Challenges and opportunities for tuberculosis prevention and care in an HIV epidemic area, Chiang Rai, Thailand

Abstract: Objective: To describe the impact of HIV/AIDS on the perceptions, attitudes and behaviors of various groups of people that may effect TB transmission, prevention and care. Methods: The study was conducted in Chiang Rai, the northernmost province of Thailand with some of the highest rates of TB and HIV. The study employed qualitative and quantitative methods: (i) adherence to the 9-month TB preventive therapy among people with HIV infection (PLWH) was investigated by pill count, in-depth interviews were used with poor- adherent cases while focus group discussions (FGD) were utilized with the good-adherent cases; (ii) perceptions about TB, HIV and the feasibility of implementing Directly Observed Therapy (DOT) was investigated through FGD with health providers, patients, community people, drug users and people living with HIV; (iii) health seeking behavior of HIV- positive TB patients (TB (HIV+)) and HIV-negative TB patients (TB (HIV-)) was investigated through interviews with patients using a structured questionnaire; (iv) the lifestyles before and after the TB diagnosis of TB (HIV+) and TB (HIV-) of patients were examined by conducting repeated home visits during a period of 6-8 months applying indepth interviews and observations. Major findings: (i) The adherence rate to TB-preventive therapy among PLWH, defined as the proportion of those who took more than 80% of the pills was 67.5% (n=278). Default took place at the early phase of the therapy. Females displayed a significantly higher adherent rate than males (OR 3.45: 95%CI 1.79-6.67). Major reasons for non-adherence included migration due to work, denial of HIV status and perceived medicinal side effects. Important reasons motivating adherence were the concern for children and family and good provider relationships; (as) In general, people expressed a high awareness of AIDS symptoms and transmission causes but had an inadequate knowledge regarding TB. AIDS stigma and several misconceptions of TB-associated AIDS caused a delay in seeking TB service and a non-adherence to TB treatment in some patients who suspected they had AIDS and therefore, feared AIDS detection. Most TB (HIV-) patients were labeled as having AIDS by their family and community; (iii) The high mortality of TB (HIV+) and HIV-related complications in TB patients negatively affected the credibility of the TB treatment and influenced the attitudes of the health staff and the community resulting in perceived low priority or low motivation to treat TB for HIV infected persons expecting that the patients would eventually die from AIDS; (iv) In the HIV epidemic area, both health center-based DOT and home-based DOT have their problems. TB (HIV+) patients were usually too sick to visit a health center independently on a daily basis. These patients frequently suffered from other opportunistic infections and drug reactions. Therefore, the ability of the health center staff in clinical management during the implementation of home-based DOT was challenging. The health staff had low motivation to implement DOT unless financial incentives were offered. However, the monetary demand could be avoided if staff are well informed about the risk of multi-drug resistant TB and how to safeguard their own health; (v) The median patient delays for TB (HIV+), TB (HIV-) and TB (HIV unknown) were 10, 15 and 15 days, respectively. The risk factors for long patient delays (>21 days) included being HIV-negative, having no health insurance, being of hill-tribe ethnicity, having had no previous visits to the hospital and needing to borrow money for the hospital visits. Provider delay was significantly longer for female patients than male patients; (vi) clinically, socially and financially, the TB (HIV+) patients suffered more than the TB (HIV-) patients. The TB (HIV+) patients suffered more complications and had more problems in drug taking. The AIDS stigma led to the discrimination of TB (HIV+) patients and their exclusion from social activities as well as the negative effect on family income including the loss of their job; (vii) Following the Grounded Theory tradition, the study developed a model presenting that the risk of TB and HIV transmissions may be attributed to the following: role and responsibility, virtue, stigma, learning for life, human bond and accepting fate. Conclusion: HIV/AIDS provides a graphic and tragic example of complex interactions between the disease agent and human behavior, which further complicates the patient's care-seeking behavior, adherence to the therapy and the effort to control tuberculosis. Despite the enormous clinical and social impact of HIV/AIDS on TB, some socio-cultural interventions may improve TB prevention and care.