PROJECT ABSTRACT
In 2018, ~10 million individuals developed TB disease globally, of which ~1.5 million died; HIV was the leading
cause of death. Ongoing transmission results from an estimated 4.3 million “missing” TB cases along with active
TB cases not retained in care. We will conduct our study in South Africa (TB prevalence=852/100,000 population;
HIV co-infection=>50%), where a recent TB cascade analysis and national TB program indicators report significant
gaps along the entire TB care cascade. Qualitative studies suggest TB stigma as a barrier to case finding, care
seeking, treatment initiation, and adherence. However, few studies have quantified the impact of stigma on the TB
care cascade, fewer have used validated stigma measures, and none have employed prospective, full care
cascade study designs. We propose a 4-aim, rigorous, multilevel, mixed-methods study. We will perform household
surveys, which will be aggregated into community-level data and incorporated into the analysis of all aims. Aim 1:
Utilize mixed-methods to identify and measure individual- and community-level stigma and social
determinants associated with presentation for TB testing among actively referred contacts. We will conduct
a prospective study amongst symptomatic HHCs actively referred for testing (n= 750) to investigate the
relationships within and between the multiple levels of TB and HIV stigma and other social determinants and uptake
of TB testing. Aim 2: Utilize mixed-methods to identify and measure individual- and community-level stigma
and social determinants associated with returning for test results among symptomatic individuals tested
for TB. We will conduct a prospective study of individuals with TB symptoms who passively present to a study
clinic and are tested for TB (n= 1000) to investigate the relationships between the multiple levels of TB and HIV
stigma and other social determinants and returning for or obtaining the test results. Aim 3: Utilize mixed-methods
to identify and measure individual- and community-level stigma and social determinants associated with
LTFU and treatment outcomes among individuals initiated on TB treatment. We will conduct a prospective
study among TB patients initiating treatment (n= 1250) to investigate the association of anticipated, enacted and
internalized TB and HIV stigma on LTFU and poor TB treatment outcomes. Qualitative methods will explore the
trajectory, persistence, and impact of perceived and experienced TB stigma during and after treatment. Aim 4:
Utilize mixed-methods to identify and measure individual- and community-level stigma and social
determinants associated with LTFU from HIV care following TB treatment among co-infected individuals.
Relevant data for TB/HIV co-infected participant previously collected as part of Aim 3 (n= ~600), and additional
HIV outcome data will be used. Through this, we will investigate the presence and potential impact of intersecting
stigmas on retention in HIV care following completion of TB treatment. This study will ultimately inform targeted,
multi-level interventions, rooted in the needs and challenges of communities, theoretically informed, and fully
contextualized, to address the TB crisis in South Africa, and inform similar interventions globally.
