Inconsistent Condom Use among Public Primary Care Patients with Tuberculosis in South Africa

Inconsistent Condom Use among Public Primary Care Patients with Tuberculosis in South Africa
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  The Scientific World JournalVolume 2012, Article ID 501807, 6 pagesdoi:10.1100/2012/501807  The cientific WorldJOURNAL Research Article InconsistentCondomUseamong PublicPrimary Care Patients withTuberculosisinSouthAfrica  GladysMatseke, 1 Karl Peltzer, 1,2 JuliaLouw, 1 Pamela Naidoo, 1,3 GuguMchunu, 1 andBomkazi Tutshana  1 1 HIV/AIDS, STI, and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Private Bag X41,Pretoria 0001, South Africa  2 Department of Psychology, University of the Free State, Bloemfontein, South Africa 3 Department of Psychology, University of the Western Cape, Cape Town, South Africa Correspondence should be addressed to Karl Peltzer, 11 March 2012; Accepted 3 May 2012Academic Editors: J. Arbiza, A. Arminio Monforte, and P. ChouCopyright © 2012 Gladys Matseke et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the srcinal work is properly cited.The high rate of HIV infections among tuberculosis (TB) patients in South Africa calls for urgent HIV reduction interventions inthissubpopulation.Whilecorrectandconsistentcondomuseisoneofthee ff  ectivemeansofHIVpreventionamongsexuallyactivepeople, there is insu ffi cient research on condom use among TB patients in South Africa. The aim of this paper was to determinethe prevalence of inconsistent condom use among public primary care TB patients and its associated factors using a sample of 4900TB patients from a cross-sectional survey in three health districts in South Africa. Results indicated that when asked abouttheir consistency of condom use in the past 3 months, 63.5% of the participants reported that they did not always use condoms.In the multivariable analysis, being married (OR   =  1 . 66; 95% CI 1.25–2.20) or cohabitating or separated, divorced, or widowed(OR  = 3 . 67; 1.85–7.29), lower educational level (OR  = 0 . 66; 0.46–0.94), greater poverty (OR  = 1 . 60; 1.25–2.20), not having HIVstatus disclosed (OR   =  0 . 34; 0.25–0.48), sexual partner on antiretroviral treatment (OR   =  0 . 38; 0.23–0.60), and partner alcoholuse before sex (OR   =  1 . 56; 1.30–1.90) were significantly associated with inconsistent condom use in the past 3 months. The low proportion of consistent condom use among TB patients needs to be improved. 1.Introduction HIV prevalence has gradually increased among newly diag-nosed tuberculosis (TB) patients in South Africa, from 44%in 2006 [1] to 60% in 2010 [2]. The high rate of HIV infections among TB patients calls for urgent HIV reductioninterventions in this subpopulation. A study by Zachariahet al. [3] has shown that TB patients are prone to risky sexualbehaviour including unprotected sex. Since most HIV infec-tions in South Africa are sexually transmitted [2], there isa need to encourage sexual behaviour change among TBpatients as an HIV prevention measure [4]. Correct andconsistent condom use is one of the e ff  ective means of HIVprevention among sexually active people. There is scarcity of information on condom use behaviour among TB patientsin South Africa. Talbot et al. [5] found among tuberculosispatients in Botswana that the majority inconsistently hadused a condom in their last 10 sexual encounters, among asurvey of adult TB patients in Ethiopia 78% had not usedcondom [6], and among HIV-infected tuberculosis patientsin Thailand 42% reported never using condoms at all [7]. Aninvestigation into condom use behaviour and its associatedfactors is important in assisting to plan for HIV preventionprogrammes that focus on promoting condom use amongTB patients. The aim of this study is to determine the preva-lence of inconsistent condom use among TB patients and itsassociated factors using a sample of 4900 TB public primary care patients from three health districts in South Africa. 2.Methods  2.1. Participants and Procedures.  Thisisacross-sectionalsur-vey with tuberculosis patients in public primary care clinicsin South Africa. Three provinces, in South Africa, with  2 The Scientific World Journalthe highest TB caseloads were selected for inclusion in thestudy. One district in each province ( N   = 3) with the highestTB caseloads was ultimately included. These districts wereSiyanda in Northern Cape Province, Nelson Mandela Metroin the Eastern Cape Province, and eThekwini in KwaZulu-Natal Province. Within each of these three study districts,14 public primary health care facilities were selected onthe basis of the highest TB caseloads per clinic ( N   =  42).The type of health facilities were public primary health careclinic or community health centre. All new TB and new retreatment patients were consecutively interviewed withinone month of antituberculosis treatment. The interview was conducted by trained external research assistants for aperiod of 6 months in all 42 clinics in 2011. A health careprovider who identified a new TB treatment or retreatmentpatient (within one month on treatment) and 18 years andabove informed the patient about the study and referred thepatient for participation if interested. A research assistantasked for permission/consent from patients attending thepublic primary care facility to participate in the interview.Wehavereceived’sethicalapprovalfromtheHumanSciencesResearch Council Research Ethics Committee (Protocol RECno.1/16/02/11). The Department of Health in South Africahas also provided approval for this study.  2.2. Measures 2.2.1. Socioeconomic Characteristics.  A researcher-designedquestionnaire was used to record information on partici-pants’ age, gender, educational level, marital status, income,employment status, dwelling characteristics, and residentialstatus.  Poverty   was assessed with 5 items on the availability ornonavailabilityofshelter,fuelorelectricity,cleanwater,food,and cash income in the past week. Response options rangedfrom 1  =  “Not one day” to 4  =  “Every day of the week”.Poverty was defined as higher scores on non-availability of essentialitems.Thetotalscorerangedfrom5to20,5  =  beinglow, 6–12  =  medium, and 13–20  =  high poverty. Cronbachalpha for this poverty index was 0.89 in this sample.  2.2.2. Condom Use.  It was assessed with the question “How frequently did you use condoms when you had sex with your most recent sexual partner in the past three months?”.Responseoptionswere1  =  always,2  =  frequently,3  = some-times, and 4  =  never. Inconsistent condom use was definedas not always using a condom with the most recent sexualpartner in the past three months.  2.2.3. The Kessler Psychological Distress Scale (K-10).  It wasused to measure global psychological distress, includingsignificant pathology which does not meet formal criteria fora psychiatric illness [8, 9]. This scale measures the following symptoms over the preceding 30 days by asking: “In the past30 days, how often did you feel: nervous; so nervous thatnothingcouldcalmyoudown;hopeless;restlessorfidgety;sorestless that you could not sit still; depressed; that everythingwas an e ff  ort; so sad that nothing could cheer you up;worthless; tired out for no good reason?”. The frequency with which each of these items was experienced was recordedusingafive-pointlikertscalerangingfrom“noneofthetime”to “all the time”. This score was then summed with increasingscores reflecting an increasing degree of psychological dis-tress.Thisscaleservestoidentifyindividualswhoarelikelytomeet formal definitions for anxiety and/or depressive disor-ders, as well as to identify individuals with subclinical illnesswho may not meet formal definitions for a specific disorder[8]. This scale has been validated in HIV positive individualsin South Africa [10]. There was significant agreementbetween the K-10 and the MINI-defined depressive andanxiety disorders. A receiver operating characteristic (ROC)curve analysis indicated that the K-10 showed agreeablesensitivity and specificity in detecting depression (area underthe ROC curve, 0.77), generalized anxiety disorder (0.78),and posttraumatic stress disorder (PTSD) (0.77) [10]. TheK-10 scale was used as a binary variable comparing scores of 30 or more or less. The internal reliability coe ffi cient for theK-10 in this study was alpha  =  0.92.  2.2.4. Alcohol Consumption.  The 10-item Alcohol DisorderIdentification Test (AUDIT) [11] assesses alcohol consump-tion level (3 items), symptoms of alcohol dependence (3items), and problems associated with alcohol use (4 items).Heavy episodic drinking is defined as the consumption of six standard drinks (10g alcohol) or more on a single occasion[11]. In South Africa, a standard drink is 12g alcohol.Because AUDIT is reported to be less sensitive at identifyingrisk drinking in women [12], the cut-o ff   points of bingedrinking for women (4 units) were reduced by one unit ascompared with men (5 units), as recommended by Freebornet al. [12]. Responses to items on the AUDIT are rated ona 4-point Likert scale from 0 to 4, for a maximum scoreof 40 points. Higher AUDIT scores indicate more severelevels of risk; score 8 indicates a tendency to problematicdrinking including 8–19 high risk, and 20–40 probablealcohol dependence [11]. The AUDIT has been validated inHIV patients in South Africa showing excellent sensitivity and specificity in detecting MINI-defined dependence/abuse(area under the receiver-operating characteristic curve, 0.96)[13], and among TB and HIV patients in primary care inZambiademonstratinggooddiscriminatoryabilityindetect-ing MINI-defined current AUDs (AUDIT  =  0.98 for womenand 0.75 for men) [14]. Cronbach alpha for the AUDIT inthis sample was 0.92, indicating excellent reliability.  2.2.5. Alcohol Use in the Context of Sex.  Participants wereasked if they and their sexual partner had used alcohol beforehaving sex in the past three months.  2.2.6. Perceived General Health.  Participants were asked—ingeneral, would you say your health is excellent, very good,good, fair, or poor? This measure was categorized based onparticipant response (1  =  very good  =  excellent/very good,2  =  good, and 3  =  fair/poor).TB treatment status, HIV status, Sexually TransmittedInfection (STI) history, and antiretroviral treatment wereassessed by self-report and from medical information. HIVtesting status was assessed by self-report.  The Scientific World Journal 3 3.DataAnalysis Data were analyzed using Statistical Package for the SocialSciences (SPSS) for Windows software application pro-gramme version 19.0. Frequencies, means, and standarddeviations were calculated to describe the sample. Data werechecked for normality distribution and outliers. For non-normaldistribution,nonparametrictestswereused.Associa-tionsofinconsistentcondomuse,sociodemographics,healthvariables, and alcohol and drug use were identified usinglogistic regression analyses. Interaction between predictorvariables was examined; none of the variables had a varianceiInflation factor (VIF) value above 2.5. Following each uni-variateregression,multivariableregressionmodelswerecon-structed. Independent variables from the univariate analyseswereenteredintothemultivariablemodelifsignificantat P < 0 . 05 level. For each model, the  R 2 are presented to describethe amount of variance explained by the multivariablemodel. Probability below 0.05 was regarded as statistically significant. 4.Results 4.1. Sample Characteristics and Inconsistent Condom Use. From the total sample ( N   =  4935) included in the study,35 (0.7%) refused to participate, so the final sample included4900, 54.5% men and 45.5% women, with a mean age of 36.2 years (SD  =  11.5), range from 18 to 93 years. Almost two-thirds of the participants (65.2%) were between 25 to 44 years old, 84.6% were Black Africans, 72.5% was never mar-ried, 27.7% had completed secondary education, and 17%scored high on the poverty index. Regarding health statusof the TB patients, 55% were coinfected with HIV, 23.3%were retreatment TB patients, 46.3% rated their health statusas fair or poor, and 26.2% had severe psychological distress.Twenty-two percent were on antiretroviral treatment, 63.5%haddisclosedtheirHIVstatustotheirlastsexualpartner,and72.8% had a sexual partner with unknown or HIV negativestatus.Almostoneinfiveoftheparticipants(23.3%)engagedin hazardous or harmful alcohol use, 11.2% had used alcoholbefore sex in the past three months, and 9.6% reportedthat their sexual partner had used alcohol before sex in thepast three months. When asked about their consistency of condom use in the past 3 months, 63.5% had used condomsinconsistently (see Table 1).Table 2 shows both the bivariate analysis reporting theunadjusted odds ratios and multivariable analysis reportingthe adjusted odds ratios of all possible predictors of incon-sistent condom use. The bivariate analysis showed that olderage,beingmarriedorcohabitating,orseparated,divorced,orwidowed, lower educational level, greater poverty, being HIVnegative, ever having had a sexually transmitted infection(STI), severe psychological stress, not being on ART, sexualpartner not on ART, not having HIV status disclosed to theirlast sexual partner, partner HIV status unknown or negative,alcohol use, alcohol use before sex, and partner alcohol usebefore sex were associated with inconsistent condom use inthepast3months.Finally,inthemultivariableanalysis,beingmarried or cohabitating or separated, divorced or widowed,lower educational level, greater poverty, not having HIV sta-tus disclosed, sexual partner on ART, and partner alcohol usebefore sex were significantly associated with inconsistentcondom use in the past 3 months (see Table 2). 5.Discussion The study found high rates of inconsistent condom use, asfound in some other studies [5–7], among a large sample of  TB patients in South Africa. This finding is alarming giventhe high rate of HIV and TB coinfection at a national levelin South Africa [2]. The dual epidemics of HIV and TB havebecome a public health priority and is beginning to receiveincreasingattentionfromtheNationalDepartmentofHealthas specified in the National Strategic Plan 2012–2016 [15].TB, therefore, cannot be managed as a single disease entity.A comprehensive treatment and prevention programme forTB, HIV, and indeed other comorbid disorders is required inorder to meet this public health challenge. In the context of this study, condom use needs to be considered as one of theHIVpreventionmeasureswhenplanningforHIVpreventionprogrammes for TB patients.Further, the results of the study suggest that people whowere married/cohabitating and those separated/divorced/widowed, with lower education and living in poverty weremore likely to report inconsistent condom use compared totheir respective counterparts. Similar to the results suggestedin this study, other studies showed that lower levels of educa-tion were associated with lack of condom use [16, 17]. Lack  of condom use by married people in this study is consistentwith findings from previous studies [18, 19]. This finding may be because there is some trust built among people insuch relationships leading to decisions to use condoms occa-sionally or stop altogether. Furthermore, it was suggested by study results that people who have not disclosed their HIVstatus, those whose sexual partner was not on ART, and thosewhose partner took alcohol before sex, were more likely toreport inconsistent condom use. This finding is of concernsince nondisclosure of HIV status and alcohol use in thecontext of sex coupled with inconsistent condom use may lead to further HIV infection [20, 21]. E ff  orts should also bemade for follow-up couple counselling and testing, useof behaviour rehearsal technique to overcome barriers of disclosure, and integrating alcohol use into HIV/AIDS risk reduction interventions. 6.Study Limitations Caution should be taken when interpreting the results of this study because of certain limitations. As this was a cross-sectional study, causality between the compared variablescannot be concluded. A further limitation was that mostvariables were assessed by self-report and desirable responsesmay have been given, in particular regarding condom use. 7.Conclusion The control of the concomitant HIV and tuberculosis epi-demics is one of the greatest challenges facing South Africa.  4 The Scientific World Journal Table  1: Sample characteristics and inconsistent condom use.Socioeconomic factors Total Inconsistent condom useN (%) or M (SD) N (%) or M (SD)All 4900 2697 (63.5)Age18–24 643 (13.3) 315 (57.2)25–34 1841 (38.1) 1004 (60.4)35–44 1313 (27.1) 742 (63.6)45 or more 1040 (21.5) 601 (73.1)Male 1631 (54.5) 1477 (64.8)Female 2194 (45.5) 1178 (61.9)Never married 3356 (72.5) 1772 (60.8)Married/cohabitating 1001 (21.6) 609 (66.8)Separated/divorced/widowed 275 (5.9) 165 (80.9)Grade 7 or less 1269 (26.3) 730 (71.8)Grade 8–11 2213 (45.9) 1219 (61.6)Grade 12 or more 1336 (27.7) 714 (59.5)Poverty index Low 1617 (35.0) 802 (56.8)Medium 2227 (48.2) 1287 (64.5)High 275 (16.8) 454 (72.3)Black African 4078 (84.6) 2277 (62.9)Coloured 634 (13.1) 331 (66.6)Indian, Asian, White, other 111 (2.3) 59 (66.3)Health status HIV status HIV negative 1759 (36.9) 954 (64.1)HIV unknown 385 (8.1) 258 (79.6)HIV positive 2619 (55.0) 1417 (60.6)Ever STI 329 (7.3) 212 (69.1)New TB patient 3707 (76.7) 2061 (63.5)Retreatment TB patient 1128 (23.3) 610 (63.0)Perceived health statusExcellent/very good 928 (19.2) 516 (64.3)Good 1667 (34.5) 916 (62.7)Fair/poor 2238 (46.3) 1245 (63.8)Severe psychological distress 1195 (26.2) 709 (67.1)On ART 906 (22.0) 421 (53.3)Disclosed HIV status to last partner 2769 (63.5) 1480 (54.9)Partner with HIV unknown or negative versus positive 3244 (72.8) 2010 (66.6)Sexual partner on ART 440 (11.1) 189 (44.8)Alcohol useAUDITAbstinent or low risk (score 0–7) 3688 (76.7) 1985 (61.2)High risk (8–19) 799 (16.6) 470 (68.5)Probably alcohol dependent (20–40) 321 (6.7) 205 (76.2)Alcohol before sex in the past 3 months 549 (11.2) 368 (73.6)Partner alcohol before sex in the past 3 months 408 (9.6) 325 (75.6)  The Scientific World Journal 5 Table  2: Association between inconsistent condom use, socioeconomic factors, health status, and alcohol use.Crude OR (95% CI) Adjusted OR  a,b (95% CI)Socioeconomic factorsAge 1.02 (1.02–1.03) ∗∗∗ 1.00 (0.99–1.01)Male versus female 1.13 (1.00–1.28) 0.96 (0.75–1.24)Never married 1.00 1.00Married/cohabitating 1.30 (1.11–1.52) ∗∗∗ 1.66 (1.25–2.20) ∗∗∗ Separated/divorced/widowed 2.73 (1.91–3.90) ∗∗∗ 3.67 (1.85–7.29) ∗∗∗ Grade 7 or less 1.00 1.00Grade 8–11 0.63 (0.54–0.74) ∗∗∗ 0.72 (0.53–0.99) ∗ Grade 12 or more 0.58 (0.48–0.69) ∗∗∗ 0.66 (0.46–0.94) ∗∗ Poverty index Low 1.00 1.00Medium 1.38 (1.20–1.59) ∗∗∗ 1.60 (1.24–2.20) ∗∗∗ High 1.98 (1.62–2.43) ∗∗∗ 1.54 (1.05–2.25) ∗ Black African 1.00 —Coloured 1.17 (0.96–1.43)Indian, Asian, White, other 1.16 (0.74–1.81)Health statusHIV positive versus negative 0.86 (0.75–0.99) ∗ 0.96 (0.72–1.28)Ever STI 1.38 (1.07–177) ∗ 1.10 (0.72–1.67)New TB versus retreatment 1.02 (0.88–1.19) —Perceived health statusExcellent/very good 1.00 —Good 0.94 (0.78–1.12)Fair/poor 0.99 (0.83–1.17)Severe psychological distress 1.26 (1.09–1.47) ∗∗ 1.21 (0.92–1.59)On ART 0.60 (0.51–0.70) ∗∗∗ 0.79 (0.58–1.08)Disclosed HIV status to last partner 0.32 (0.28–0.37) ∗∗∗ 0.34 (0.25–0.48) ∗∗∗ Partner HIV unknown or negative versus positive 1.60 (1.39–1.84) ∗∗∗ 1.18 (0.87–2.12)Sexual partner on ART 0.41 (0.33–0.50) ∗∗∗ 0.38 (0.23–0.60) ∗∗∗ Alcohol use  AUDIT  Abstinent or Low risk (0–7) 1.00 1.00High risk (8–19) 1.38 (1.16–1.64) ∗∗∗ 1.14 (0.82–1.58)Probably alcohol dependent (20–40) 2.03 (1.52–2.71) ∗∗∗ 1.44 (0.86–2.42)Alcohol before sex 1.22 (1.12–1.32) ∗∗∗ 1.08 (0.78–1.50)Partner alcohol before sex 1.33 (1.21–1.46) ∗∗∗ 1.56 (1.30–1.90) ∗∗∗ a Using “enter” LR selection of variables. b Hosmer and Lemeshow Chi-square 7.16, df 8, 0.516; Cox and Snell R 2 0.15; Nagelkerke R 2 0.20. ∗ P <  0 . 05;  ∗∗ P <  0 . 01;  ∗∗∗ P <  0 . 001. It is essential to link TB and HIV treatment and preventionprogrammes in situations where both diseases are prevalentto improve the diagnosis, treatment, and outcomes forpatients a ff  ected by both diseases. The high rates of incon-sistent condom use among TB patients found in this study needs to be improved and both male and female condomuse should be considered HIV prevention measures whenplanning for HIV prevention programmes for TB patients.  Acknowledgments The Department of Health in South Africa funded this study through a tender “NDOH: 21/2010-2011 Implementationand monitoring of Screening and Brief Intervention for alco-hol use disorders among Tuberculosis patients” that wasawarded to the HSRC. References [1] World Health Organization, “Global tuberculosis control.Surveillance, planning, financing,” WHO Report 2008 WHO/HTM/TB/2008.393, World Health Organization, Geneva,Switzerland, 2008.[2] WorldHealthOrganization,“Globaltuberculosiscontrol.Epi-demiology, strategy, financing,” Tech. Rep. WHO/HTM/TB/2009.411, World Health Organization, Geneva, Switzerland,2011.
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