visual representation. The participants are encouraged to make use of this newly acquired knowledge to tell stories from their chosen communities in Khayelitsha, a township in Cape Town. Through its engagement with the complex manner in which TB is experienced, framed and understood by biomedical scientists, young people, and those who have been affected by the disease, Eh!woza presents alternative ways of exploring the complexities of human illness. The integration and interrogation of biomedical understandings, lay narratives and the young participants' framing of the disease poses questions about 'knowing', and the meanings people attribute to ways of 'knowing' and the actions they impel. The project also presents contrasting reflections on cure-from a biomedical perspective, and care-from the perspective of TB-affected young people and community members. In this article, we describe the Eh!woza project, present thoughts from the participating students on the science and media workshops, and detail the narratives of ill-health and disease from people within their neighbourhoods. We conclude with a critical analysis of the complexities of knowledge communication, notions of cure versus care, and a consideration of the potential contribution of this project to the growth of medical humanities in Africa.
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Affiliation(s)
- Bianca Masuku
- SAMRC/NHLS/UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nolwazi Mkhwanazi
- Wits Institute for Social and Economic Research (WiSER), University of the Witwatersrand, Johannesburg, South Africa
| | - Ed Young
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Anastasia Koch
- SAMRC/NHLS/UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Digby Warner
- SAMRC/NHLS/UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
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Integrating HIV care and treatment into tuberculosis clinics in Lusaka, Zambia: results from a before-after quasi-experimental study. BMC Infect Dis 2018; 18:536. [PMID: 30367622 PMCID: PMC6204013 DOI: 10.1186/s12879-018-3392-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 09/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with HIV-associated tuberculosis (TB) often have their TB and HIV managed in separate vertical programs that offer care for each disease with little coordination. Such "siloed" approaches are associated with diagnostic and treatment delays, which contribute to unnecessary morbidity and mortality. To improve TB/HIV care coordination and early ART initiation, we integrated HIV care and treatment into two busy TB clinics in Zambia. We report here the effects of our intervention on outcomes of linkage to HIV care, early ART uptake, and TB treatment success for patients with HIV-associated TB in Lusaka, Zambia. METHODS We provided integrated HIV treatment and care using a "one-stop shop" model intervention. All new or relapse HIV-positive TB patients were offered immediate HIV program enrolment and ART within 8 weeks of anti-TB therapy (ATT) initiation. We used a quasi-experimental design, review of routine program data, and survival analysis and logistic regression methods to estimate study outcomes before (June 1, 2010-January 31, 2011) and after (August 1, 2011-March 31, 2012) our intervention among 473 patients with HIV-associated TB categorized into pre- (n = 248) and post-intervention (n = 225) cohorts. RESULTS Patients in the pre- and post-intervention cohorts were mostly male (60.1% and 52.9%, respectively) and young (median age: 33 years). In time-to-event analyses, a significantly higher proportion of patients in the post-intervention cohort linked to HIV care by 4 weeks post-ATT initiation (53.9% vs. 43.4%, p = 0.03), with median time to care linkage being 59 and 25 days in the pre- and post-intervention cohorts, respectively. In Cox proportional hazard modelling, patients receiving the integration intervention started ART by 8 weeks post-ATT at 1.33 times the rate (HR = 1.33, 95% CI: 1.00-1.77) as patients pre-intervention. In logistic regression modelling, patients receiving the intervention were 2.02 times (95% CI: 1.11-3.67) as likely to have a successful TB treatment outcome as patients not receiving the intervention. CONCLUSIONS Integrating HIV treatment and care services into routine TB clinics using a one-stop shop model increased linkage to HIV care, rates of early ART initiation, and TB treatment success among patients with HIV-associated TB in Lusaka, Zambia.
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Cohen DB, Phiri M, Banda H, Squire SB, Namakhoma I, Desmond N. A qualitative evaluation of hospital versus community-based management of patients on injectable treatments for tuberculosis. BMC Public Health 2018; 18:1127. [PMID: 30223808 PMCID: PMC6142700 DOI: 10.1186/s12889-018-6015-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 09/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients being treated for recurrent or multidrug-resistant tuberculosis (TB) require long courses of injectable anti-tuberculous agents. In order to maintain strong TB control programmes, it is vital that the experiences of people who receive long-term injectables for TB are well understood. To investigate the feasibility of a novel model of care delivery, a clinical trial (The TB-RROC Study) was conducted at two central hospitals in Malawi. Hospital-based care was compared to a community-based approach for patients on TB retreatment in which 'guardians' (patient-nominated lay people) were trained to deliver injections to patients at home. This study is the qualitative evaluation of the TB-RROC trial. It examines the experiences of people receiving injectables as part of TB treatment delivered in hospital and community-based settings. METHODS A qualitative evaluation of the TB-RROC intervention was conducted using phenomenographic methods. Trial participants were purposively sampled, and in-depth interviews were conducted with patients and guardians in both arms of the trial. Key informant interviews and observations in the wards and community were performed. Thematic content analysis was used to derive analytical themes. RESULTS Fourteen patients, 12 guardians and 9 key informants were interviewed. Three key themes relating to TB retreatment emerged: medical experiences (including symptoms, treatment, and HIV); the effects of the physical environment (conditions on the ward, disruption to daily routines and livelihoods); and trust (in other people, the community and in the health system). Experiences were affected by the nature of a person's prior role in their community and resulted in a range of emotional responses. Patients and guardians in the community benefited from better environment, social interactions and financial stability. Concerns were expressed about the potential for patients' health or relationships to be adversely affected in the community. These potential concerns were rarely realised. CONCLUSIONS Guardian administered intramuscular injections were safe and well received. Community-based care offered many advantages over hospital-based care for patients receiving long-term injectable treatment for TB and their families.
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Affiliation(s)
- D. B. Cohen
- Malawi Liverpool Wellcome Clinical Research Programme, Box 30096, Blantyre 3, Malawi
- Liverpool School of Tropical Medicine, Pembrooke Place, Liverpool, L3 5PH UK
- University of Sheffield, Medical School, Beech Hill Road, Sheffield, S10 2RX UK
| | - M. Phiri
- Malawi Liverpool Wellcome Clinical Research Programme, Box 30096, Blantyre 3, Malawi
| | - H. Banda
- REACH Trust, Box 1597, Lilongwe, Malawi
| | - S. B. Squire
- Liverpool School of Tropical Medicine, Pembrooke Place, Liverpool, L3 5PH UK
| | | | - N. Desmond
- Malawi Liverpool Wellcome Clinical Research Programme, Box 30096, Blantyre 3, Malawi
- Liverpool School of Tropical Medicine, Pembrooke Place, Liverpool, L3 5PH UK
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Kashangura R, Jullien S, Garner P, Young T, Johnson S. MVA85A vaccine to enhance BCG for preventing tuberculosis. Hippokratia 2018. [DOI: 10.1002/14651858.cd012915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Sophie Jullien
- Jigme Dorji Wangchuck National Referral Hospital; Thimphu Bhutan
| | - Paul Garner
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Pembroke Place Liverpool Merseyside UK L3 5QA
| | - Taryn Young
- Stellenbosch University; Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences; PO Box 241 Cape Town South Africa 8000
- South African Medical Research Council; Cochrane South Africa; PO Box 19070 Tygerberg Cape Town South Africa 7505
| | - Samuel Johnson
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Pembroke Place Liverpool Merseyside UK L3 5QA
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Biru M, Lunqvist P, Molla M, Jerene D, Hallström I. Hope for the Future But Fear the Risk of Stigma: Ethiopian Family Caregivers' Lived Experience of Caring for Their HIV Positive Child Two Years After Starting Antiretroviral Treatment. Compr Child Adolesc Nurs 2017; 41:293-309. [PMID: 29220598 DOI: 10.1080/24694193.2017.1372531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Family caregivers are believed to be the primary source of support for HIV-affected children. There is limited evidence about practices of support for caregivers, to strengthen them and to enhance the welfare of HIV positive children, especially in African settings. Our aim was therefore to illuminate caregivers' lived experiences of caring for a child in Ethiopia 2 years after the child was enrolled in antiretroviral therapy. Qualitative interviews with 18 family caregivers of 18 children were performed and analyzed using an inductive design with a hermeneutic phenomenological approach. The family caregivers' lived experience was shown in two main themes comprising "lifelong medication gives hope for the future" and "support challenged by the fear of stigma." The family caregivers experienced hope and dreams for the future as they saw their child as healthy and they had regained normality in life after the child's diagnosis. The caregivers still feared the disclosure of the child's diagnosis, which gave rise to conflicts with the child, the family, and society. Good quality support from the healthcare staff lightened their burdens. Further studies are recommended on the strategies of stigma reduction and developing need-specific modalities to support caregivers in the community.
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Affiliation(s)
- Mulatu Biru
- a Department of Health Sciences, Faculty of Medicine , Lund University , Lund , Sweden
| | - Pia Lunqvist
- a Department of Health Sciences, Faculty of Medicine , Lund University , Lund , Sweden
| | - Mitikie Molla
- b School of Public Health , Addis Ababa University , Addis Ababa , Ethiopia
| | - Degu Jerene
- c Management Sciences for Health , Addis Ababa , Ethiopia
| | - Inger Hallström
- a Department of Health Sciences, Faculty of Medicine , Lund University , Lund , Sweden
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Bukachi SA, Wandibba S, Nyamongo IK. The socio-economic burden of human African trypanosomiasis and the coping strategies of households in the South Western Kenya foci. PLoS Negl Trop Dis 2017; 11:e0006002. [PMID: 29073144 PMCID: PMC5675461 DOI: 10.1371/journal.pntd.0006002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 11/07/2017] [Accepted: 09/30/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction Human African Trypanosomiasis (HAT), a disease caused by protozoan parasites transmitted by tsetse flies, is an important neglected tropical disease endemic in remote regions of sub-Saharan Africa. Although the determination of the burden of HAT has been based on incidence, mortality and morbidity rates, the true burden of HAT goes beyond these metrics. This study sought to establish the socio-economic burden that households with HAT faced and the coping strategies they employed to deal with the increased burden. Materials and methods A mixed methods approach was used and data were obtained through: review of hospital records; structured interviews (152); key informant interviews (11); case narratives (12) and focus group discussions (15) with participants drawn from sleeping sickness patients in the south western HAT foci in Kenya. Quantitative data were analysed using descriptive statistics while qualitative data was analysed based on emerging themes. Results Socio-economic impacts included, disruption of daily activities, food insecurity, neglect of homestead, poor academic performance/school drop-outs and death. Delayed diagnosis of HAT caused 93% of the affected households to experience an increase in financial expenditure (ranging from US$ 60–170) in seeking treatment. Out of these, 81.5% experienced difficulties in raising money for treatment resorting to various ways of raising it. The coping strategies employed to deal with the increased financial expenditure included: sale of agricultural produce (64%); seeking assistance from family and friends (54%); sale/lease of family assets (22%); seeking credit (22%) and use of personal savings (17%). Conclusion and recommendation Coping strategies outlined in this study impacted negatively on the affected households leading to further food insecurity and impoverishment. Calculation of the true burden of disease needs to go beyond incidence, mortality and morbidity rates to capture socio-economic variables entailed in seeking treatment and coping strategies of HAT affected households. Sleeping sickness affects people often living in remote rural areas and those who mainly depend on subsistence agriculture. We carried out a study among former sleeping sickness patients in Kenya to find out the socio-economic challenges they faced in seeking treatment and the coping strategies they used to deal with them. This is important because the socio-economic effects of sleeping sickness and its coping strategies have not been adequately researched on yet it is on the strength of these impacts that policies and control programmes are formulated. If the real burden of sleeping sickness is not known, then it will continue to be neglected in terms of the attention it receives world-wide. Sleeping sickness patients and their households spent a lot of money seeking treatment besides facing challenges of disruption of daily activities, food insecurity, neglect of homesteads, poor academic performance/school drop-outs and death. Majority of them faced difficulties in raising the money required for seeking treatment hence resorted to various coping strategies. These negatively impacted on them and their households, already living on less than a dollar per day. There is need to pay attention to these effects of sleeping sickness in establishing the real burden of the disease.
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Affiliation(s)
- Salome A. Bukachi
- Institute of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya
- * E-mail:
| | - Simiyu Wandibba
- Institute of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya
| | - Isaac K. Nyamongo
- Institute of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya
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Kapwata T, Morris N, Campbell A, Mthiyane T, Mpangase P, Nelson KN, Allana S, Brust JCM, Moodley P, Mlisana K, Gandhi NR, Shah NS. Spatial distribution of extensively drug-resistant tuberculosis (XDR TB) patients in KwaZulu-Natal, South Africa. PLoS One 2017; 12:e0181797. [PMID: 29028800 PMCID: PMC5640212 DOI: 10.1371/journal.pone.0181797] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/09/2017] [Indexed: 11/18/2022] Open
Abstract
Background KwaZulu-Natal province, South Africa, has among the highest burden of XDR TB worldwide with the majority of cases occurring due to transmission. Poor access to health facilities can be a barrier to timely diagnosis and treatment of TB, which can contribute to ongoing transmission. We sought to determine the geographic distribution of XDR TB patients and proximity to health facilities in KwaZulu-Natal. Methods We recruited adults and children with XDR TB diagnosed in KwaZulu-Natal. We calculated distance and time from participants’ home to the closest hospital or clinic, as well as to the actual facility that diagnosed XDR TB, using tools within ArcGIS Network analyst. Speed of travel was assigned to road classes based on Department of Transport regulations. Results were compared to guidelines for the provision of social facilities in South Africa: 5km to a clinic and 30km to a hospital. Results During 2011–2014, 1027 new XDR TB cases were diagnosed throughout all 11 districts of KwaZulu-Natal, of whom 404 (39%) were enrolled and had geospatial data collected. Participants would have had to travel a mean distance of 2.9 km (CI 95%: 1.8–4.1) to the nearest clinic and 17.6 km (CI 95%: 11.4–23.8) to the nearest hospital. Actual distances that participants travelled to the health facility that diagnosed XDR TB ranged from <10 km (n = 143, 36%) to >50 km (n = 109, 27%), with a mean of 69 km. The majority (77%) of participants travelled farther than the recommended distance to a clinic (5 km) and 39% travelled farther than the recommended distance to a hospital (30 km). Nearly half (46%) of participants were diagnosed at a health facility in eThekwini district, of whom, 36% resided outside the Durban metropolitan area. Conclusions XDR TB cases are widely distributed throughout KwaZulu-Natal province with a denser focus in eThekwini district. Patients travelled long distances to the health facility where they were diagnosed with XDR TB, suggesting a potential role for migration or transportation in the XDR TB epidemic.
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Affiliation(s)
- Thandi Kapwata
- Environment and Health Research Unit, South African Medical Research Council, Johannesburg, South Africa
| | - Natashia Morris
- Biostatistics Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa
| | - Angela Campbell
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Thuli Mthiyane
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Primrose Mpangase
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Kristin N. Nelson
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Salim Allana
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - James C. M. Brust
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States of America
| | - Pravi Moodley
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Koleka Mlisana
- Departments of Medical Microbiology and Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Neel R. Gandhi
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Division of Infectious Diseases, Emory School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
| | - N. Sarita Shah
- Departments of Epidemiology and Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
- Global Tuberculosis Branch, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Kehr J. ‘Exotic no more’: Tuberculosis, public debt and global health in Berlin. Glob Public Health 2017; 13:369-382. [DOI: 10.1080/17441692.2017.1362568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Janina Kehr
- History of Medicine Section, Centre for Medical Humanities, Institute for Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
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Abstract
OBJECTIVE The aim of this study was to identify the range and frequency of patient-reported barriers and facilitators to antiretroviral treatment (ART) adherence in sub-Saharan Africa (SSA). DESIGN Studies from 2005 to 2016 were identified by searching 10 electronic databases and through additional hand and web-searching. METHODS Inclusion criteria were HIV-positive adults taking ART based in any SSA country, qualitative study or quantitative survey and included at least one patient-reported barrier or facilitator to ART adherence. Exclusion criteria were only including data from treatment-naive patients initiating ART, only single-dose treatment, participants residing outside of SSA and reviews. RESULTS After screening 11 283 records, 154 studies (161 papers) were included in this review. Forty-three barriers and 30 facilitators were reported across 24 SSA countries. The most frequently identified barriers across studies were forgetting (n = 76), lack of access to adequate food (n = 72), stigma and discrimination (n = 68), side effects (n = 67) and being outside the house or travelling (n = 60). The most frequently identified facilitators across studies were social support (n = 60), reminders (n = 55), feeling better or healthier after taking ART (n = 35), disclosing their HIV status (n = 26) and having a good relationship with a health provider (n = 22). CONCLUSION This review addresses the gap in knowledge by collating all the patient-reported barriers and facilitators to ART adherence in SSA. Current barriers measures need to be adapted or new tools developed to include the wide variety of factors identified. The factors that have the greatest impact need to be isolated so interventions are developed that reduce the barriers and enhance the facilitators.
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García-Fernández L, Benites C, Huamán B. [Access barriers to comprehensive care for people affected by tuberculosis and human immunodeficiency virus coinfection in Peru, 2010-2015]. Rev Panam Salud Publica 2017; 41:e23. [PMID: 28591330 PMCID: PMC6660896 DOI: 10.26633/rpsp.2017.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Identify the programmatic barriers that hinder access to comprehensive care of patients with tuberculosis and human immunodeficiency virus (TB/HIV) coinfection. METHODS This is a mixed-method study. Qualitative research was conducted via in-depth interviews with key actors and the quantitative component involved cross-sectional descriptive analysis of programmatic data from 2010-2015 on tuberculosis and HIV programs at health facilities in the cities of Lima and Iquitos. RESULTS Twenty-two key actors in seven establishments were interviewed. The identified barriers were: little or no coordination between tuberculosis and HIV teams, separate management of tuberculosis and HIV cases at different levels of care, insufficient financing, limited or poorly trained human resources, and lack of an integrated information system. It was found that HIV screening in TB patients increased (from 18.8% in 2011 to 95.2% in 2015), isoniazid coverage of HIV patients declined (from 62% to 9%), and the proportion of deaths among TB/HIV coinfection cases averaged 20%. CONCLUSIONS There is poor coordination between HIV and TB health strategies. Management of TB/HIV coinfection is fragmented into different levels of care, which has an impact on comprehensive patient care. As a result of this research, a technical document was prepared to establish joint procedures that should be implemented to improve comprehensive care of TB/HIV coinfection.
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Affiliation(s)
- Lisset García-Fernández
- Estrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAPerúEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDA. Ministerio de Salud de Perú, Perú.,La correspondencia se debe dirigir a Lisset García-Fernández. Correo electrónico:
| | - Carlos Benites
- Estrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAPerúEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDA. Ministerio de Salud de Perú, Perú.
| | - Byelca Huamán
- Estrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDAPerúEstrategia Sanitaria Nacional de Infecciones de Transmisión Sexual VIH/SIDA. Ministerio de Salud de Perú, Perú.
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Yoko JLM, Tumbo JM, Mills AB, Kabongo CD. Characteristics of pulmonary tuberculosis patients in Moses Kotane region North West Province, South Africa. S Afr Fam Pract (2004) 2017. [DOI: 10.1080/20786190.2016.1272249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- JLM Yoko
- Department of Family Medicine and PHC, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - JM Tumbo
- Department of Family Medicine and PHC, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - AB Mills
- Department of Family Medicine and PHC, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - CD Kabongo
- Department of Family Medicine and PHC, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Hayes-Larson E, Hirsch-Moverman Y, Saito S, Frederix K, Pitt B, Maama BL, Howard AA. Prevalence, patterns, and correlates of HIV disclosure among TB-HIV patients initiating antiretroviral therapy in Lesotho. AIDS Care 2017; 29:978-984. [PMID: 28100068 DOI: 10.1080/09540121.2017.1280124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Disclosure of HIV-positive status has important implications for patient outcomes and preventing HIV transmission, but has been understudied in TB-HIV patients. We assessed disclosure patterns and correlates of non-disclosure among adult TB-HIV patients initiating ART enrolled in the START Study, a mixed-methods cluster-randomized trial conducted in Lesotho, which evaluated a combination intervention package (CIP) versus standard of care. Interviewer-administered questionnaire data were analyzed to describe patterns of disclosure. Patient-related factors were assessed for association with non-disclosure to anyone other than a health-care provider and primary partners using generalized linear mixed models. Among 371 participants, 95% had disclosed their HIV diagnosis to someone other than a health-care provider, most commonly a spouse/primary partner (76%). Age, TB knowledge, not planning to disclose TB status, greater perceived TB stigma, and CIP were associated with non-disclosure in unadjusted models (p < .1). In adjusted models, all point estimates were similar and greater TB knowledge (adjusted odds ratio [aOR] 0.59, 95% confidence interval [CI] 0.39-0.90) and CIP (aOR 0.20, 95% CI 0.05-0.79) remained statistically significant. Among 220 participants with a primary partner, 76% had disclosed to that partner. Significant correlates of partner non-disclosure (p < .1) in unadjusted analyses included being female, married/cohabitating, electricity at home, not knowing if partner was HIV-positive, and TB knowledge. Adjusted point estimates were largely similar, and being married/cohabitating (aOR 0.03, 95% CI 0.01-0.12), having electricity at home (aOR 0.38, 95% CI 0.17-0.85) and greater TB knowledge (aOR 0.76, 95% CI 0.59-0.98) remained significant. In conclusion, although nearly all participants reported disclosing their HIV status to someone other than a health-care provider at ART initiation, nearly a quarter of participants with a primary partner had not disclosed to their partner. Additional efforts to support HIV disclosure (e.g., counseling) may be needed for TB-HIV patients, particularly for women and those unaware of their partners' status.
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Affiliation(s)
- Eleanor Hayes-Larson
- a ICAP, Mailman School of Public Health, Columbia University , New York , NY , USA.,b Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Yael Hirsch-Moverman
- a ICAP, Mailman School of Public Health, Columbia University , New York , NY , USA.,b Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Suzue Saito
- a ICAP, Mailman School of Public Health, Columbia University , New York , NY , USA.,b Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Koen Frederix
- a ICAP, Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Blanche Pitt
- a ICAP, Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Bridget Llang Maama
- c National Tuberculosis Control Programme, Lesotho Ministry of Health , Maseru , Lesotho
| | - Andrea A Howard
- a ICAP, Mailman School of Public Health, Columbia University , New York , NY , USA.,b Department of Epidemiology , Mailman School of Public Health, Columbia University , New York , NY , USA
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Abstract
HIV disclosure can help people living with HIV to access social support, enhance antiretroviral adherence, facilitate engagement in care and reduce unprotected sex. Given interpersonal risks associated with HIV disclosure, however, anxiety about sharing one's status is common. To investigate anxiety about HIV disclosure in HIV-positive populations, we conducted a systematic review of qualitative and quantitative studies, with 119 studies included. The review demonstrated that perceived interpersonal risks are associated with HIV disclosure and outlined evidence of associations with anxiety, fear and worry. We present a new cognitive model of HIV disclosure anxiety adapted from clinical theories of health and social anxiety, consistent with evidence from the review. The model attempts to explain the development and maintenance of anxiety in individuals whose functioning is most affected by concerns about sharing their status. Implications for helping people living with HIV struggling with significant levels of anxiety about HIV disclosure are discussed.
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Affiliation(s)
- Michael Evangeli
- Department of Psychology, Royal Holloway University of London, Egham, Surrey, TW20 0EX, UK.
| | - Abigail L Wroe
- Department of Psychology, Royal Holloway University of London, Egham, Surrey, TW20 0EX, UK
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Lohiniva AL, Mokhtar A, Azer A, Elmoghazy E, Kamal E, Benkirane M, Dueger E. Qualitative interviews with non-national tuberculosis patients in Cairo, Egypt: understanding the financial and social cost of treatment adherence. HEALTH & SOCIAL CARE IN THE COMMUNITY 2016; 24:e164-e172. [PMID: 26429771 PMCID: PMC4818192 DOI: 10.1111/hsc.12280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/03/2015] [Indexed: 06/05/2023]
Abstract
Limited data are available about the challenges of non-national TB patients undergoing long-term treatment courses in an urban setting. This study aimed to understand the financial and social cost of adherence of non-national TB patients in Cairo, Egypt as a means to inform the development of context-specific interventions to support treatment adherence. In 2011, 22 in-depth interviews were conducted with TB patients from Sudan, Ethiopia, Eritrea, Somalia and Djibouti to obtain qualitative data. Analysis was based on thematic analysis that aimed to identify recurrent themes and codes from the narratives. The study identified a number of factors that influence TB treatment adherence. Uncertain financial status due to limited or no employment was frequently discussed in interviews, which resulted in fear of not being able to support family, loss of pride, dependence on family and friends, fear of losing housing, food insecurity and limited food options. Respondents also feared infecting other household members and longed for opportunities to discuss their illness and treatment experiences with other individuals but their social networks were often limited. TB-related stigma was driven by shame and blame of infection. Respondents also believed stigma was based on their foreign origin. Stigma manifested in distancing and exclusion in various ways, resulting in isolation, psychological distress and reluctance to disclose TB status to others. Poverty-related factors and social context with a special focus on stigma should be considered when developing strategies for supporting long-term treatment courses for non-national patients in Cairo and other similar urban settings.
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Affiliation(s)
- Anna L Lohiniva
- Global Disease Detection and Response Program, U.S. Naval Medical Research Unit No 3, Cairo, Egypt.
| | - Alaa Mokhtar
- National Tuberculosis Program, Ministry of Health in Egypt, Cairo, Egypt
| | - Ashraf Azer
- United Nations High Commissioner for Refugees, 7th District, Egypt
| | - Esaam Elmoghazy
- Cairo Association Against Smoking, Tuberculosis and Lung diseases, Cairo, Egypt
| | | | - Manal Benkirane
- Global Disease Detection and Response Program, U.S. Naval Medical Research Unit No 3, Cairo, Egypt
| | - Erica Dueger
- Global Disease Detection and Response Program, U.S. Naval Medical Research Unit No 3, Cairo, Egypt
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Webb Mazinyo E, Kim L, Masuku S, Lancaster JL, Odendaal R, Uys M, Podewils LJ, Van der Walt ML. Adherence to Concurrent Tuberculosis Treatment and Antiretroviral Treatment among Co-Infected Persons in South Africa, 2008-2010. PLoS One 2016; 11:e0159317. [PMID: 27442440 PMCID: PMC4956242 DOI: 10.1371/journal.pone.0159317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 06/30/2016] [Indexed: 11/19/2022] Open
Abstract
Background Adherence to tuberculosis (TB) treatment and antiretroviral therapy (ART) reduces morbidity and mortality among persons co-infected with TB/HIV. We measured adherence and determined factors associated with non-adherence to concurrent TB treatment and ART among co-infected persons in two provinces in South Africa. Methods A convenience sample of 35 clinics providing integrated TB/HIV care was included due to financial and logistic considerations. Retrospective chart reviews were conducted among persons who received concurrent TB treatment and ART and who had a TB treatment outcome recorded during 1 January 2008–31 December 2010. Adherence to concurrent TB and HIV treatment was defined as: (1) taking ≥80% of TB prescribed doses by directly observed therapy (DOT) as noted in the patient card; and (2) taking >90% ART doses as documented in the ART medical record during the concurrent treatment period (period of time when the patient was prescribed both TB treatment and ART). Risk ratios (RRs) and 95% confidence intervals (CIs) were used to identify factors associated with non-adherence. Results Of the 1,252 persons receiving concurrent treatment, 138 (11.0%) were not adherent. Non-adherent persons were more likely to have extrapulmonary TB (RR: 1.71, 95% CI: 1.12 to 2.60) and had not disclosed their HIV status (RR: 1.96, 95% CI: 1.96 to 3.76). Conclusions The majority of persons with TB/HIV were adherent to concurrent treatment. Close monitoring and support of persons with extrapulmonary TB and for persons who have not disclosed their HIV status may further improve adherence to concurrent TB and antiretroviral treatment.
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Affiliation(s)
- Ernesha Webb Mazinyo
- Tuberculosis HIV/AIDS Treatment Support and Integrated Therapy (THAT’SIT), Johannesburg, South Africa and Foundation for Professional Development, Pretoria, South Africa
- * E-mail:
| | - Lindsay Kim
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sikhethiwe Masuku
- Tuberculosis Epidemiology and Intervention Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - Joey L. Lancaster
- Tuberculosis Epidemiology and Intervention Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - Ronel Odendaal
- Tuberculosis Epidemiology and Intervention Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - Margot Uys
- Tuberculosis HIV/AIDS Treatment Support and Integrated Therapy (THAT’SIT), Johannesburg, South Africa and Foundation for Professional Development, Pretoria, South Africa
| | - Laura Jean Podewils
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Martie L. Van der Walt
- Tuberculosis Epidemiology and Intervention Research Unit, South African Medical Research Council, Pretoria, South Africa
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Ranti KO, Glory AO, Victoria BT, Isaac KO. Prevalence of HIV infection among tuberculosis patients in a teaching hospital in south-west Nigeria: A four-year retrospective study. HIV & AIDS REVIEW 2016. [DOI: 10.1016/j.hivar.2016.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Heunis C, Wouters E, Kigozi G, Janse van Rensburg-Bonthuyzen E, Jacobs N. TB/HIV-related training, knowledge and attitudes of community health workers in the Free State province, South Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 12:113-9. [PMID: 25871381 DOI: 10.2989/16085906.2013.855641] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
With its emphasis on task shifting and multi-trained and skilled outreach teams the primary healthcare (PHC) re-engineering strategy in South Africa depends on the training, knowledge and attitudes of community health workers (CHWs) to provide a variety of TB/HIV services. The aim of this exploratory research was to assess TB/ HIV-related training, knowledge and attitudes of CHWs. Interviews were conducted with 206 CHWs at 28 clinics in 1 urban and 2 rural sub-districts in the Free State province. Descriptive and bivariate analyses were performed using chi-square, Kruskal-Wallis (H) and Mann-Whitney (U) tests for non-parametric data. More than half (54.9%) had not received basic training in HIV counselling and testing; almost one-third (31.1%) had not received basic training in TB/directly observed treatment (DOT) support. Furthermore, most CHWs had not received any follow-up training in HIV counselling and testing and in TB/DOT support. Significant associations (0.01 < p < 0.05) between the types of CHWs and their sub-district location, and their TB/HIV-related training, knowledge and attitudes were observed. In respect of the TB/HIV knowledge items assessed, a large majority (>95%) were knowledgeable, with only a few being ignorant about important facts related to TB/HIV. Lay counsellors were significantly more knowledgeable about TB/HIV than TB/DOT supporters and other CHWs were. Most CHWs disagreed with stigmatising statements about people with TB/HIV. The sub-district location of CHWs was significantly associated with their attitudes towards people with TB/HIV. CHWs in the two rural sub-districts were more likely to agree with stigmatising statements. In the context of PHC re-engineering, this exploratory research suggests that CHW TB/HIV training, knowledge and attitudes can and need to be improved if integrated TB/HIV services are to be successfully task-shifted to them in line with policy recommendations.
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Affiliation(s)
- Christo Heunis
- a University of the Free State, Centre for Health Systems Research & Development , PO Box 339, Bloemfontein 9300 , South Africa
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Foster N, Vassall A, Cleary S, Cunnama L, Churchyard G, Sinanovic E. The economic burden of TB diagnosis and treatment in South Africa. Soc Sci Med 2015; 130:42-50. [PMID: 25681713 DOI: 10.1016/j.socscimed.2015.01.046] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Social protection against the cost of illness is a central policy objective of Universal Health Coverage and the post-2015 Global strategy for Tuberculosis (TB). Understanding the economic burden associated with TB illness and care is key to identifying appropriate interventions towards achieving this target. The aims of this study were to identify points in patient pathways from start of TB symptoms to treatment completion where interventions could be targeted to reduce the economic impact on patients and households, and to identify those most vulnerable to these costs. Two cohorts of patients accessing TB services from ten clinics in four provinces in South Africa were surveyed between July 2012 and June 2013. One cohort of 351 people with suspected TB were interviewed at the point of receiving a TB diagnostic and followed up six months later. Another cohort of 168 patients on TB treatment, at the same ten facilities, was interviewed at two-months and five-months on treatment. Patients were asked about their health-seeking behaviour, associated costs, income loss, and coping strategies used. Patients incurred the greatest share of TB episode costs (41%) prior to starting treatment, with the largest portion of these costs being due to income loss. Poorer patients incurred higher direct costs during treatment than those who were less poor but only 5% of those interviewed were accessing cash-transfers during treatment. Indirect costs accounted for 52% of total episode cost. Despite free TB diagnosis and care in South Africa, patients incur substantial direct and indirect costs particularly prior to starting treatment. The poorest group of patients were incurring higher costs, with fewer resources to pay for it. Both the direct and indirect cost of illness should be taken into account when setting levels of financial protection and social support, to prevent TB illness from pushing the poor further into poverty.
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Affiliation(s)
- Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa.
| | - Anna Vassall
- Social and Mathematical Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa
| | - Gavin Churchyard
- Aurum Institute, Queens Road, Parktown, Johannesburg, South Africa; Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, South Africa
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Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc 2013; 16:18640. [PMID: 24242258 PMCID: PMC3833107 DOI: 10.7448/ias.16.3.18640] [Citation(s) in RCA: 715] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/22/2013] [Accepted: 08/29/2013] [Indexed: 01/20/2023] Open
Abstract
Introduction Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. Methods We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. Results Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants’ ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ2=7.7; p=0.005). Conclusions We found that HIV-related stigma compromised participants’ abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.
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Daftary A, Padayatchi N. Integrating patients' perspectives into integrated tuberculosis-human immunodeficiency virus health care. Int J Tuberc Lung Dis 2013; 17:546-51. [PMID: 23407149 DOI: 10.5588/ijtld.12.0714] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Escalating rates of tuberculosis-human immunodeficiency virus (TB-HIV) co-infection call for improved coordination of TB and HIV health care services in high-burden countries such as South Africa. Patient perspectives, however, are poorly understood in the context of current integration efforts. METHOD Under a qualitative research framework, we interviewed 40 HIV-positive adult TB patients and eight key-informant health care workers across three clinics in KwaZulu-Natal Province to explore non-clinical and non-operational aspects of TB-HIV health care. FINDINGS Qualitative analysis highlighted critical social and ethical considerations for the concurrent delivery of TB and HIV care. Co-infected patients navigating between TB and HIV programs are exposed to missed opportunities for TB and HIV service integration, fragmented or vertical care for their dual infections and contrasting experiences within TB and HIV clinics. These intersecting issues appear to affect patients' health-related decisions, particularly nondisclosure of HIV status to non-HIV health care workers and their preferences for integrated health care. CONCLUSION Our study highlights the imperative to address service fragmentation, HIV medical confidentiality and provider mistrust within the health care system, and the cultural differences associated with TB and HIV disease control.
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Affiliation(s)
- A Daftary
- ICAP, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
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Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi. J Int AIDS Soc 2012; 15:18020. [PMID: 23336700 PMCID: PMC3535694 DOI: 10.7448/ias.15.2.18020] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/02/2012] [Accepted: 12/05/2012] [Indexed: 11/08/2022] Open
Abstract
Introduction Linkage from HIV testing and counselling (HTC) to initiation of antiretroviral therapy (ART) is suboptimal in many national programmes in sub-Saharan Africa, leading to delayed initiation of ART and increased risk of death. Reasons for failure of linkage are poorly understood. Methods Semi-structured qualitative interviews were undertaken with health providers and HIV-positive primary care patients as part of a prospective cohort study at primary health centres in Blantyre, Malawi. Patients successful and unsuccessful in linking to ART were included. Results Progression through the HIV care pathway was strongly influenced by socio-cultural norms, particularly around the perceived need to regain respect lost during a period of visibly declining health. Capacity to call upon the support of networks of families, friends and employers was a key determinant of successful progression. Over-busy clinics, non-functioning laboratories and unsuitable tools used for ART eligibility assessment (WHO clinical staging system and centralized CD4 count measurement) were important health systems determinants of drop-out. Conclusions Key interventions that could rapidly improve linkage include guarantee of same-day, same-clinic ART eligibility assessments; utilization of the support offered by peer-groups and community health workers; and integration of HTC and ART programmes.
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Nglazi MD, Kaplan R, Caldwell J, Peton N, Lawn SD, Wood R, Bekker LG. Antiretroviral treatment uptake in patients with HIV-associated TB attending co-located TB and ART services. S Afr Med J 2012; 102:936-9. [PMID: 23498041 PMCID: PMC3960570 DOI: 10.7196/samj.6024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 07/05/2012] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Delivery of integrated care for patients with HIV-associated TB is challenging. We assessed the uptake and timing of antiretroviral treatment (ART) among eligible patients attending a primary care service with co-located ART and TB clinics. METHODS In a retrospective cohort study, all HIV-associated TB patients (≥18 years old) who commenced TB treatment in 2010 were included. Data were analysed using basic descriptive statistics and log-binomial regression analysis. RESULTS Of a total of 497 patients diagnosed with HIV-associated TB, 274 were eligible to start ART for the first time (median CD4 count, 159 cells/µl). ART was started during TB treatment by 220 (80.3%) patients. Among the 54 (19.7%) who did not start ART, 23 (42.6%) were either lost to follow-up (LTFU) or died before enrolling for ART; 12 (22.2%) were either LTFU or died after enrolling but before starting ART; 5 (9.3%) were transferred out; and 14 (25.9%) only started ART after completion of TB treatment. The median delay between starting TB treatment and starting ART was 51 days (IQR 29 - 77). Overall, only 58.6% of patients started ART within 8 weeks of TB treatment, and 12.7% of those with CD4 counts <50 cells/µl started ART within 2 weeks. CONCLUSIONS In a setting with co-located TB and ART clinics, delays to starting ART were substantial, and one-fifth of eligible patients did not start ART during TB treatment. Co-location of services alone is insufficient to permit timely initiation of ART; further measures need to be implemented to facilitate integrated treatment.
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