Tuberculosis and AIDS: epidemiologic, clinical, and social dimensions

Integrating patients' perspectives into integrated tuberculosis-human immunodeficiency virus health care

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.

[Two patterns of social inequalities in mortality in Barcelona, Spain?]

BACKGROUND

The aims of this study were to describe social inequalities in mortality amongst Basic Health Areas in Barcelona Spain and to analyze the patterns of social inequalities in health.

METHODS

This is an ecological study of all deaths of residents in Barcelona in 1989-93. The unit of analysis was the Basic Health Area. Socio-economic and mortality indicators (overall mortality and the main causes of death) were studied. Relative risk estimates between socio-economic and mortality indicators were calculated through Poisson regression models.

RESULTS

An unequal socioeconomical and mortality distribution was observed between areas. The following variables were found to be associated with lower socio-economic conditions: overall mortality (RR = 1,48, males), specific mortality: malignant neoplasm of trachea, bronchus and lung (RR = 1, 64, males), chronic liver disease and cirrhosis (RR = 2,33, males), AIDS (RR = 3,42, males and females), drug overdose (RR = 5,18, males and females), tuberculosis (RR = 6,3, males and females), pneumonia, bronchitis, emphysema and asthma (RR = 1,41, males), and external causes (RR = 2,29, males). The increase in risk with deteriorating socioeconomic situation was linear for cirrhosis and bronchitis, emphysema and asthma, and close to linearity for malignant neoplasm of trachea, bronchus and lung. For AIDS, drug overdose, and tuberculosis, the increase in risk was not linear, being much higher for those areas with higher levels of unemployment.

CONCLUSIONS

All causes of death that have been found to be associated with social inequalities are related with life-styles (smoking, excessive alcohol consumption and parenteral drug use). There are two patterns of social inequalities in health: AIDS, drug overdose and tuberculosis stand out as pathologies associated to extreme unfavourable socioeconomic situation, for which it is likely that there are some conditions favouring health problems associated with margination.