Social constraints to TB/HIV healthcare: Accounts from coinfected patients in South Africa

Abstract

There is a growing imperative to improve the coordination and collaboration of tuberculosis (TB) and HIV healthcare services in response to escalating rates of TB/HIV coinfection. Patient-specific challenges associated with the delivery of TB/HIV care have been minimally explored in this regard. As part of a larger study conducted in South Africa, this article highlights coinfected patients' experiences with TB and HIV healthcare in light of their broader social environments. Qualitative, in-depth interviews were conducted with 40 adult, coinfected patients (24 women and 16 men) and eight key-informant healthcare workers at three urban/peri-urban, ambulatory, public health clinics in the high-burden province of KwaZulu-Natal. Transcribed interviews were analyzed under a modified grounded theory approach to capture subjective meanings of healthcare experience subsequent to patients' codiagnosis with TB and HIV. Emerging analytic themes highlighted critical sociomedical constraints to TB/HIV care in relation to patients' income and employment, eligibility for social assistance and antiretroviral treatment, fears around illness disclosure, social and material support, and treatment adherence. Patients' healthcare experiences were bound by their poor access to essential resources, multiple life responsibilities, disparate gender roles, limits within the healthcare system, and the stigmatizing social symbolism of their illness. Overlapping social inequalities perpetuated coinfected patients' experiences with stigma and collectively mediated their health decisions around disclosure, adherence, and retention in medical care. The study urges a contextualized understanding of the social challenges associated with TB/HIV healthcare and helps inform more patient-sensitive and socially responsive interventions against the co-epidemic.

Keywords:

• South Africa
• patient perspectives
• TB/HIV coinfection
• integration
• qualitative methods

Acknowledgements

The authors would like to thank the study participants and study sites, Centre for the AIDS Programme of Research in South Africa (CAPRISA), KwaZulu-Natal Department of Health, Canadian Institutes of Health Research (CIHR) Social Research Centre in HIV Prevention, and Ms. Zanele Gwamanda. The study was in partial completion of AD's doctoral dissertation at the Dalla Lana School of Public Health, University of Toronto, and received funding from CIHR and the International Development Research Centre (IDRC), Canada. CAPRISA was established as part of the Comprehensive International Program of Research on AIDS (CIPRA; grant no. AI51794) from the US National Institutes of Health; the Columbia University-Southern African Fogarty AIDS International Training and Research Program (AITRP) funded by the Fogarty International Center, National Institutes of Heath (grant no. D43TW00231) to NP.