The synergy between TB and HIV co-infection on perceived stigma in Ethiopia

Background The synergy between tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection on perceived stigma is not well studied. The objective of this study was to assess the effect of TB/HIV co-infection on perceived stigma in selected hospitals of Oromiya region, Ethiopia. A cross sectional study was conducted from February to April, 2009 in Adama, Nekemet and Jimma Specialized hospitals. Data were collected by trained HIV counselors. A structured questionnaire which consisted of socio-demographic variables, clinical information, perceived stigma, and depression was used to collect the data Findings A total of 591 participants were included in the study of whom 124 (20.9%) were co-infected with TB/HIV. The stigma items were highly reliable (Cronbach's alpha = 0.93) and had strong inter dimension correlation. Respondents who were co-infected with TB and HIV were more likely to have perceived stigma compared to non-co-infected HIV patients, [OR = 1.4, (95% CI: 1.2, 2.0)]. Non-literate individuals [OR = 1.9, (95% CI: 1.2, 3.0)] and females [OR = 1.6, (95% CI: 1.2, 2.3)] had also more perceived stigma. Conclusions TB/HIV co-infected patients, non-literate individuals and females were more likely to have high perceived stigma. Behavioral Change Communication should focus on these segments of the population to rectify the high perceived stigma.


Background
The extensive nature of stigma against people with AIDS is well established [1,2]. People living with HIV/ AIDS (PLHA) have been stigmatized worldwide since the beginning of the epidemic; leading to severe social consequences related to their rights, health care services, freedom, self identity and social interactions [1]. Stigma and discrimination related to HIV/AIDS would undermine public health efforts to combat the epidemic. The UN stated that stigma against PLHA still hamper prevention, care and treatment efforts everywhere [2].
The literature showed that perceived HIV stigma has a negative and constant impact on life satisfaction [3] and quality of life [4,5]. HIV related stigma has been correlated with poorer mental health outcomes, lowered selfesteem, lowered self-efficacy, and decreased adherence to antiretroviral treatments [6].
Several studies have been conducted on the consequences of stigma [7] and its effect on receiving HIV/ AIDS related services [8,9]. However, little is known about the synergy between TB and HIV co-infection on perceived stigma. The present study assessed effect of TB/HIV co-infection on perceived stigma towards TB/ HIV co-infection.

Methods
From February to April, 2009, we conducted a cross sectional study in three hospitals in Ethiopia. A detail method of the study is published elsewhere [10]. In brief, the study was conducted in Adama, Nekemet and Jimma specialized hospitals located at the east, west and southwest part of Ethiopia. The study population consisted of 155 TB/HIV co infected and 465 HIV patients. During the study period, new TB patients (n = 124) in each TB/HIV clinic of the hospitals were included. For each TB/HIV co-infected patient, 3 HIV patients with no TB were included. The non-co-infected HIV patients were selected using a simple random sampling technique using the patients' unique identification number in the HIV clinics. The exclusion criteria for both groups included age less than 15 years and presence of known chronic illnesses like diabetes mellitus and hypertension.
A structured questionnaire was used to collect information from the respondents. The content of the questionnaire included socio-demographic variables, clinical information, social support, perceived stigma and depression. Perceived stigma was measured by 23 Likert scale items adopted from Berger et al [11].
Data were entered into computer and analyzed using SPSS version 15.0 software. The stigma questions were scaled in positive direction where higher score denotes high perceived stigma. A total stigma score was created by summing all the scores of the stigma questions. The mean was calculated from the total stigma score and individuals who scored below the mean were categorized as having 'low' perceived stigma. Those who scored above the mean were categorized as having 'high' perceived stigma. Bivariate analysis was computed to identify factors associated with perceived stigma. To control the effect of confounding variables, stepwise logistic regression model was done to identify predictors of perceived stigma. Variables which had statistically significant association in the bivariate analysis were candidates for the multivariate logistic regression model. Interaction between variables were tested but are not reported as none were significant.
Ethical clearance was obtained from Jimma University ethical review board. The purpose of the study was explained to the respondents. Written consent was obtained from the study participants. To ensure confidentiality, codes were anonymous.

Results
Of the 620 eligible respondents, complete data were obtained from 591 (95%) of them. One hundred twenty four (20.9%) of the study participants were co-infected with TB and HIV. From the planned 155 TB/HIV coinfected patients, only 124 of them were interviewed and the rest 31 patients lost to follow up. Of the coinfected patients, 61 (49.2%) and 42 (33.8%) had smear negative and positive TB respectively. About two third (67.2%) of the patients had CD4 lymphocyte count of less than 200/μL. Of the total participants, 107 (18%) and 355 (60%) were in the 2 nd and 3 rd stage of the WHO clinical stage classification respectively.
The Majority, 344 (58.2%) of the study participants were females. The mean age of the respondents was 33.4 years (SD ± 8.1). Nearly half 276 (46.7%) of the respondents were in the age group of 25-34 years (Table-1).
More than half of the respondents (56%) had high perceived stigma. The Multivariate analysis predicted that there was a significant relationship between perceived stigma and TB/HIV co-infection, depression, level of education and gender. Respondents who were co-infected with TB and HIV were 1.4 times more likely to have high perceived stigma as compared to non-co-  (Table-2).
Age, Social support, income, CD4 lymphocyte count, and WHO staging didn't have statistically significant association with perceived stigma.

Discussion
This study identified factors associated with perceived stigma in HIV patients. More than half of our study participants had experienced high perceived stigma. This figure is much higher than the finding of Vissel et al (33%) in South Africa [12]. However, the burden of stigma by other people (negative reaction towards PLHA) might be lower than the perceived stigma in Ethiopia. A study done in India found that actual stigma was much lower than perceived stigma [13]. The high proportion of people with high perceived stigma in our setting could have negative consequences on adherence to antiretroviral therapy and other HIV/AIDS related care [8,9,13] and disclosure of the HIV status of individuals [14]. Self stigmatized people might develop negative attitude towards health professionals and health care and are less likely to disclose their HIV status and could spread the virus to others [14].
A study in South Africa showed that older individuals, males and the less educated ones were more likely to had high perceived stigma [12]. In our study, non-literate individuals and females were more likely to have high perceived stigma. The low social status and economic dependency of women and non-literate individuals in our country could act in synergy with TB/HIV co-infection to increase the perceived stigma among women and nonliterate individuals. Unlike other studies [14,15], we did not show an association between age and income with perceived stigma. The literature showed that social support is a good buffer in reducing perceived stigma [15]. However, our study couldn't prove this hypothesis.
People with mental health problems are at higher risk of experiencing perceived stigma [15,16]. However, in our study, stigma could be also the risk factor for depression. Internalized shame and feeling of guilty is one of the predictor of depression or other form of mental distress [16].
TB/HIV co-infected patients were more likely to have perceived stigma. The literature showed that people with TB have been discriminated and isolated from the society for fear of infection [17]. Co-infected patients might perceive that the community would avoid them for fear of infection in our setting. This double burden stigma of TB might aggravate the already existing perceived stigma due to HIV. WHO staging and lower CD4 lymphocyte count didn't show significant association with perceived stigma in our setting. Other literature showed that clinical stage was one of the predictors of perceived stigma [15].
Although we tried to document the effect of TB/HIV co-infection on perceived stigma for the first time, our finding didn't include survey on actual stigma and qualitative study to triangulate the findings.

Conclusions
More than half of the study participants had high perceived stigma. Non-literate individuals, females and TB/ HIV coinfected patients were more likely to have high perceived stigma. Behavioral Change Communication should focus on these segments of the population to reduce perceived stigma.