Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers

Edwin Wouters,Michelle Engelbrecht,Gladys Kigozi,Nina Sommerland,Caroline Masquillier,André Janse Van Rensburg,Wim Van Damme,Asta Rau,Koen Ponnet

doi:10.1186/s12879-020-4816-3

Abstract

BackgroundHIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma.MethodsUsing Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group.ResultsThe results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy.ConclusionsThis is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences.Trial registrationSouth African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Highlights

HIV and tuberculosis (TB) are intricably interlinked in South Africa
Health care workforce The current study focuses on health care workers (HCWs) as the dual burden of TB and HIV has a severe impact on these professionals
The current study aims to explore the dynamics of double stigma and its impact on TB stigma among HCWs by analyzing the baseline data of a cluster randomized controlled trial – the HIV and TB Stigma among Health Care Workers Study (HaTSaH study)

Summary

Introduction

HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this coepidemic remain relatively unexplored. The country has the highest number of people living with HIV (7.0 million in 2016) [1,2,3,4] It has one of the most severe TB epidemics in the world, with the highest incidence of TB (834 per 100,000 in 2015) and 19,613 reported cases of multi-drug resistant TB in 2015 [5]. Ample research has addressed the clinical and health system challenges of the HIV and TB co-epidemic [7, 8], but – as Daftary (2012) rightfully pointed out – “the social aspects remain relatively unexplored” [9], especially the potential stigma associated with HIV and TB in a setting confronted with this dual epidemic. Evidencebased knowledge on the double stigma generated by the interlinked nature of both epidemics is urgently needed as both HIV and TB stigma have been individually extensively associated with non-disclosure [10,11,12], delayed health care [13,14,15,16], and worse (physical and psychological) health outcomes [10, 14, 17,18,19,20,21]

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Conclusion