Integrating Patients into Integrated Healthcare: Perspectives from Individuals Coinfected with Tuberculosis and HIV

Background: Tuberculosis (TB) and human-immunodeficiency virus (HIV) infections are intertwined through complex biological and social pathways that affect over one million people worldwide. Mitigation of the co-epidemic is undermined by a failure to integrate TB and HIV healthcare services as a result of critical clinical, operational and social challenges. The social challenges of TB/HIV coinfection and integrated care are least understood. Objectives: This research examines the social contexts of TB/HIV illness and related healthcare from the perspective of patients coinfected with TB and HIV. Methods: The study was set within a constructivist-interpretivist theoretical framework. Non-participant field observations and semi-structured in-depth interviews were held with 40 coinfected adults (24 women, 16 men) and 8 healthcare workers at 3 ambulatory clinics in KwaZulu-Natal, South Africa, providing varying models of TB and HIV care. Subjective meanings of illness and healthcare were analyzed in relation to patients’ social contexts. Findings and Interpretations: Coinfection exposes patients to a double and unequal form of social stigma around TB and HIV. Affected individuals construct dual identities and negotiate selective disclosure of TB over HIV in order to manage this double stigma. Their experiences with stigma are bound by social, structural and gendered inequalities, and mediate their decisions to disclose, access and adhere to medical care. Coinfection also exposes patients to pluralistic, disparate and fragmented forms of healthcare delivery. Experiences with stigma and with distinct cultures of TB and HIV care affect their decisions for integrated healthcare. While integration may allow for some technical and clinical efficiency, it may also heighten some patients’ social burden of illness as a result of HIV disclosure and stigmatization. Conclusion: Integration efforts should consider the social contexts of TB/HIV coinfection, social consequences of patients’ health decisions, and paradigms within which such efforts are set in the design and execution of successful interventions.Ph