WORKING TOGETHER TO ERADICATE TB:REACH THE 3 MILLION:A TB TEST, TREATMENT & CURE FOR ALL

1. WORKING TOGETHER TO ERADICATE TB:REACH THE 3 MILLION:A TB TEST, TREATMENT & CURE FOR ALL Joint Round Table: HSRC, UCT & SU

2. PSYCHOSOCIAL ASPECTS OF TB Professor Pamela Naidoo Population Health, Health Systems & Innovation (PHHSI): Human Sciences Research Council (HSRC), South Africa, & Extraordinary Professor at the University of the Western Cape (UWC) pnaidoo@hsrc.ac.za HSRC, 02 June 2014

3. INTRODUCTION • Presentations at the round table provide a ‘holistic’ perspective of TB: framed by a Bio-Psycho-Social Model • Fellow speakers focus primarily on the biomedical aspects of TB • This presentation will hone in on the psychosocial aspects of TB • By the end of the round table we should have demonstrated how the biological, psychological and socio-economic factors associated with an infectious disease such as TB, are inter-related

4. INTRODUCTION cont… HISTORICAL CONTEXT • Prior to mid-1800s TB was almost unknown in SA • Since then there’s been a steady increase in TB prevalence • Historically poor living & working conditions of miners set the stage for rapid TB transmission in SA • Route of transmission can be traced from the migratory patterns of mine workers to rural communities • Additionally, poor socio-economic & environmental conditions during apartheid ‘facilitated’ the spread of TB

5. INTRODUCTION cont… • Socio-economic determinants of TB are well-known: over-crowding, poverty (& associated poor nutritional status), lack of health resources including lack of access to health care Read: Paul Farmer’s work which provides an excellent understanding of the socio-economic determinant’s-TB • It’s estimated that about 1% of the SA population develops TB every year • SA has a high TB/HIV rate making up 25% of all TB-HIV co-infections in the world • Given this: Social & Human Sciences need to play a role in eradicating TB and improving cure rates

6. PSYCHOSOCIAL FACTORS: MEDIATING DISEASE OUTCOME • There has been prolific biomedical research on TB relating to disease pathways & effective medicines that can cure the disease • The role of Socio-Economic factors in TB disease onset is also relatively well known • GAP: What has been understudied and underestimated is the role of psycho-social factors in mediating TB disease outcome (including TB cure & HR-QoL of those infected and those with TB/HIV co-morbidity)

7. PSYCHOSOCIAL FACTORS: MEDIATING DISEASE OUTCOME • There are many psychological (individual level) & social factors (environmental, household, work and community levels) that influence TB disease outcome • This presentation will focus broadly on 2 of these factors: (1) Knowledge and Awareness (2) Common Mental Disorders, Substance Abuse and TB • Will present some findings based on studies (namely, SANHANES I & SBI:TB) conducted at the HSRC

8. PSYCHOSOCIAL FACTORS: MEDIATING DISEASE OUTCOME Knowledgeand Awareness • Appropriate knowledge & awareness of TB, as well the fact that TB is curable even in the face of HIV remain vital messages required for effective TB control in SA • These messages are important when TB patients decide to use health services, seek a diagnosis & adhere to treatment • TB knowledge & awareness of TB as an infectious disease forms the basis for people taking protective measures to avoid becoming infected

9. PSYCHOSOCIAL FACTORS: MEDIATING DISEASE OUTCOME • SANHANES 1- Population based household survey -sample 15 years & older (Shisana, Labadarios et al., 2013) found: *Majority of participants (91.4%, n=14 739) perceived TB to be a very serious disease *Know TB can be cured (92.2%, n=14 903) *Only 3.3% (n=15 140) had knowledge of 6 or more signs & symptoms of TB *Only 22.3% (n=14 664) were concerned about TB presence in HIV + people *30% of =/>55years did not know whether people with TB should take an HIV test

10. TB KNOWLEDGE OF PARTICIPANTS 15 YEARS AND OLDER

11. PSYCHOSOCIAL FACTORS: MEDIATING DISEASE OUTCOME Common Mental Disorders, Substance Abuse and TB • CMDs: cluster of psychiatric disorders which include depression and anxiety. At least one third of all individuals seen in public primary care health facilities in low & middle income countries (LMICs) suffer from CMDs which are not recognized nor treated • Co-morbidity of CMDs & TB in LMICs range from 30% to 70% • Alcohol & Substance Abuse: co-existing prevalence of TB & alcohol use disorders range from 4% to 62%

12. PSYCHOSOCIAL FACTORS: MEDIATING DISEASE OUTCOME • Screening and Brief Interventions: TB (SBI:TB)- conducted in a cluster of public primary clinic based adult sample across 3 provinces in SA (Peltzer, Naidoo et al., 2012, 2013). Adult sample, n=3107 Baseline data from SBI: TB study revealed the ffg prevalence figures for participants on anti-TB drugs: *Psychological distress (26.3%) *PTSD symptoms (29.6%) *Males who met the criteria for hazardous drinking on the AUDIT (22.5%) *Women who met the criteria for hazardous drinking on the AUDIT (9.5%)

13. PSYCHOSOCIAL FACTORS: MEDIATING DISEASE OUTCOME *Current tobacco use in the past month (27.6%) *Anti-TB treatment non-adherence rate (24.5% missed meds at least once over past 10 days) *Anti-TB/ARV non-adherence rates (11.8% missed meds at least once in the last 7 days)

14. CONCLUSION • In order to address the socio-economic determinants of TB on-going structural adjustments need to be made for which political will is necessary • In order to address the psycho-social mediators of TB disease the following is needed: *Health literacy campaigns at targeted groups of individuals *Screening & treatment for CMDs, alcohol & substance use disorders at health care facilities as part of the integrated services offered

15. CONCLUSION cont… *Monitor the quadruple burden of ‘disease’, namely TB, HIV, Depression (CMDs), Alcohol & Substance Use Disorders *Use a sound M&E system to assess the impact of screening and treating for CMDs/Alcohol & Substance use Disorders whilst simultaneously using the ant-TB DOTS strategy recommended by WHO

16. THANK YOU