Perceived stigma among people with TB and household contacts.

BACKGROUND: TB-related stigma hampers access to diagnosis and treatment, making it important to understand the demographic and clinical characteristics associated with perceived TB stigma. TB stigma has not been studied in household contacts before, yet they comprise an important population for epidemic control, with high risk of infection.METHOD: A cross-sectional study was conducted among people with TB and household contacts in South Africa using a 12-item perceived TB stigma scale (score range: 0-36). Demographic and clinical characteristic data were collected using a close-ended questionnaire. A linear mixed-effects regression model was used to explore perceived TB stigma levels and its associated characteristics.RESULTS: The sample included 143 people with TB and 135 household contacts. The mean perceived TB stigma score among people with TB was 22.1 (95% CI 21.1-23.1) and 22.2 (95% CI 21.1-23.3) among household contacts. Being in the same household explained 24.3% variability in stigma perception. Residence in the urban study site (Soshanguve) and a positive HIV diagnosis were associated with higher perceived TB stigma score.CONCLUSIONS: People with TB and household contacts have similarly high prevalence of perceived TB stigma. Positive HIV status and urban location were associated with higher prevalence of perceived TB stigma.

Time to care-seeking for TB symptoms.

BACKGROUND: Early presentation to healthcare facilities is critical for early diagnosis and treatment of TB. We studied self-reported time to care-seeking from the onset of TB symptoms among primary healthcare clinic (PHC) attendees in Limpopo Province, South Africa.METHODS: We used data from participants enrolled in a cluster-randomized trial of TB case finding in 56 PHC clinics across two health districts. We fitted log-normal accelerated failure time regression models and we present time ratios (TRs) for potential risk factors.RESULTS: We included 2,160 participants. Among the 1,757 (81%) diagnosed with active TB, the median time to care-seeking was 30 days (IQR 14-60); adults sought care later than children/adolescents (adjusted TR aTR 1.47, 95% CI 1.10-1.96). Among those not diagnosed with TB, the median was 14 days (IQR 7-60); being HIV-positive (aTR 1.57, 95% CI 1.03-2.40); having less than grade 8 education and currently smoking were associated with longer time to care-seeking. In the combined analysis, living with HIV and having underlying active TB was associated with faster care-seeking (TB status x HIV interaction: TR 0.68, 95% CI 0.48-0.96).CONCLUSION: Delay in care-seeking was associated with age, lower education and being a current smoker. TB awareness campaigns targeting these population groups may improve care-seeking behavior and reduce community TB transmission.

Geographic mobility and time to seeking care among people with TB in Limpopo, South Africa.

SETTING: Human mobility contributes to the spread of infectious diseases. South Africa has a long history of internal labor migration and a high burden of TB.METHODS: People newly diagnosed with TB in the Vhembe and Waterberg Districts of Limpopo answered a questionnaire regarding geographic movement over the past year. Participants were classified as 'highly mobile' (spending more than 30 nights at a residence other than their primary residence in the past year, or being ≥250 km from their primary residence at the time of the interview) or 'less mobile'. We explored associations between sociodemographic characteristics and high mobility, and between mobility and time to presentation at a clinic.RESULTS: Of the 717 participants included, 185 (25.7%) were classified as 'highly mobile'. Factors associated with high mobility included living with someone outside of Limpopo Province, HIV-positive status (men only), and current smoking (men only). Highly mobile individuals had similar care-seeking behavior as less mobile individuals (adjusted time ratio 0.9, 95% CI 0.6-1.2, P = 0.304)CONCLUSION: Highly mobile people with TB in Limpopo Province were more likely to live with people from outside the province, smoke, and have HIV. These patients had similar delays in seeking care as less mobile individuals.

Combined HIV Adolescent Prevention Study (CHAPS): comparison of HIV pre-exposure prophylaxis regimens for adolescents in sub-Saharan Africa-study protocol for a mixed-methods study including a randomised controlled trial.

BACKGROUND: HIV remains a major public health issue, especially in Eastern and Southern Africa. Pre-exposure prophylaxis is highly effective when adhered to, but its effectiveness is limited by cost, user acceptability and uptake. The cost of a non-inferiority phase III trial is likely to be prohibitive, and thus, it is essential to select the best possible drug, dose and schedule in advance. The aim of this study, the Combined HIV Adolescent PrEP and Prevention Study (CHAPS), is to investigate the drug, dose and schedule of pre-exposure prophylaxis (PrEP) required for the protection against HIV and the acceptability of PrEP amongst young people in sub-Saharan Africa, and hence to inform the choice of intervention for future phase III PrEP studies and to improve strategies for PrEP implementation. METHODS: We propose a mixed-methods study amongst young people aged 13-24 years. The first component consists of qualitative research to identify the barriers and motivators towards the uptake of PrEP amongst young people in South Africa, Uganda and Zimbabwe. The second component is a randomised clinical trial (ClinicalTrials.gov NCT03986970, June 2019) using a novel ex vivo HIV challenge method to investigate the optimal PrEP treatment (FTC-TDF vs FTC-TAF), dose and schedule. We will recruit 144 amongst HIV-negative uncircumcised men aged 13-24 years from voluntary male medical circumcision clinics in two sites (South Africa and Uganda) and randomise them into one of nine arms. One group will receive no PrEP prior to surgery; the other arms will receive either FTC-TDF or FTC-TAF, over 1 or 2 days, and with the final dose given either 6 or 20 h prior to surgery. We will conduct an ex vivo HIV challenge on their resected foreskin tissue. DISCUSSION: This study will provide both qualitative and quantitative results to help decide the optimum drug, dose and schedule for a future phase III trial of PrEP. The study will also provide crucial information on successful strategies for providing PrEP to young people in sub-Saharan Africa. TRIAL REGISTRATION: ClinicalTrials.gov NCT03986970 . Registered on 14 June 2019.

Tuberculosis patients with higher levels of poverty face equal or greater costs of illness.

SETTING: Fifty-six public clinics in Limpopo Province, South Africa.OBJECTIVE: To evaluate the association between tuberculosis (TB) patient costs and poverty as measured by a multidimensional poverty index.DESIGN: We performed cross-sectional interviews of consecutive patients with TB. TB episode costs were estimated from self-reported income, travel costs, and care-seeking time. Poverty was assessed using the South African Multidimensional Poverty Index (SAMPI) deprivation score (a 12-item household-level index), with higher scores indicating greater poverty. We used multivariable linear regression to adjust for age, sex, human immunodeficiency virus status and travel time.RESULTS: Among 323 participants, 108 (33%) were 'deprived' (deprivation score >0.33). For each 0.1-unit increase in deprivation score, absolute TB episode costs were 1.11 times greater (95%CI 0.97-1.26). TB episode costs were 1.19 times greater with each quintile of higher deprivation score (95%CI 1.00-1.40), but lower by a factor of 0.54 with each quintile of lower self-reported income (higher poverty, 95%CI 0.46-0.62).CONCLUSION: Individuals experiencing multidimensional poverty and the cost of tuberculosis illness in Limpopo, South Africa faced equal or higher costs of TB than non-impoverished patients. Individuals with lower self-reported income experienced higher costs as a proportion of household income but lower absolute costs. Targeted interventions are needed to reduce the economic burden of TB on patients with multidimensional poverty.

An observational study of safe and risky practices in funeral homes in South Africa.

BACKGROUND: Funeral home personnel are at risk of exposure to infectious hazards. The high prevalence of infectious diseases in South Africa means that these workers and family members of deceased individuals are vulnerable to infection if proper safety measures and equipment are not used. OBJECTIVES:  To collect observational information on funeral industry practices in order to assess the safety of handling corpses and exposure to risk that could result in disease transmission. METHODS: A cross-sectional study was conducted across two locations from August to October 2015. Funeral homes in Klerksdorp and Soweto were approached. The study team did facility assessments and observed preparation practices, focusing on safety equipment, personal protective equipment (PPE) and contact with hazardous materials. Interviews with funeral home personnel and relatives of the deceased were also conducted. RESULTS: Of the funeral homes, 23.0% (20/87) agreed to participate. A median of 5 personnel (interquartile range 4 - 8) were employed per facility. It was observed that not all PPE was used despite availability. Gloves, aprons and face masks were most commonly worn, and no personnel were observed wearing boots, gowns or plastic sleeves. Funeral homes were located near food outlets, schools and open public spaces, and not all had access to proper biohazardous waste disposal services. Of 5 family members who were interviewed for the study, none reported being willing to partake in the funeral preparation procedure. CONCLUSIONS: There is a need to standardise the use of safety equipment, waste disposal methods and location designation in the funeral industry.

Risk factors for catastrophic costs associated with tuberculosis in rural South Africa.

Fifty-five public clinics in northern South Africa. To estimate patient costs and identify the factors associated with catastrophic costs among individuals treated for tuberculosis (TB). We performed cross-sectional interviews of consecutive patients at public clinics from October 2017 to January 2018. 'Catastrophic costs' were defined as costs totalling ≥20% of annual household income. For participants with no reported income, we considered scenarios where costs were considered non-catastrophic if 1) costs totalled Among 327 participants, the estimated mean TB episode costs were US$365 (95%CI 233-498): out-of-pocket costs comprised 58% of costs, wages lost due to health care-seeking represented 26%, and income reduction accounted for 16% of costs. Ninety (28%) participants experienced catastrophic costs, which were associated with clinic travel times of 60-90 min (adjusted prevalence ratio [aPR] 1.7, 95%CI 0.9-3.1), unemployment (aPR 2.0, 95%CI 1.0-4.0) and having fewer household members (aPR 0.6, 95%CI 0.3-1.0). In rural South Africa, catastrophic costs from TB are common and associated with distance to clinics, unemployment, and household size. These findings can help tailor social protection programs and enhance service delivery to patients at greatest risk of experiencing financial hardship. .

An observational study of safe and risky practices in funeral homes in South Africa

Background. Funeral home personnel are at risk of exposure to infectious hazards. The high prevalence of infectious diseases in South Africa means that these workers and family members of deceased individuals are vulnerable to infection if proper safety measures and equipment are not used. Objectives. To collect observational information on funeral industry practices in order to assess the safety of handling corpses and exposure to risk that could result in disease transmission. Methods. A cross-sectional study was conducted across two locations from August to October 2015. Funeral homes in Klerksdorp and Soweto were approached. The study team did facility assessments and observed preparation practices, focusing on safety equipment, personal protective equipment (PPE) and contact with hazardous materials. Interviews with funeral home personnel and relatives of the deceased were also conducted. Results. Of the funeral homes, 23.0% (20/87) agreed to participate. A median of 5 personnel (interquartile range 4 - 8) were employed per facility. It was observed that not all PPE was used despite availability. Gloves, aprons and face masks were most commonly worn, and no personnel were observed wearing boots, gowns or plastic sleeves. Funeral homes were located near food outlets, schools and open public spaces, and not all had access to proper biohazardous waste disposal services. Of 5 family members who were interviewed for the study, none reported being willing to partake in the funeral preparation procedure. Conclusions. There is a need to standardise the use of safety equipment, waste disposal methods and location designation in the funeral industry

Latent tuberculous infection in schoolchildren and contact tracing in Matlosana, North West Province, South Africa.

This is a cross-sectional study to estimate the prevalence of latent tuberculous infection (LTBI) and the annual risk of tuberculous infection (ARTI) among a sample of children aged 5 and 7 years in Matlosana, South Africa. LTBI prevalence was significantly higher in children aged 7 years (n = 704) (19.7%, 95%CI 16.75-22.65) than in those aged 5 years (212/1401, 15.1%, 95%CI 13.23-16.97) (P = 0.0075). The ARI was 2.9% (95%CI 2.2-3.6).

Undiagnosed TB in adults dying at home from natural causes in a high TB burden setting: a post-mortem study.

BACKGROUND: A high proportion of deaths in Africa occur at home, where cause of death (CoD) is often unknown. We ascertained undiagnosed pulmonary tuberculosis (TB) by performing limited autopsies in adults dying at home in whom there was no apparent CoD. METHODS: Mortuaries in Matlosana, South Africa, identified potentially eligible adults with no ante-mortem diagnosis and/or no recent hospital admission. A questionnaire was administered to family members. Bilateral lung core biopsies and modified bronchoalveolar lavage (BAL) were performed. The biopsies were examined histologically and submitted with BAL aspirates for mycobacterial culture (MGIT(TM)) and Xpert(®) MTB/RIF testing. Human immunodeficiency virus (HIV) testing was not performed. RESULTS: Of 162 families approached, 28 refused and 29 of the deceased were on or had recently stopped anti-tuberculosis treatment; 85 were included. All were Black and 53% were men. The median age was 57 years (interquartile range [IQR] 44-66) and median symptom duration (mainly cough) was 63 days (IQR 14-112). Laboratory evidence of TB was found in 27 (31.8%); 21 were Xpert-positive, 23 were MGIT-positive and 14 had histological evidence consistent with active TB. CONCLUSION: In this high HIV prevalence setting, a quarter of the home deaths had evidence of undiagnosed, likely infectious TB, suggesting that TB-related mortality is under-ascertained and under-reported, with serious implications for TB control in high TB burden settings.