Comprehensive Approach to
HIV/TB Burden: A focus on
Human Behaviour Change
Pamela Naidoo (MA, MPH, DPhil)
CRS & Head:HIV/TB (HSRC)
Extra-Ord Prof:UWC
WCP Premier’s Health & Wellness
Summit: 08/11/2011
BACKGROUND & CONTEXT
• TB & HIV infections: 2 deadliest chronic infections globally
• TB: causes ¼ of AIDS-related deaths
• HIV infects 15% of patients with TB worldwide
• TB: weak advocacy & lack of research funding (until recently)
• TB: Historically associated with poverty-now all at risk in high
burden areas
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Background cont…..
•Factors: Biomedical, Social, Cultural & Economic
•Biomedical: TB is curable using effective drug therapy
(even in those co-infected with HIV) yet it has a low cure
rate (way below WHO target of 85% cure rate)
• WHO: Stop TB strategy using DOTS
•TB activism started around 2004 at the time when the
“double-burden” of TB & HIV became increasingly
recognized. At this time: also an increase in MDR & XDRTB
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Background cont…..
• Biomedical research: many advancements wrt diagnostic
efficiency & drug therapy
• Social, Cultural & Economic (SEC)factors: has this been
neglected in TB research in sub-Sahara?
• Increasing focus on research asking questions about
what the most effective & efficient comprehensive
treatment & prevention approaches are will help
increase the TB cure rate & decrease mortality
associated with HIV/TB co-infection
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Background cont…..
• Barriers to diagnosis & improved cure rates for TB: SEC
environment
stigma: at home, in the community & place of
work (e.g.Naidoo et al,2009/10 (in view of HIV/TB
association)
gender (certain areas women access TB related
health care more than men) Case study: Cape Town
(e.g. Naidoo et al)
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Background cont…..
poor treatment up-take linked to behavioural
factors e.g. poor adherence, excessive alcohol use
Marginalized communities (e.g. homeless,
prisoners, immigrants) – disproportionately
affected
Lack of awareness when symptomatic: need to
focus on rural & hard to reach communities
Optimistic Bias
Research Considerations
1. Concurrent HIV/TB surveillance
Must include marginalized & hard to reach
communities
2. View TB & HIV as 1 disease both for research & clinical
practice especially in sub-Saharan Africa
3. Test simple prevention methods: condomise for HIV &
wear a face mask for TB! Already showing promise for
reduction in transmission of TB
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Research Considerations cont….
4. Health sector strengthening with view to development &
refinement of policy (e.g. adequately trained staff &
comprehensive health care)
5. Prevention Programmes based on attitudinal &
behavioural change (should include encouraging
disclosure of possible source of infection, reduction of
default rates-i.e. non-adherence)
6. Educational programmes for children & youth need to be
tested: p of TB is also high in this group
Social science that makes a difference
FOCUS ON HUMAN BEHAV CHANGE
• Effectiveness of comprehensive approach to HIV/TB
treatment & prevention is backed by evidence.
• Challenge 1: grey area »»» HUMAN BEHAVIOUR (HB)
• Challenge 2: »»» HB in different SOCIAL CONTEXTS
• MODELS that Work? HBC models (e.g. HBM, TTM &
other Social Cog Th) commonly utilized & found to be
effective in health promotion & disease prevention.
However: success is restricted to contexts in which there
are adequate individual, social & economic resources.
• Focus in SCT models: “individualistic” underpinned by
ind. attitudes, perceptions, knowledge & beh.
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HBC…cont.
• What about WCP:SA?
• Remember that disease burden areas are also underresourced ones
• Consequently: when using HBC methods as part of the
comprehensive care approach - need to consider ffg
IND & SEC (social, eco & cultural) CONTEXTS
• Implications: HIV/TB prevention focussed on behaviour
change including: male & female regular & consistent
condom use, HCT, pregnancy prevention & early sexual
debut, adherence to DOTS & ARVs & so on needs a
multi-pronged approach
Social science that makes a difference
HBC…cont.
• REDUCTION IN HIV/TB DISEASE BURDEN NEEDS:
(1) Health Sector Input: Health System
Strengthening to focus on the individual (beyond medical
treatment) – stronger allied health care
(2) Empowerment Model: Community participation &
self-empowerment: Health sector collaboration with
NGOs focusing on norm shifting, power & gender, youth
empowerment & so on
(3) Gain the trust of Advocacy Groups
(4) Use the power of the media & social forums
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SO: WILL HBC WORK IN SA/WCP?
• RESOUNDING YES
• HOWEVER: MUST BE PARALLEL PROCESSES
• AT HEALTH SYSTEMS LEVEL: TREAT THE IND,
PARTNERS, FAMILIES & SO ON (MICROCOSM)
• AT COMMUNITY , PROVINCIAL & SOCIETAL LEVEL
(MACROCOSM): INCULCATE INTELLECTUAL
KNOWLEDGE ABOUT THE CONSEQUENCES OF
PERPETUATING “UNHEALTHY BEHAVIOUR”
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CONCLUSION
 A COMPREHENSIVE APPROACH TO
REDUCE DISEASE BURDEN MAY BE
DIFFICULT TO SUBJECT TO RCTs !
 HOWEVER, USING A BIOMEDICAL &
SOCIAL/CRITICAL
CONSCIOUSNESS/HUMAN RIGHTS
APPROACH WILL BE KEY TO OVERALL
WELL-BEING. LET’S IMPLEMENT WHAT WE
KNOW TO BE THE RIGHT THING TO DO
BASED ON THE EVIDENCE OF THE SOCIAL
DRIVERS OF HIV/TB DISEASE BURDEN
Social science that makes a difference
THANK YOU
pnaidoo@hsrc.ac.za
Social science that makes a difference