Social Stigma and Knowledge of Tuberculosis and HIV among Patients with Both Diseases in Thailand

INTRODUCTION: Disease-related stigma and knowledge are believed to be associated with patients' willingness to seek treatment and adherence to treatment. HIV-associated tuberculosis (TB) presents unique challenges, because TB and HIV are both medically complex and stigmatizing diseases. In Thailand, we assessed knowledge and beliefs about these diseases among HIV-infected TB patients. METHODS: We prospectively interviewed and examined HIV-infected TB patients from three provinces and one national referral hospital in Thailand from 2005-2006. At the beginning of TB treatment, we asked patients standardized questions about TB stigma, TB knowledge, and HIV knowledge. Responses were grouped into scores; scores equal to or greater than the median score of study population were considered high. Multiple logistic regression analysis was used to identify factors associated with scores. RESULTS: Of 769 patients enrolled, 500 (65%) reported high TB stigma, 177 (23%) low TB knowledge, and 379 (49%) low HIV knowledge. Patients reporting high TB stigma were more likely to have taken antibiotics before TB treatment, to have first visited a traditional healer or private provider, to not know that monogamy can reduce the risk of acquiring HIV infection, and to have been hospitalized at enrollment. Patients with low TB knowledge were more likely to have severe TB disease, to be hospitalized at enrollment, to be treated at the national infectious diseases referral hospital, and to have low HIV knowledge. Patients with low HIV knowledge were more likely to know a TB patient and to have low TB knowledge. DISCUSSION: We found that stigma and low disease-specific knowledge were common among HIV-infected TB patients and associated with similar factors. Further research is needed to determine whether reducing stigma and increasing TB and HIV knowledge among the general community and patients reduces diagnostic delay and improves patient outcomes

Baseline TB stigma, TB knowledge, and HIV knowledge among HIV-infected TB patients in Thailand.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome.</p>a<p>Those with available answers.</p>b<p>Five hundred patients had high TB stigma; 75 did not respond to one or more TB stigma questions.</p>c<p>One hundred and seventy-seven had low TB knowledge; 171 did not respond to one or more TB knowledge questions.</p>d<p>Three hundred and seventy-nine patients had low HIV knowledge; 69 did not respond to one or more HIV knowledge questions.</p

Bivariable and multiple logistic regression analyses of predictors for having low TB knowledge^a among HIV-infected TB patients.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; CD4, CD4+ T-lymphocyte; variables for which p≤0.20 in bivariable analyses and potential confounders were included in multiple logistic regression analysis.</p>a<p>TB knowledge score<5; TB knowledge score is a summary score of the number of TB knowledge questions (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0006360#pone-0006360-t002" target="_blank">table 2</a> - each question is worth 1 point) that a patient correctly answered.</p>b<p>Compared with being treated in Bangkok.</p>c<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p

Patient characteristics stratified by TB stigma, TB knowledge, and HIV knowledge.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; CD4, CD4+ T-lymphocyte.</p>a<p>Those with available results only.</p>b<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p>c<p>Patients who reported having a cough lasting greater than one month before TB diagnosis or had other symptoms that lasted longer than 14 days and self-assessed these symptoms as being severe.</p>d<p>High TB stigma defined as TB stigma score ≥1; low TB knowledge defined as TB knowledge score<5; and low HIV knowledge defined as HIV knowledge score<5.</p

Bivariable and multiple logistic regression analyses of predictors for having low HIV knowledge^a among HIV-infected TB patients.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; variables for which p≤0.20 in bivariable analyses and potential confounders were included in multiple logistic regression analysis.</p>a<p>HIV knowledge score<5; HIV knowledge score is a summary score of the number of HIV knowledge questions (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0006360#pone-0006360-t002" target="_blank">table 2</a> - each question is worth 1 point) that a patient correctly answered.</p>b<p>Compared with being treated in Bangkok.</p>c<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p

Bivariable and multiple logistic regression analyses of predictors for having high TB stigma^a among HIV-infected TB patients.

<p>TB, tuberculosis; HIV, human immunodeficiency virus; OR, odds ratio; AOR, adjusted odds ratio; CI, confidence interval; variables for which p≤0.20 in bivariable analyses and potential confounders were included in multiple logistic regression analysis.</p>a<p>TB stigma score ≥1; TB stigma score is a summary score of the number of TB stigma questions (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0006360#pone-0006360-t001" target="_blank">Table 1</a>; each question was worth 1 point) that a patient answered consistent with stigma.</p>b<p>Compared with being treated in Bangkok.</p>c<p>Patients who had extra-pulmonary TB other than peripheral lymphatic TB or had all of the following characteristics: self-reported weight loss >10% of body weight, coughing up blood, difficulty breathing in past 4 weeks before TB diagnosis, and cavitary TB or >1/3 involvement of either lung at the initial evaluation.</p

Safety and tolerability of nevirapine-based antiretroviral therapy in HIV-infected patients receiving fluconazole for cryptococcal prophylaxis: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>To compare the adverse events after initiation of nevirapine-based ART among HIV-infected patients who did not receive fluconazole (group A), received fluconazole 400 mg/week (group B), and received fluconazole 200 mg/day (group C).</p> <p>Methods</p> <p>A retrospective cohort study was conducted among HIV-infected patients who began NVP-based ART between December 2003 and September 2004. Patients were followed up for 6 months. Clinical hepatitis, elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (> 3 times from baseline), and skin rashes were studied.</p> <p>Results</p> <p>There were 686 patients; 225, 392, and 69 patients in group A, B, and C, respectively. Baseline characteristics including age, previous opportunistic infections, use of antituberculous drugs, and baseline aminotransferase levels among the three groups were similar. Group C had a higher proportion of men (<it>p </it>= 0.016). Baseline median (IQR) CD4 cell counts were 85 (21–159), 18 (7–48), and 16 (5–35) cell/mm³in group A, B, and C, respectively (<it>p </it>< 0.001). Of 2/225 (0.9%), 4/392 (1.0%), and 0/69 (0%) patients in group A, B, and C developed clinical hepatitis (<it>p </it>= 0.705). There were no significant difference of elevated AST or ALT among the three groups (<it>p </it>> 0.05). By logistic regression, receiving fluconazole was not predictive of clinical hepatitis, elevated aminotransferase, or skin rashes. At 6 months after initiating NVP, 174 (77.3%) patients in group A, 309 (78.8%) patients in group B, and 58 (84.1%) patients in group C remained on NVP.</p> <p>Conclusion</p> <p>Initiation of NVP-based ART among Thais with advance HIV disease receiving fluconazole is safe and well-tolerated. nevirapine should not be contraindicated for patients receiving fluconazole for treatment or prophylaxis of cryptococcosis.</p