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Palacios CF, Hough MA, Shrestha R, Moll AP, Kompala T, Andrews L, Shenoi SV. Perceived stigma related to TB preventive therapy. Int J Tuberc Lung Dis 2023; 27:209-214. [PMID: 36855038 DOI: 10.5588/ijtld.22.0570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND: TB preventative therapy (TPT) is crucial for reducing the burden of TB in endemic settings. We assessed stigma associated with TPT and the social groups from whom stigma was anticipated.METHODS: We conducted an anonymous cross-sectional survey of community-dwelling adults in rural South Africa. Descriptive statistics, exploratory factor analysis, χ² tests, Kruskal-Wallis tests, and Poisson regression were used to identify factors associated with TPT stigma.RESULTS: The mean age of the 104 participants was 35 years, 65% were female, and 26% had completed secondary school. The vast majority perceived stigma associated with TPT (71%; mean score 1.7, SD ± 1.4). Factor analysis identified a two-factor solution that explained 61.9% of the variance. Being single (P < 0.001), previously screened for TB (P = 0.04), worried about being infected by TB (P = 0.006), and interested in taking TPT (P = 0.01) were associated with higher perceived stigma scores. TPT stigma was perceived among 8%, 16%, and 66% of their family, friends, and other community members, respectively.CONCLUSION: The prevalence of TPT-related stigma in a rural South African community was high. Community members anticipated less stigma from family members compared to other social groups. Global expansion and implementation of TPT will require novel interventions, such as engaging patients´ families to support uptake and promote adherence.
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Affiliation(s)
- C F Palacios
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - M A Hough
- New York University School of Global Public Health, New York, NY, USA
| | - R Shrestha
- University of Connecticut, Storrs, CT, USA
| | - A P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa, Philanjalo NGO, Tugela Ferry, South Africa
| | - T Kompala
- University of California School of Medicine, San Francisco, CA, USA
| | - L Andrews
- Yale University School of Medicine, New Haven, CT, USA
| | - S V Shenoi
- Yale University School of Medicine, New Haven, CT, USA, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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Sinha P, Moll AP, Brooks RP, Deng YH, Shenoi SV. Synergism between diabetes and human immunodeficiency virus in increasing the risk of tuberculosis. Int J Tuberc Lung Dis 2019; 22:793-799. [PMID: 29914606 DOI: 10.5588/ijtld.17.0936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
SETTING Community health screenings in KwaZulu-Natal Province, South Africa. OBJECTIVE To study the synergism between diabetes mellitus (DM) and human immunodeficiency virus (HIV) infection in increasing the risk of tuberculosis (TB). DESIGN In this cross-sectional study, we analyzed data from two community health projects, one at congregate settings, and one at household settings (n = 7708), in a rural resource-limited region where integrated communicable and non-communicable disease screening services were offered. Odds ratios (ORs) for demographic factors, socio-economic factors, DM status, and HIV positivity were calculated using multivariate analysis, and the statistical interaction between HIV and DM was tested. The primary outcome was the presence of TB symptoms. RESULTS Among 7708 individuals, age >65 years (OR 1.72, 95%CI 1.47-2.02), HIV infection (OR 1.66, 95%CI 1.40-1.97) and DM (OR 1.36, 95%CI 1.11-1.67) were independently associated with increased odds of TB symptoms. Receiving monthly grants (OR 0.78, 95%CI 0.66-0.91), access to a toilet (OR 0.54, 95%CI 0.35-0.83), and access to solar or electric energy (OR 0.86, 95%CI 0.77-0.97) reduced the odds. There was evidence of significant interaction between DM and HIV on the multiplicative scale. CONCLUSION DM and HIV synergistically increased the odds of TB symptoms according to these retrospective data. Future studies should prospectively evaluate synergism between HIV and DM in increasing the risk of active TB.
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Affiliation(s)
- P Sinha
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - A P Moll
- Church of Scotland Hospital, ARV Programme, Tugela Ferry, South Africa
| | - R P Brooks
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Y-H Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - S V Shenoi
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, USA
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Kompala T, Moll AP, Mtungwa N, Brooks RP, Friedland GH, Shenoi SV. Impact of nurse-delivered community-based CD4 services on facilitating pre-ART care in rural South Africa. BMC Health Serv Res 2016; 16:374. [PMID: 27515233 PMCID: PMC4982129 DOI: 10.1186/s12913-016-1627-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 08/04/2016] [Indexed: 11/25/2022] Open
Abstract
Background HIV testing, diagnosis and treatment programs have expanded globally, particularly in resource-limited settings. Diagnosis must be followed by determination of treatment eligibility and referral to care prior to initiation of antiretroviral treatment (ART). However, barriers and delays along these early steps in the treatment cascade may impede successful ART initiation. New strategies are needed to facilitate the treatment cascade. We evaluated the role of on site CD4+ T cell count phlebotomy services by nurses in facilitating pre-ART care in a community-based voluntary counseling and testing program (CBVCT) in rural South Africa. Methods We retrospectively evaluated CBVCT services during five continuous time periods over three years: three periods when a nurse was present on site, and two periods when the nurse was absent. When a nurse was present, CD4 count phlebotomy was performed immediately after HIV testing to determine ART eligibility. When a nurse was absent, patients were referred to their local primary care clinic for CD4 testing. For each period, we determined the proportion of HIV-positive community members who completed CD4 testing, received notification of CD4 count results, as well as the time to test completion and result notification. Results Between 2010 and 2013, 7213 individuals accessed CBVCT services; of these, 620 (8.6 %) individuals were HIV-positive, 205 (33.1 %) were eligible for ART according to South African national CD4 count criteria, and 78 (38.0 % of those eligible) initiated ART. During the periods when a professional nurse was available to provide CD4 phlebotomy services, HIV-positive clients were significantly more likely to complete CD4 testing than during periods when these services were not available (85.5 % vs. 37.3 %, p < 0.001). Additionally, when nurses were present, individuals were significantly more likely to be notified of CD4 results (60.6 % vs. 26.7 %, p <0.001). The time from HIV screening to CD4 test completion was also significantly shorter during nurse presence than nurse absence (median 8 days (IQR 4–19) vs. 35 days (IQR 15–131), p < 0.001). Conclusions These findings indicate that in addition to CBVCT, availability of on site CD4 phlebotomy may reduce loss along the pre-ART care cascade and facilitate timely entry into HIV care.
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Affiliation(s)
- T Kompala
- Department of Medicine, University of California, San Francisco, CA, USA
| | - A P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa
| | - N Mtungwa
- Philanjalo NGO, Tugela Ferry, South Africa
| | - R P Brooks
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, 135 College Street, Suite 323, New Haven, CT, 06510, USA
| | - G H Friedland
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, 135 College Street, Suite 323, New Haven, CT, 06510, USA
| | - S V Shenoi
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, 135 College Street, Suite 323, New Haven, CT, 06510, USA.
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Shenoi SV, Brooks RP, Catterick K, Moll AP, Friedland GH. 'Cough officer' nurses in a general medical clinic successfully detect drug-susceptible and -resistant tuberculosis. Public Health Action 2013; 3:46-50. [PMID: 25392815 DOI: 10.5588/pha.12.0056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Intensive case finding (ICF) for tuberculosis (TB) is recommended by the World Health Organization among known human immunodeficiency virus (HIV) patients. However, ICF may also be appropriate in generalized patient populations. OBJECTIVE To evaluate the yield of ICF in a general medical clinic in a high HIV prevalence setting. METHODS A nurse designated as a 'cough officer' identified clinic attendees with cough of >2 weeks and collected sputum for evaluation at the hospital and provincial referral laboratories. We retrospectively evaluated the number and proportion of patients with microbiologically confirmed TB identified in 2007-2008. RESULTS Among 56 207 clinic attendees, 1442 (2.6%) TB suspects were identified and 122 (8.5%) were sputum Ziehl-Neelsen (ZN) positive. Of 389 available results, 72 (18.5%) were auramine-positive and 99 (25.4%) were culture-positive; multidrug-resistant and extensively drug-resistant TB were identified in 16 (16.2%). The number needed to screen was 11.8 patients to identify one ZN-positive case and 3.9 to identify one culture-positive case. CONCLUSIONS A nurse-facilitated cough officer program successfully identified TB suspects and drug-susceptible and drug-resistant TB. Culture was more sensitive for TB screening and critical for identifying drug resistance. ICF is operationally feasible, and should be expanded to general medical clinics in high HIV and TB prevalence, resource-limited settings.
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Affiliation(s)
- S V Shenoi
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - R P Brooks
- Philanjalo Care Centre, Tugela Ferry, South Africa
| | - K Catterick
- Church of Scotland Hospital, Tugela Ferry, South Africa
| | - A P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa
| | - G H Friedland
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, USA
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Brust JCM, Shah NS, Scott M, Chaiyachati K, Lygizos M, van der Merwe TL, Bamber S, Radebe Z, Loveday M, Moll AP, Margot B, Lalloo UG, Friedland GH, Gandhi NR. Integrated, home-based treatment for MDR-TB and HIV in rural South Africa: an alternate model of care. Int J Tuberc Lung Dis 2012; 16:998-1004. [PMID: 22668560 PMCID: PMC3390442 DOI: 10.5588/ijtld.11.0713] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Treatment outcomes for multidrug-resistant tuberculosis (MDR-TB) in South Africa have suffered as centralized, in-patient treatment programs struggle to cope with rising prevalence and human immunodeficiency virus (HIV) co-infection rates. A new treatment model is needed to expand treatment capacity and improve MDR-TB and HIV outcomes. OBJECTIVE To describe the design and preliminary results of an integrated, home-based MDR-TB-HIV treatment program created in rural KwaZulu-Natal. METHOD In 2008, a decentralized center was established to provide out-patient MDR-TB and HIV treatment. Nurses, community health workers and family supporters have been trained to administer injections, provide adherence support and monitor adverse reactions in patients' homes. Physicians assess clinical response, adherence and the severity of adverse reactions to MDR-TB and HIV treatment at monthly follow-up visits. Treatment outcomes are assessed by monthly cultures and CD4 and viral load every 6 months. RESULTS Of 80 patients initiating MDR-TB treatment from February 2008 to April 2010, 66 were HIV-co-infected. Retention has been high (only 5% defaults, 93% of visits attended), and preliminary outcomes have been favorable (77% cured/still on treatment, 82% undetectable viral load). Few patients have required escalation of care (9%), had severe adverse events (8%) or died (6%). CONCLUSION Integrated, home-based treatment for MDR-TB and HIV is a promising treatment model to expand capacity and achieve improved outcomes in rural, resource-poor and high HIV prevalent settings.
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Affiliation(s)
- J C M Brust
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York 10467, USA.
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Gandhi NR, Andrews JR, Brust JCM, Montreuil R, Weissman D, Heo M, Moll AP, Friedland GH, Shah NS. Risk factors for mortality among MDR- and XDR-TB patients in a high HIV prevalence setting. Int J Tuberc Lung Dis 2012; 16:90-7. [PMID: 22236852 DOI: 10.5588/ijtld.11.0153] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Recent studies suggest that the prevalence of drug-resistant tuberculosis (TB) in sub-Saharan Africa may be rising. This is of concern, as human immunodeficiency virus (HIV) co-infection in multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB has been associated with exceedingly high mortality rates. OBJECTIVE To identify risk factors associated with mortality in MDR- and XDR-TB patients co-infected with HIV in South Africa. DESIGN Case-control study of patients who died of all causes within 2 years of diagnosis with MDR- or XDR-TB. RESULTS Among 123 MDR-TB patients, 78 (63%) died following diagnosis. CD4 count ≤ 50 (HR 4.64, P = 0.01) and 51-200 cells/mm(3) (HR 4.17, P = 0.008) were the strongest independent risk factors for mortality. Among 139 XDR-TB patients, 111 (80%) died. CD4 count ≤ 50 cells/mm(3) (HR 4.46, P = 0.01) and resistance to all six drugs tested (HR 2.54, P = 0.04) were the principal risk factors. Use of antiretroviral therapy (ART) was protective (HR 0.34, P = 0.009). CONCLUSIONS Mortality due to MDR- and XDR-TB was associated with greater degree of immunosuppression and drug resistance. Efforts to reduce mortality must focus on preventing the amplification of resistance by strengthening TB treatment programs, as well as reducing the pool of immunosuppressed HIV-infected patients through aggressive HIV testing and ART initiation.
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Affiliation(s)
- N R Gandhi
- Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York 10467, USA.
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Kanjee Z, Amico KR, Li F, Mbolekwa K, Moll AP, Friedland GH. Tuberculosis infection control in a high drug-resistance setting in rural South Africa: information, motivation, and behavioral skills. J Infect Public Health 2012; 5:67-81. [PMID: 22341846 DOI: 10.1016/j.jiph.2011.10.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/22/2011] [Accepted: 10/21/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is transmitted in resource-limited facilities where TB infection control (IC) is poorly implemented. Theory-based behavioral models can potentially improve IC practices. METHODS The present study used an anonymous questionnaire to assess healthcare worker (HCW) TB IC information, motivation, and behavioral skills (IMB) and implementation in two resource-limited rural South African hospitals with prevalent drug-resistant TB. RESULTS Between June and August 2010, 198 surveys were completed. Although the respondents demonstrated information proficiency and positive motivation, 22.8% did not consider TB IC to be worthwhile. Most tasks were rated as easy by survey participants, but responding HCWs highlighted challenges in discrete behavioral skills. The majority of responding HCWs reported that they always wore respirators (54.3%), instructed patients on cough hygiene (63.0%), and ensured natural ventilation (67.4%) in high-risk areas. Most respondents (74.0%) knew their HIV status. Social support items correlated with the implementation of the first three aforementioned practices but not with the respondents' knowledge of their HIV status. In most cases, motivation and behavioral skills, but not information, were associated with implementation. CONCLUSION HCWs in rural South African hospitals with high drug-resistance demonstrated moderate IMB and implementation of TB IC. Improvement efforts should emphasize the development of HCW motivation and behavioral skills as well as social support from colleagues and supervisors. Such interventions should be informed by baseline IMB assessments. In the present study, a trimmed/modified IMB model helped characterize TB IC implementation.
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Affiliation(s)
- Z Kanjee
- Office of Student Affairs, Yale University School of Medicine, New Haven, CT, USA.
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Kanjee Z, Catterick K, Moll AP, Amico KR, Friedland GH. Tuberculosis infection control in rural South Africa: survey of knowledge, attitude and practice in hospital staff. J Hosp Infect 2011; 79:333-8. [PMID: 21978608 DOI: 10.1016/j.jhin.2011.06.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Accepted: 06/07/2011] [Indexed: 10/17/2022]
Abstract
A baseline assessment of tuberculosis infection control (TB IC) knowledge, attitude and practice (KAP) was conducted among staff in a resource-limited rural South African hospital where nosocomially transmitted multi- and extensively drug-resistant (M/XDR) TB had been reported. Assessment consisted of anonymous questionnaires and direct observation during July-September 2007, soon after the report of M/XDR-TB. Data were obtained from 57 questionnaires and 10h of direct observation. While knowledge and attitudes were generally supportive of TB IC implementation, 49.1% of staff felt that the hospital did not care about them and/or was not working to prevent staff TB infections, and 42.9% were less willing to continue as a healthcare worker because of staff TB/MDR-TB/XDR-TB deaths. Practices were variable. The recent appointment of an IC officer and implementation of natural ventilation were strengths, but the facility lacked a TB IC policy, the patient TB screening process was inadequate, and 41.5% of respondents were unaware of their personal human immunodeficiency virus (HIV) status. Respondents reported a number of barriers to TB IC implementation such as concerns about the confidentiality of staff health information, the stigma of TB and HIV, inadequate resources, and patient non-compliance. Assessment of staff KAP provided useful data regarding deficits and barriers to TB IC, and helped to focus subsequent IC strategies. Given the critical importance of reducing nosocomial TB transmission, it is recommended that facilities should conduct simplified TB IC assessment, ensure the confidentiality of staff health information, address the stigma of TB/HIV, and implement multi-faceted TB IC facility and behavioural change interventions. Behavioural science methods have the potential to improve TB IC research and implementation.
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Affiliation(s)
- Z Kanjee
- Yale University School of Medicine, New Haven, CT, USA.
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Eksteen FJ, Moll AP, van der Merwe TL. Abortion objectors--further points. S Afr Med J 1997; 87:1557-8. [PMID: 9472289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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van der Merwe TL, Moll AP, Eksteen FJ. Abortion on demand. S Afr Med J 1997; 87:74-5. [PMID: 9063324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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