1 Dignitas International, Zomba, Malawi, 2 University of Toronto, Toronto, Canada,

1. M. Kumwenda1, S. Tom2, A.K. Chan1,2, E. Mwinjiwa1, S. Sodhi2,3, M. Joshua4, M. van Lettow1 Reasons to accept or decline uptake of HIV testing and counselling and antiretroviral therapy by TB and TB/HIV co-infected patients at Zomba Central Hospital, Malawi TB Office: Zomba Central Hospital 1Dignitas International, Zomba, Malawi, 2University of Toronto, Toronto, Canada, 3Dignitas International, Toronto, Canada, 4Ministry of Health, Zomba Central Hospital, Malawi

2. Background TB/HIV clinic established at ZCH in April 2008: • To register and provide TB treatment • To offer and provide HIV services • Despite integrated services, less than 50% patients initiate ART • Estimated National Adult HIV prevalence = 11%north 6% - south 16.5% • TB/HIV co-infection rate = 70% • Case fatality in TB/HIV = 20%

3. Purpose • Determine whether gender and age is associated with uptake of HIV services • Explore reasons why co-infected patients accept or decline uptake of HTC/ART Methods • Retrospective quantitative descriptive analysis • 2110 patients registered for TB Treatment between April 2008-March 2009 • Qualitative analysis • In-depth interviews with 99 patients

4. Registered TB patients on subsequent clinic visits In-depth Interviews <2 weeks of TB treatment Between 2 weeks -2 months Between 2 - 6 months Motivating factors to HTC Barriers to HTC Barriers to HTC Barriers to ART Motivating factors Barriers to HTC Barriers to ART Motivating factors Unknown HIVn=15 HIV+No ARTn=14 Unknown HIV n=4 HIV+No ARTn=16 HIV+ARTn=15 Unknown HIVn=4 HIV+No ARTn=16 HIV+ARTn=15 Purposeful sample

5. Results Demographic data

6. Uptake of ART by sex and age and timing of ART initiation

7. Reasons to Accept HTC (88%) • Persistent and/or recurrent sickness or experiencing multiple infections or suspected HIV (n=60) “I was very weak and I was frequently getting ill with Malaria and diarrhea and headaches, I also lost a lot of weight and all the medication I took never seemed to work so I decided to get tested.”(Male, married, farmer, 33 years, 2wks- 2mnthsART). • Curious to know ones HIV status because of perceived importance of having this knowledge (n=25) • Advised or instructed by the health provider to have an HIV test (n=10). “Doctors here .. told me that it is recommended to get tested to know if a person has HIV or not.”(Female, divorced, business woman, 41 years, 2mnths-6mnthsHIV). • Encouragement by positive testimonies from HIV+ persons on ART or friends and relatives (n=4). “I saw on local television channel a woman saying that she has lived for 20 years since she knew that she was HIV positive and she looked so healthy, so I told my wife that we had to go for HTC.” (Male, married, driver, 25 years, 2wks-2mnthsART).

8. Reasons to decline HTC (12%) • Fear of knowing ones HIV+ status and/or fear of initiating ARV’s and TB drugs concurrently (n=4) “If I get tested now and they find that I have HIV, I will be thinking a lot. … if they find me HIV positive, I will be required to take both drugs. I have refused to get tested ….. I may faint or die on the spot because of worries ….” (Female, widowed, Business lady, 37 years, <2wksUnk). • Lack of resources or HTC provider at an HTC centre (n=4). “…I want to get tested but they told me that they do not have the tests....”(Male, married, laborer, 35 years, 2mnths-6mnthsUnk). • No perceived risk i.e. being faithful or not married (n=3) “I have been faithful as long as I have been with my wife. Even when they came to our home to offer us testing, we told them that … we have both been faithful to each other. So, I don’t think it is necessary for me to get tested.” (Male, married, farmer, 43 years, <2wksUnk). • No time to visit an HTC site to test for HIV (n=2)

9. Reasons to Accept ART (48%) • To regain good health and have a long life (n=30) “I used to get sick often so I decided that I should take ART so that I can stay alive… I have children so I was worried that if I die my children will not have anyone to take care of them.” (Female, married, business woman, 26 years, 2mnths-6mnthsART). • Followed instructions from health care providers (n=25) “I was following doctor’s orders. I was weighing only 45 kg when I started TB treatment. I had lost about 10 kg.... My CD4 count was very low so the doctor told me that I had to start ART…. I couldn’t wait … I came after 3 weeks and started ART.”(Male, married, Builder, 34 years, <2wksHIV).

10. Reasons for not taking up or declining ART (52%) • Not offered ART despite being HIV+ (n=8) “I was not offered to start ART…. I have just been coming to get TB drugs. If given a chance to start ART, I will because I want to live.” (Male, married, farmer, 30 years, 2mnths-6mnthsHIV). • Fear of side-effects resulting from combining TB treatment and ART (n=7) “TB drugs are very strong drugs ... It will be difficult for me to start ART which is yet another strong drug. So I decided that I should not take both drugs together.” (Male, married, welder, 35 years, 2wks-2mnthsHIV). • Unable to find a guardian needed for ART initiation (n=3) “I was told to come with a guardian but I have not yet found anyone.”(Female, widowed, farmer, 48 years, 2wks-2mnthsHIV). • Lack of transport to go for ART initiation (n=2) “I accepted to start ART but … I have to bring my guardian so that we can learn about ART. I delayed to come because of transport money, I could not afford to pay transport for two people.” (Male, married, farmer, 41 years, 2mnths-6mnthsHIV).

11. <2 weeks of TB treatment Between 2 weeks -2 months Between 2 - 6 months Barriers to HTC Motivating factors to HTC Barriers to HTC Barriers to ART Motivating factors Barriers to HTC Barriers to ART Motivating factors Motivating factors to HTCPoor healthSuspected HIV Questioning HIV status Advised by provider Motivating factors to ART Regain good health Advised by provider Barriers to HTCNot offered HTCNo HTC provider/kitsNo perceived risk to be HIV+ No time to go for HTC Fear of knowing HIV+ status Fear of drug-drug interactions Barriers to ART No guardian Fear of drug-drug interactions Lack of transport Not offered ART Themes by time on TB treatment

12. Discussion • 12% of TB patients decline or are not tested for HIV • 20% of TB patients already on ART before TB diagnoses and treatment, andless than 30% initiated ART during the course of TB treatment • Acceptance of HTC was highest in younger and lowest in older TB patients • Barriers to uptake of HTC diminished with time on TB treatment • Patient’s poor health status motivates uptake of HTC and ART • Adolescent TB patients were least likely to accept and initiate ART • Timing of ART initiation jointly determined by changes in patient perception and provider advice • Intrinsic and extrinsic factors were barriers to uptake of HTC and ARTfear; myths and misconceptions - not being offered; lack of resources, support or time

13. Conclusions • Uptake of HTC and ART in TB/HIV co-infected patients is still sub-optimal. • Health providers are both a barrier and motivating factor to the uptake of HTC and ART • It is essential to address health providers and patients fears and misconception regarding the benefits of HTC and ART during TB treatment. • It is crucial that health providers repeatedly offer HTC and ART to patients rather than only at the time of TB registration

14. Acknowledgment