Coinfection problems boost patient social problems
Harlem Hospital has model DOT program
Patients treated for active TB are more likely to be homeless, unemployed, and actively abusing controlled substances if they also are infected with the human immunodeficiency virus (HIV), according to a new study presented at the 14th International AIDS Conference, held July 7-12, 2002, in Barcelona, Spain.
The study also found a higher percentage of foreign-born people among the TB-only group and a significantly greater number of African-Americans among the TB/HIV coinfected cohort in the TB treatment program at Harlem Hospital in New York City.1
"We were curious about what we could find that might be distinctive about the HIV-positive group, and that’s what led to this analysis," says Paul Colson, PhD, program director of the Charles P. Felton National Tuberculosis Center, affiliated with the division of infectious diseases at Harlem Hospital and Columbia University.
Patients who are coinfected with TB/HIV have substantial social problems and barriers to treatment, says Yael Hirsch-Moverman, MS, MPH, an epidemiologist with the Charles P. Felton National TB Center.
Social programs imperative
"It is therefore imperative that TB programs incorporate social services — such as a case manager, peer support, etc. — incentives and enablers, including transportation and food coupons, and health education into their curriculum," Hirsch-Moverman says.
There were some other differences between the TB-only and HIV/TB groups, but these were not statistically significant. For example, 47.7% of the women among the total 112 patients with TB also were HIV-positive, and 30% of the men were coinfected with TB and HIV. A small percentage of TB patients had an unknown HIV status. "People who were HIV-positive were less likely to be married," Colson says. "Among those who were foreign-born, 12% of the TB patients were HIV-positive, and 88% were HIV-negative."
Participants were asked 24 questions about TB and 12 questions pertaining to HIV infection. Investigators found that 28.6% of those who were both TB- and HIV-infected and 4.4% of those who were only TB infected answered at least 75% of the questions correctly. Also, 69% of those with HIV/TB coinfection answered at least three-quarters of the HIV questions correctly, compared with 44.3% of the TB patients who were not HIV-infected.1
The study concluded that coinfected HIV/TB patients face significant barriers to completing TB treatment, although they tend to be more knowledgeable about both TB and HIV.1 "The people who had HIV tended to know a bit more about TB than the non-HIV patients with TB," Colson says. "It was very close to being significant."
A surprising finding
This finding was not surprising to the researchers, Hirsch-Moverman says. "Being infected with HIV, clearly these patients are more exposed to education efforts regarding HIV infection," Hirsch-Moverman says. "Moreover, since TB poses additional risks for persons infected with HIV, it is essential that they understand the nature of TB disease and its treatment."
Another interesting factor relating to TB and HIV education is the paradox that in the Harlem community TB has a greater stigma attached to it than does HIV infection, Colson notes. "Nobody wants it broadcast that they have HIV," Colson adds.
But since HIV infection in Harlem is closely tied to injection drug use, it doesn’t have the stigma of being associated with homosexuality as it does in other places, whereas the community sees TB as a dirty disease, Colson explains. "With TB, it’s hard to hold your head up and say you have TB," he adds. "Who would you rather be in a room with — someone with active TB or HIV infection?"
For example, people seen at Harlem Hospital often ask if they can catch TB from being in a subway car with an infected person who is coughing. Educators then explain that there is little risk of TB infection in that scenario because there is an active exchange of air in the subway, Colson says. "When somebody is identified with active TB, there has to be a contact investigation to make sure people in the household don’t have the disease," Colson says. "If patients don’t live with their families, then their families may not know they’re in treatment; and people are often very protective of that information."
Avoiding the stigma
For this reason, clinic staff are very careful to never identify the TB connection on envelopes and in phone messages sent to TB patients. "There’s a great amount of stigma attached to this disease, despite the fact that most people raised in America don’t have much experience with TB," Colson adds. "So people tend not to know much about it, but they fear it greatly."
While it’s not always easy to educate TB patients about their disease and also about the possibility of HIV infection, this sort of knowledge, as well as HIV testing and counseling, can be important if they are to be given the best course of care. "HIV infection does have implications for the TB regimens," he adds. "But you can’t force people to be tested, and that’s why we didn’t know the HIV status of everybody in the study."
The social and demographic issues are important to consider during TB care, particularly when a program offers a holistic approach to TB treatment as does the Harlem Hospital direct observational therapy (DOT) program, Colson notes. "With our on-site DOT program, it offers the opportunity to address other problems, such as we have food available and a warm, friendly environment," Colson says.
It didn’t surprise researchers that the HIV-positive TB patients tended to have personal problems that could interfere with therapy, Colson says. "What we didn’t find actually was any differences in treatment completion among the two groups of patients," Colson adds. "That’s an artifact of the whole DOT system: We don’t allow people to run around the community untreated, so that anybody with active TB is provided follow-up until they complete treatment."
(Editor’s note: Charles P. Felton National TB Center of New York City has a training booklet, titled Social Support Services for Tuberculosis Centers, which is available through the center’s web site at www.harlemtbcenter.org.)
1. Hirsch-Moverman Y, El-Sadr WM, Colson P. Characteristics, needs, and HIV and TB knowledge among HIV-infected and HIV-uninfected patients undergoing treatment for tuberculosis (TB) in Harlem, NY. Abstract ThPeC7562. Presented at the XIV International AIDS Conference. Barcelona, Spain; July 7-11, 2002.
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