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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 105-109

Clinical and Psychosocial Determinants of Patients with Tuberculosis/Human Immunodeficiency Virus Co-Infection: A Structural Equation Model Approach


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 Submission25-Jul-2020
Date of Acceptance18-Sep-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Dr. M A Alao
Department of Paediatrics, Bowen University Teaching Hospital, Box 15, Ogbomoso, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_466_20

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   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 Top


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.[1],[2],[3],[4],[5],[6],[7],[8] 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.[1],[2],[3],[4],[5],[6],[8] 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.[6],[9],[10] 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.[5],[6]

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.[11]

The implication of a restricted clinical view of TB/HIV treatment outcomes alone is multi-fold and lethal.[11],[12] 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.[12] 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.[13],[14]

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 Top


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

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The different treatment outcomes as defined by the WHO guidelines and the International Union Against Tuberculosis and Lung Diseases are as follows:[15],[16]

  1. Cure: Sputum smears negative on two occasions, one of which must be at treatment end.
  2. Treatment completed: Patient completed treatment but last smear unavailable or extrapulmonary TB.
  3. Successful treatment is i or ii.
  4. Relapse: Patient who was declared cured but later develops a smear-positive TB.
  5. Treatment failure: Patient remains smear positive ≥5-months after beginning treatment.
  6. Default: Patient had ≥1-month of treatment with >2 month interruption.
  7. Death: Patient dies of any cause during the course of treatment course.
  8. Transfer out: Patient referred out of catchment area and outcome of treatment is unknown.
  9. Potentially unsatisfactory treatment outcome is a combination of treatment default, transferred out and treatment failure.[15]
  10. Treatment adherence: Failure of a patient with TB to receive TB drug for more than 3 days in a week.[17]



   Result Top


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.

Treatment adherence

Non-adherence led to potentially unsatisfactory outcomes but did not impact mortality (β = -0.557, P < 0.001 and β = 0.000, respectively).

Stigmatization

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

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 Top


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.[18] 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.[12],[19] 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.[20]

The findings of non-adherence to treatment being associated with potentially unsatistactory outcome (treatment failure and default) is comparable to the report in literature.[13],[14] 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.[13],[14]

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.[6],[11],[21] Of particular interest is the significant impact of stigmatization observed on HIV negative patients with tuberculosis similar to the reports by researchers.[22],[23],[24],[25] 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.[21],[26] 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.[27] 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.).[28] A systematic review found a high level of psychological distress and decreased quality of life among TB patients.[29] 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.[1],[6],[30] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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