|Year : 2022 | Volume
| Issue : 1 | Page : 105-109
Clinical and Psychosocial Determinants of Patients with Tuberculosis/Human Immunodeficiency Virus Co-Infection: A Structural Equation Model Approach
MA Alao1, OR Ibrahim2, YH Chan3
1 Department of Paediatrics, Bowen University Teaching Hospital, Ogbomoso, Oyo State; Bowen University College of Medicine Iwo, Osun State; University College Hospital Ibadan, Oyo State, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Kastina, Katsina State, Nigeria
3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
|Date of Submission||25-Jul-2020|
|Date of Acceptance||18-Sep-2021|
|Date of Web Publication||19-Jan-2022|
Dr. M A Alao
Department of Paediatrics, Bowen University Teaching Hospital, Box 15, Ogbomoso, Oyo State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Tuberculosis (TB)/human immunodeficiency virus (HIV) co-infection is a complex mesh of physical and psychosocial disorders that require a multimodal and multifaceted approach for improved outcomes. Aims: This study determined the treatment outcomes of patients with TB/HIV co-infection and the clinico-psychosocial predictors of the disease over a 10-year period in resource-limited settings. Patients and Methods: This study reviewed the 10-year retrospective treatment outcomes of patients with TB/HIV co-infection in a tertiary centre. The data were retrieved from the TB treatment registers and analyzed with STATA 16.0. The effects of latent constructs of high clinical severity, stigmatization, and family stress/burden on treatment outcomes were evaluated using a structural equation model. Results: Of the 1,321 who met the inclusion criteria, 1,193 had sufficient data. The mean age of the patients was 38.2 ± 16.7 years. The treatment adherence rate over the 10 years was 93.8% (±6.8%) but successful treatment outcome was 75.5% (±8.1%). Stigmatism of TB/HIV infections was experienced by adults and males (β = 0.972; P < 0.001 β = 0.674; P < 0.001, β = -0.770; P < 0.001, respectively), non-adherent to treatment (β = -0.460; P < 0.001) clinical severity of illness (β = 0.940; P < 0.001), and being HIV negative (β = -0.770; P < 0.001). Family Stress/Burden was strongly affected by both Death (β = 1.000; P < 0.001) and higher Stigmatism (β = 0.602; P < 0.001). Clinical severity of illness significantly influenced both Death and Unsatisfactory outcomes (β = 0.207; P < 0.001, β = 0.203; P < 0.05, respectively). Non-Adherence led to potentially unsatisfactory outcome. Conclusion: TB/HIV co-infection is a complex psychosocial disorder that is significantly and negatively impacted by social determinants of the disease. A holistic approach to treatment intervention that addresses the latent factors of stigmatization, family stress/burden, and high clinical severity is key to achieving a successful treatment outcome.
Keywords: Family stress/burden, human immunodeficiency-virus, social determinant, stigmatization, structural equation model, tuberculosis
|How to cite this article:|
Alao M A, Ibrahim O R, Chan Y H. Clinical and Psychosocial Determinants of Patients with Tuberculosis/Human Immunodeficiency Virus Co-Infection: A Structural Equation Model Approach. Niger J Clin Pract 2022;25:105-9
|How to cite this URL:|
Alao M A, Ibrahim O R, Chan Y H. Clinical and Psychosocial Determinants of Patients with Tuberculosis/Human Immunodeficiency Virus Co-Infection: A Structural Equation Model Approach. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 3];25:105-9. Available from: https://www.njcponline.com/text.asp?2022/25/1/105/335983
| Introduction|| |
Historical accounts of tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection are shrouded with assumptions, beliefs, words, and images that have severe negative psychosocial impacts on patients and their families.,,,,,,, TB, for example, has been referred to as a disease cured by the gods, meaning the patients are a reprobate to humanity and have little hope for survival while HIV infection has deep roots in sexual deviance and promiscuity.,,,,,, The fear-driven perceived contagiousness of these diseases and the association of these diseases with abject poverty and shame, malnutrition, the foreign-born, and prisoners have resulted in stigmatization, discrimination, depression, low self-esteem, and family stress and burden.,, These social determinants have been shown to serve as barriers to healthcare access, increased risk for non-adherence to treatment, risk factors for treatment default and treatment failure, and a motivating factor for suicide.,
Despite the complexity of TB/HIV co-infection and its psychosocial impacts, several authors have reported the outcomes of the TB/HIV co-infections using linear models, undermining the social determinants and multifaceted nature of this co-infection, especially in resource-limited settings. This strategy may be one of the reasons why achieving the 85% successful treatment target set by the World Health Organization (WHO) in low-resource settings is not a reality. While there are reviews on this co-infection and psychosocial determinants on treatment outcomes, the data are predominantly from Asia and the Pacific Islands, Europe, and North America, and there are conspicuously few reports from Sub-Saharan Africa.
The implication of a restricted clinical view of TB/HIV treatment outcomes alone is multi-fold and lethal., This view could result in under-reporting of prevalence, as affected individuals would rarely present themselves for treatment or may prefer alternative treatment from non-certified medical practitioners without credentials or from alternative medicine physicians. There is potential for poor adherence to treatment, treatment default and failure, and increased risk for the development of extensively drug-resistant TB and HIV. The entire family's socioeconomic status may be affected by the dire consequence of neglecting the social determinants of these diseases.,
This study, therefore, explored the relationship between psychosocial latent factors and TB/HIV co-infection treatment outcomes using structural equation modelling in a tertiary centre in Southwest Nigeria.
| Methods|| |
This study evaluated a 10-year retrospective review of the interaction between HIV/TB co-infection manifest variables of treatment outcomes (treatment adherence, potentially unsatisfactory outcome, death, patients age, gender, HIV status, forms of TB, sputum status at diagnosis, patients enrolment status of either new, relapse case, treatment default or failure), and the effects of three postulated latent constructs of high clinical severity, stigmatization, and family stress/burden using a SEM in a tertiary centre, Southwest Nigeria. The data were retrieved from the TB treatment registers and analyzed with STATA 16.0. Assessment of model fit was based on a comparative factor index of >0.9, Chi-square indices of P values >0.05 according to Hu and Bentler indication for Good fit. The estimated probit regression coefficient and the corresponding P value from the SEM are shown in [Figure 1]. The Bowen University Teaching Hospital ethics review board approved the research with approval number BUTH/REC/045.
|Figure 1: Structure Equation Model associating the complex psycho-social disorder of TB/HIV co-infection subjects with treatment outcomes|
Click here to view
The different treatment outcomes as defined by the WHO guidelines and the International Union Against Tuberculosis and Lung Diseases are as follows:,
- Cure: Sputum smears negative on two occasions, one of which must be at treatment end.
- Treatment completed: Patient completed treatment but last smear unavailable or extrapulmonary TB.
- Successful treatment is i or ii.
- Relapse: Patient who was declared cured but later develops a smear-positive TB.
- Treatment failure: Patient remains smear positive ≥5-months after beginning treatment.
- Default: Patient had ≥1-month of treatment with >2 month interruption.
- Death: Patient dies of any cause during the course of treatment course.
- Transfer out: Patient referred out of catchment area and outcome of treatment is unknown.
- Potentially unsatisfactory treatment outcome is a combination of treatment default, transferred out and treatment failure.
- Treatment adherence: Failure of a patient with TB to receive TB drug for more than 3 days in a week.
| Result|| |
Of the 1,321 patients who met the inclusion criteria, 1,193 had sufficient data. The mean (sd) age of the patients was 38.2 (16.7) years. The proportion of adults was 91.8%, while 55.4% of the participants were male with a gender ratio of M: F 1.3:1.1. The treatment adherence rate over the 10-year period was 93.8% (±6.8)%) but successful outcomes 75.5% (±8.1) was obtained. Potentially unsatisfactory outcomes occurred in 14.4% (range, 7.9% to 24.4%) of patients, and the mortality rate was 10.1% (range, 6.4% to 11.1%).
High clinical severity of illness
The high clinical severity of illness significantly influenced both mortality and unsatisfactory outcomes (β = 0.207, P < 0.001 and β = 0.203, P < 0.05, respectively).
High clinical severity was positively associated with pulmonary tuberculosis (PTB), sputum smear negative PTB (β = -0.741; P < 0.001; β = -0.665; P < 0.001, respectively). The pre-treatment status of relapse, treatment default and transferred out were positively influence by high clinical severity (β = 0.672; P < 0.001, β = 0.510; P < 0.001, and β = 0.322; P < 0.01 respectively) in contrast with new cases (β = -0.520; P < 0.001) and surprisingly pre-treatment status of failure (β = -0.225; P < 0.001) which negatively impacted high clinical severity.
Non-adherence led to potentially unsatisfactory outcomes but did not impact mortality (β = -0.557, P < 0.001 and β = 0.000, respectively).
Stigmatization of TB/HIV infections was experienced by adults and males (β = 0.972; P < 0.001 β = 0.674; P < 0.001, β = -0.770; P < 0.001, respectively), non-adherence to treatment (β = -0.460; P < 0.001) high clinical severity of illness (β = 0.940; P < 0.001), and (surprisingly) being HIV negative (β = -0.770; P < 0.001). Patient's stigmatization did not impact unsatisfactory outcome.
Family Stress/Burden was strongly affected by both Death (β = 1.000; P < 0.001) and higher stigmatization (β = 0.602; P < 0.001).
| Discussion|| |
Our study showed a high treatment adherence rate of 93.8%. This is comparable to the 89% adherence rate found in a study from South Africa. The higher treatment adherence rate and a sub-optimal successful treatment outcome observed in this study is in tandem with the postulation that successful treatment outcome goes far beyond a strict adherence to treatment regimen., It further substantiates the fact that the panacea for improved care for patients with TB/HIV co-infection depends not only on attention to diagnosis and treatment but also on holistic approach that addresses the latent factors which not are measurable with a linear statistical model.
Our study showed an unsatisfactory outcome in about 14.4% in the study population (Tuberculosis/HIV co-infection), which is lower compared with 24.5% reported among co-infection in South Africa.
The findings of non-adherence to treatment being associated with potentially unsatistactory outcome (treatment failure and default) is comparable to the report in literature., It stands to reason that poor and inconsistent adherence is a risk for drug resistant TB, poor response to treatment and consequent patient's dissatisfaction which ultimately leads to treatment abandonment/default.,
Our observation in the present study using the SEM is supported by existing literature on the impact of self-stigmatization and external stigmatization on TB/HIV co-infection and treatment outcomes.,, Of particular interest is the significant impact of stigmatization observed on HIV negative patients with tuberculosis similar to the reports by researchers.,,, The double jeopardy of HIV-TB co-infection patients face with regard to stigmatization raises a serious concern about how best to mitigate stigmatization, thus the exponential unfavorable treatment outcome associated with this comorbidity is explainable., A special attention should therefore be placed on policy formulation looking at social intervention that would reduce this stigma in the community as well as targeted interventions toward affected individuals.
The findings of high clinical severity and stigmatization being associated with increased mortality in TB-HIV co-infection echoes the observation by Parks et al. of 25 years reduction in survival compared with apparently normal population. A very sick patient at the backdrop of dual chronic illnesses no doubt stands at risk for increased mortality without holistic approach to treatment. These patients would usually require intensive care and high-end resources that are either not available or not affordable. The disease has already consumed the merger resources when some of the patients for fear of the disease have been abandoned by their relatives.
The implication of men being prominently affected by the latent factor of stigmatization, as opposed to women, who could be ostracized, means increased spread of the disease to partners and other family members, loss of income and delays in the diagnosis of TB/HIV co-infection among family members. Self-stigmatization, regardless of external stigmatization, negatively impacts the quality of life, self-respect, and daily lives of patients.
This study also showed that family stress and burden from the TB-HIV co-infection was associated with poor outcome. A study in Ethiopia found that HIV-TB co-infection were associated with psychological distress (Ayana et al.). A systematic review found a high level of psychological distress and decreased quality of life among TB patients. In the societies, family stress and burden have an integral influence on family members and patient care. Families provide psychosocial support to ailing family members, but this function can seriously be hampered when the family unit is stressed and overwhelmed.
The observation of family stress or burden being worsened by stigma from a family member with TB/HIV-infection is substantiated by the experience of children of the infected persons being expelled from school, the repudiation of families from the society, the reported difficulty of sons and daughters of the affected persons not getting a spouse and the increased divorce rate among discordant couple with these infections.,, Stigmatisation of the family members could also deprive daily earning or put more strain on available resources. Besides, the grief and loss experienced by family members when a relative dies and the societal discriminatory attitude to giving them a befitting burial may significantly add to the pain experienced. This highlights the need for engendering dignity and institutionalising practices that would prevent discrimination against family members of those infected with TB/HIV co-infections.
The strength of this study lies on the psychosocial approach to determine unmeasurable (by linear modelling) factors influencing the suboptimal outcomes of TB/HIV treatment in resource-limited settings, the large sample size and a decade long time span of the study. This data may be a more representation measurement compared with the largely short span, small sample available studies. However, a prospective study design that incorporates other measured sociodemographic variable into a SEM may add more to the current study.
| Conclusion|| |
This study showed that TB/HIV co-infection is a complex psychosocial disorder that is significantly and negatively impacted by social determinants of the disease. A holistic approach to treatment intervention that addresses the latent factors of stigmatization, family stress/burden, and high clinical severity is key to achieving a successful treatment outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Liefooghe R, Baliddawa JB, Kipruto EM, Vermeire C, De Munynck AO. From their own perspective. A Kenyan community's perception of tuberculosis. Trop Med Int Health 1997;2:809-21.
Gallagher R. Diseases that Plague Modern Man. Dobbs Ferry, N.Y.:Oceana Publications; 1969.
Roland CG. Tuberculosis: A half century of study and conquest. Chest 1972;61:32.
McCray E, Weinbaum CM, Braden CR, Onorato IM. The epidemiology of tuberculosis in the United States. Clin Chest Med 1997;18:99-113.
Tiberi S, Carvalho ACC, Sulis G, Vaghela D, Rendon A, de Q Mello FC, et al
. The cursed duet today: Tuberculosis and HIV-coinfection. Presse Med 2017;46:e23-39.
Herzog HB. History of tuberculosis. Respiration 1998;65:5-15.
Daniel TM. Historical review. The history of tuberculosis, in respiratory medicine, 2006;100:1862-70.
Nnoaham KE, Pool R, Bothamley G, Grant AD. Perceptions and experiences of tuberculosis among African patients attending a tuberculosis clinic in London. Int J Tuberc Lung Dis 2006;10:1013-7.
Meulemans H, Mortelmans D, Liefooghe R, Mertens P, Zaidi SA, Solangi MF, et al
. The limits to patient compliance with directly observed therapy for tuberculosis: A socio-medical study in Pakistan. Int J Health Plann Manag 2002;17:249-67.
Craig GM, Daftary A, Engel N, O'Driscoll S, Ioannaki A. Tuberculosis stigma as a social determinant of health: A systematic mapping review of research in low incidence countries. Int J Infect Dis 2017;56:90-100.
Hargreaves JR, Boccia D, Evans CA, Adato M, Petticrew M, Porter JD. The social determinants of tuberculosis: From evidence to action. Am J Public Health 2011;101:654-62.
Naidoo P, Peltzer K, Louw J, Matseke G, McHunu G, Tutshana B. Predictors of Tuberculosis (TB) and Antiretroviral (ARV) medication non-adherence in public primary care patients in South Africa: A cross sectional study. BMC Public Health 2013;13:396.
Naidoo P, Dick J, Cooper D. Exploring tuberculosis patients' adherence to treatment regimens and prevention programs at a public health site. Qual Health Res 2009;19:55-70.
Veen J, Raviglione M, Rieder HL, Migliori GB, Graf P, Grzemska M, et al
. Standardized tuberculosis treatment outcome monitoring in Europe. Recommendations of a working group of the World health organization (WHO) and the European region of the International union against tuberculosis and lung disease (IUATLD) for uniform reporting by cohort analysis of treatment outcome in tuberculosis patients. Eur Respir J 1998;12:505-10.
Federal Ministry of Health Nigeria Department of Public Health. National Tuberculosis and Leprosy Control Programme: Workers Manual. Revised 5th
ed. Abuja, Nigeria: Federal Ministry of Health; 2010.
Krasniqi S, Jakupi A, Daci A, Tigani B, Jupolli-Krasniqi N, Pira M, et al
. Tuberculosis treatment adherence of patients in Kosovo. Tuberc Res Treat 2017;2017, Article ID 4850324, 8 pages. https://doi.org/10.1155/2017/4850324
Mazinyo EW, Kim L, Masuku S, Lancaster JL, Odendaal R, Uys M, et al
. Adherence to concurrent tuberculosis treatment and antiretroviral treatment among co-infected persons in South Africa, 2008–2010. PLoS One 2016;11:e0159317.
Musenge E, Vounatsou P, Collinson M, Tollman S, Kahn K. The contribution of spatial analysis to understanding HIV/TB mortality in children: A structural equation modelling approach. Glob Health Action 2013;6:1.
Engelbrecht MC, Kigozi NG, Chikobvu P, Botha S, Rensburg HC. Unsuccessful TB treatment outcomes with a focus on HIV co-infected cases: A cross-sectional retrospective record review in a high-burdened province of South Africa. BMC Health Serv Res 2017;17:470.
Gebreegziabher SB, Bjune GA, Yimer SA. Total delay is associated with unfavorable treatment outcome among pulmonary tuberculosis patients in West Gojjam Zone, Northwest Ethiopia: A prospective cohort study. PLoS One 2016;11:e0159579.
Courtwright A, Turner AN. Tuberculosis and stigmatization: Pathways and interventions. Public Health Rep 2010;125(Suppl 4):34-42.
Chang S, Cataldo J. A systematic review of global cultural variations in knowledge, attitudes and health responses to tuberculosis stigma. Int J Tuberc Lung Dis 2014;18:168-73, i-iv.
Abioye IA, Omotayo MO, Alakija W. Socio-demographic determinants of stigma among patients with pulmonary tuberculosis in Lagos, Nigeria. Afr Health Sci 2011;11:100-4.
Dodor EA, Neal K, Kelly S. An exploration of the causes of tuberculosis stigma in an urban district in Ghana. Int J Tuberc Lung Dis 2008;12:1048-54.
Wouters E, Sommerland N, Masquillier C, Rau A, Engelbrecht M, Van Rensburg AJ, et al
. 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.
Parks J, Svendsen D, Singer P, Foti ME, Mauer B. Morbidity and Mortality in People with Serious Mental Illness. Vol. 25. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council; 2006. p. 1-87.
Ayana TM, Roba KT, Mabalhin MO. Prevalence of psychological distress and associated factors among adult tuberculosis patients attending public health institutions in Dire Dawa and Harar cities, Eastern Ethiopia. BMC Public Health 2019;19:1392.
Peddireddy V. Quality of life, psychological interventions and treatment outcome in tuberculosis patients: The Indian scenario. Front Psychol 2016;7:1664.
Liefooghe R, Michiels N, Habib S, Moran MB, De Muynck A. Perception and social consequences of tuberculosis: A focus group study of tuberculosis patients in Sialkot, Pakistan. Soc Sci Med 1995;41:1685-92.