Can Research-Based Educational Material Increase Adherence to Tuberculosis Treatment among People with AIDS? Jintana Ngamvithayapong-Yanai, PhD. 1, 2 Sarmwai Luangjina, B.A.(Hons.) 1 Amornrat Wiriyaprasopchaok 3 1 TB/HIV Research Foundation, Thailand 2 The Research Institute of Tuberculosis, Japan 3 Chiang Rai Regional Hospital, Thailand.

Objective: 1. To synthesize a series of published and non- published qualitative studies, conducted in Chiang Rai, Thailand between These qualitative studies investigated the socio-cultural factors associated with adherence to TB treatment among HIV-positive TB patients (TB/HIV) 2. To develop educational material based on the research findings in order to promote adherence to TB treatment among TB/HIV patients.

Cambodia Myanmar China Laos Vietnam Bangkok Chiang Rai Population 1.2 millions (hill tribe 13 %) 93% completed compulsory education 1 regional hospital, 16 district hospitals, 212 health centers, 3 private hospitals Chiang Rai, Thailand

New TB rate by HIV status per 100,000 persons in Chiang Rai Province,

Major research findings: AIDS related fatalism is common due to high AIDS mortality in Chiang Rai. People in most communities witness that every AIDS patient eventually died. There are no ways to survive if persons are infected by HIV. Health workers and community people also observed the high mortality resulting from TB although TB treatments were given to the patients

Cohort Analysis of TB Treatment Outcome of New AFB-smear-positive Pulmonary TB cases among HIV-positive in Chiang Rai Province (adjusted transfer cases), TB/HIV Research Project (RIT-JATA) n=179 n=241 n=272 n=270 n=283 n=302 n=241 n=227 5

Major research findings (continue) High AIDS and TB/HIV mortality negatively influenced the attitude and behavior of patients and community people. They believed TB is not curable if patients are co-infected by HIV. TB/HIV patients and family were discouraging with their HIV infection. They had no motivation to treat TB, especially when patients perceived side-effect from anti- TB medicine. AIDS fatalism and AIDS stigma caused non-adherence to TB treatment among TB/HIV patients.

Several TB/HIV patients who knew about HIV positive status at the time of TB diagnosis and could not cope with HIV, tended to be non-adherent to TB treatment. TB/HIV Research Project(RIT-JATA) “… When my husband went back home, he was angry with himself and he was upset about everything. He refused to eat and rejected his medicine. He threw the pills away. He did not take TB medicine at all”. (female TB/HIV)

However!!! Patient adherence may be promoted through the following assumptions: 1. Love: patients live with someone who care and concern for patients or patients live with the ones they love. 2. Receiving key message: “Taking anti TB medicine is the best way to prevent TB transmission to your loved ones because it kills TB germs” 3. Learning from other patients: Patients and family members see photos and hear stories of previous TB/HIV patients who were successfully cured despite complex health and psycho-social problems

Translating social science research into action! Developing a booklet aiming to reduce AIDS fatalism and AIDS stigma, with an ultimate aim to improve attitude and adherence to TB treatment. The booklet is composed of two parts: Part I: Essential knowledge about TB/HIV. Part II: Patients’ stories and patients’ photos The booklet will be ready by the 2004 International AIDS Conference (July). Impact of the booklet on patient adherence will be evaluated.

I love my mom and dad. Doctor said if I take medicine, I will not spread TB. Therefore, I must take the medicine. I must prevent my parents from getting TB from me. (Photo was taken at the time of completing TB treatment)

Photo credit: Amornrat Viriyaprasopchoak From a patient suffering from TB/HIV to be a happy person living with HIV TB/HIV Research Project (RIT-JATA)

Acknowledgement Japanese Foundation for AIDS Prevention (JFAP) and Ministry of Health, Welfare and Labor, Japan supported the study The great contribution of all patients who kindly give permission to release their photos and their valuable experiences in achieving high adherence rate to TB treatment. Maitree Oo-ngern, Utoomporn Thapthimchai, Maleerat Sampantasit, Patcharin Duangkaew, Oranuch Nampaisan, Boonchai Chiyasiriroj, TB/HIV Research Project (RIT-JATA), Chiang Rai, Thailand for their kind assistance in coordinating with the patients and preparing patients’ photos.