Delays in presenting for tuberculosis treatment associated with fear of learning one is HIV-positive

Abstract

A cornerstone of tuberculosis (TB) control is early diagnosis and treatment. The first hurdle that prospective TB patients must overcome is to present at a public health clinic for treatment. The Global Plan to Stop TB addresses the new challenges of the intersecting epidemics of TB and HIV, and it aims to cut the transmission chain by achieving early and effective treatment of all people with TB infection. This goal may be more difficult to achieve in practice. Findings from a representative community survey conducted in an area of high HIV prevalence in the Eastern Cape Province of South Africa suggest that patients must conquer fear of knowing their HIV status in order to present for TB diagnosis and treatment. A total of 1 020 adults residing in a low-income suburb of Grahamstown, Makana Municipality, participated in a questionnaire survey that probed attitudes and opinions about TB and HIV/AIDS-related issues. The respondents were presented with eight factors previously cited in the literature as causing delays in presenting for TB treatment at a public health clinic. The single largest proportion of respondents attributed delay to a fear of discovering that one is HIV-positive. While the vast majority of the respondents agreed that knowing one's HIV status is a civic responsibility (‘the right thing to do’), half indicated that the lack of privacy during voluntary counselling and testing for HIV at a public health clinic acts as a disincentive. The evidence suggests that a fear of knowing one's HIV status is a deep-seated anxiety that is often not openly acknowledged, and that it is intertwined with the stigma related to the ‘new’ TB associated with HIV and AIDS. It is crucial to allay this deep-seated fear in the general public so that South Africa's integrated HIV and TB services, designed to accelerate control of the twin epidemics, are successful.

Keywords:

• case-finding
• diagnosis and treatment
• HIV-status anxiety
• tuberculosis
• South Africa
• stigma

Notes

1. While information on respondents' education level is routinely collected in attitude surveys, the focus group discussions conducted for the pilot study suggested that religious values were also important in shaping views on TB and HIV/AIDS-related stigma. Therefore, background information was collected on religious affiliation and religiosity as well as education. Being a self-reported born-again Christian served as a proxy variable indicating religiosity in our study.

2. Moral and biomedical understanding of TB risk are likely intertwined. A follow-up study (Møller et al., 2010) found that heavy drinking and smoking in shebeens (unlicensed township liquor outlets) was associated with a risky lifestyle that can spread both TB and HIV. The self-reported born-again Christians in the survey reported on here were more likely than others to cite drinking and smoking as a TB-risk factor.

3. The respondents were defining the anchors of a scale to measure their subjective wellbeing using Anamnestic Comparative Self-Assessment (ACSA), which was applied for the first time in a South African survey. Previously the ACSA measure had been pilot-tested among Xhosa-speakers using a convenience sample (Møller, Theuns, Erstad & Bernheim, 2008).