Impact of Stigma and Level of Education on Adherence to Treatment with Both TB and HIV/AIDS in Tertiary Care Teaching Hospital, Andhra Pradesh: A Retrospective Observational Study

Objectives of our study are stigma constitutes a significant influence on medication adherence to treatment with both TB and HIV/AIDS. Due to this the immune system may collapse in the subjects. This study aims to assess the influence of social stigma on the medication adherence to both TB and HIV and also to know the subjects knowledge about disease. Methodology of the study was influence of social stigma on medication adherence was considered based on the data collection form which contain questions about the subjects medication taking behavior and the stigma that they have faced and also about the knowledge they have on the disease. The obtained data was analyzed using chi-square. This study was done at ART center, Government General Hospital Guntur for a duration of 6 months. The results obtained in project examines the medication adherence of stigmatized and non-stigmatized patients. We used the chi square test to analyze the data collected throughout the study and found a p value of >0.05, indicating that there is no relationship between stigma and medication adherence in the subjects. Purpose of the study was to compare the medication adherence of patients with stigma and no stigma. The data that was collected is analyzed using chi-square and revealed that there is no correlation between stigma and subject medication adherence, implying that stigma is not a factor influencing subject medication adherence


I. INTRODUCTION
In recent years TB in India is an uneradicated disease which is due to the lack of adherence and lack of knowledge about the disease and its spread among the individuals. Stigma is a social determinant of health, that is shaped and promulgated by institutional and community norms and interpersonal attitude which is relevant across this TB cascade from delayed care seeking behavior, delayed diagnosis or poor anti-tuberculosis treatment adherence.
Social stigma of TB is because of fear of transmission through air, fear of losing social status, social isolation, gossip, verbal abuse, fail marriage prospects and neglect from family. These is also the notion that TB is a hereditary disease therefore facial discrimination. Incidence, in every year greater than 9 million people suffer from TB in India accounts for greater than 25%.
Patients with both HIV and TB are more prone to stigma in the society, in order to check whether that stigma influences the medication adherence behavior of the patient, we are doing the project.

A. Significance
ü To identify the influence of stigma in patients receiving both TB and HIV treatment. ü To assess the knowledge about TB and HIV coinfection in infected individuals. ü To asses opportunistic infections in both HIV and TB patients. ü To counsel the infected patients.

B. Tuberculosis
TB, often known as tuberculosis, is a bacterial infection that mainly affects the lungs. Other organs including the spine, brain, or kidneys may also be involved. For instance, TB is typically spread from person to person through the air when an infected person coughs or sneezes. The main culprit behind tuberculosis is Mycobacterium tuberculosis, Overall about 5 to 10% of people with latent TB, who do not receive treatment for it, will become sick at some time in their lives [1]. If someone has pulmonary disease, then they may have a bad cough that lasts longer than two weeks.
They may also have pain in their chest and they may cough up blood or phlegm from deep inside their lungs. Other symptoms of TB include weakness or fatigue, weight loss, lack of appetite, chills, fever and night sweats [2]. M. tuberculosis causes tuberculosis [3]. Cigarette usage and HIV-positive people are the main risk factors. This tuberculosis was determined by a number of techniques, including skin testing, blood tests, lung imaging tests, and sputum culture tests, In HIV infected people molecular techniques: Nucleic acid amplification testing (NAAT) provides a reliable way of increasing the specificity of diagnosis (ruling in disease), but sensitivity is variable, especially in paucibacillary disease. A few modified or simplified versions of NAAT kits include loop-mediated isothermal amplification (LAMP), fluorescence in situ hybridization (FISH) and line probe assays (LPA) [4]. Possible TB effects include sepsis, cardiovascular illness, and metabolic failure. For new TB cases the treatment in intensive phase (IP) consists of eight weeks of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol in daily doses as per four weight band categories. There will be no need for extension of IP. Only pyrazinamide will be stopped in the continuation phase (CP), while the other three drugs will be continued for another 16 weeks as daily dosages [5].

C. HIV
The human immunodeficiency virus, or HIV, preys on the body's immune system. HIV can cause AIDS if it is not treated (acquired immunodeficiency syndrome). HIV is a sexually transmitted infection (STI). It can also be spread by contact with infected blood and from illicit injection drug use or sharing needles. It can also be spread from mother to child during pregnancy, childbirth or breastfeeding. Without medication, it may take years before HIV weakens your immune system to the point that you have AIDS. There's no cure for HIV/AIDS, but medications can control the infection and prevent progression of the disease [6]. HIV transmission occurs through anal or vaginal sex, sharing needles, syringes, and other equipment used for drug injection (for example, cookers. The infection of CD4 "helper" cells, a specific type of T-cell seen in humans, may be the first step in the pathogenesis of HIV. Some persons within may experience symptoms, which is one of the indicators of HIV comparable to the flu after infection, 2-4 weeks (called acute HIV infection). These symptoms could linger for a couple of days or a couple of weeks. There is a chance for symptoms including fever, chills, and rashes [7]. Nucleic acid tests (NAT), antigen/antibody testing, and antibody tests are the three available test methods for HIV diagnosis. Blood or oral fluid are typically utilized for HIV testing. Worm infections and vaginal candidiasis are two opportunistic diseases that can be brought on by HIV issues. HIV is treated with anti-retroviral therapy (ART), The combination oral drugs emtricitabine plus tenofovir disoproxil fumarate (Truvada) and emtricitabine plus tenofovir alafenamide fumarate (Descovy) can reduce the risk of sexually transmitted HIV infection in people at very high risk. PrEP can reduce your risk of getting HIV from sex by about 99% and from injection drug use by at least 74%, according to the Centers for Disease Control and Prevention [8].

D. TB, HIV CO-Infection
While TB-infected people have no possibility of getting HIV, HIV-positive people are at a significant risk of getting TB. For six to nine months, medical practitioners administer TB prevention medication. HIV-positive individuals are more vulnerable to contracting other opportunistic diseases, which heightens your risk. The contributing elements may include When a previous or fresh infection of Mycobacterium tuberculosis reactivates, patients with HIV acquire TB. Hemoptysis, protracted coughing, and a longlasting fever are examples of clinical signs. The signs are vague. A 6-month of rifampicin and isoniazid therapy is required. Patients with lower CD4 cell counts have the higher risk of extrapulmonary TB and mycobacteremia [9].

II. MATERIALS AND METHODS
This study is a retrospective observational study carried out in ART center, Government General Hospital Guntur for a duration of 6 months i.e, after obtaining approval from institutional ethics committee. The patients were screened based on the inclusion and exclusion criteria. Patients who satisfy inclusion criteria were included in the study after obtaining informed consent. The data was collected in the designed data collection form. It is in the form of google data entry form which contain the questionnaire about the TB and HIV and it also contains questions regarding medication adherence, stigma and patient knowledge about disease. Later the obtained data was organized into a table and represented in a graphical mode the results are analyzed by using statistical approach of chi-square test with the level of significance(p) value 0.5.

IV. DISCUSSION
This work was carried out in the ART centre of Guntur Government General Hospital to analyse the impact of stigma on medication adherence in subjects. In our study, we observedthatthere is no correlation between stigma and adherence (pvalue >0.05indicates no significance), implying that stigma has no impact on patient medication adherence (Fig.1). We collected 181 samples, with (Table  I) 102 of them dealing with stigma and medication adherence (56.04 percent. There are 21 cases of stigma and non-adherence to medication (11.53 percent). There is no stigma and medication adherence are 55 percent (30.21 percent). There is no stigma associated with non-adherence to medication (2.19 percent). According to a study conducted by [10] Experienced and felt AIDS stigma also increased the rate of missed doses among patients with HIV co-infection. Stigma has a minor impact on populations with high adherence (Table II). Illiterates are 92 participants in them with knowledge of 34.78 percent, without knowledge of 65.21 percent, high degree with knowledge of 11 (100 percent), high school with knowledge of 6 (100 percent), primary school are 34 in them with knowledge of 70.58 percent, without knowledge of 29.41 percent, secondary school are 38 in them with knowledge of 76.31 percent, without knowledge of 23.68 percent (Fig. 2.). According to [10], İt was unearthed that the school students' knowledge of HIV/AIDS was quite satisfactory; the source of information about HIV/AIDS was the television, followed by the newspaper and friends/relatives. . According to a study conducted by [11], The overall level of knowledge increased by education level: 45.2% for participants who completed primary school level, 57.8% for participants who completed secondary school level, and 68.6% for participants with greater than secondary school education. There is a correlation between education level and disease knowledge. Our study has a significance value of 0.0001, indicating that there is a strong relationship between education level and disease knowledge (p 0.05).
In our study, (Table III) we found that there is no significant relationship between education level and medication adherence significance value p=0.6477 where (p value 0.05) (Fig.3) it shows no significance, implying that medication adherence behavior has no relation. Despite the fact that the patient is illiterate, his adherence attitude is excellent. According to a study carried out by [12], Patients with higher educational degrees had higher rates of adherence to medival appointments. According to a study done by [12], TB-endemic setting, HIV-infection put patients at an equal risk for TB, irrespective of level of education. According to the study, educational status was associated with anti TB medication adherence [12]. In our study, (Table IV) we found that illiterates face more stigma than literates (Fig.4). It is obvious that illiterates face more stigma than literates due to a lack of academic achievement, awareness about the disease, disease transmission, and unsanitary behaviors. When compared to literates, they encounter more stigma. There is an indirect proportionality between educational status and stigma, which implies that as education level increases, the incidence of stigma may decrease. The significance is demonstrated by P=0.0249 (p 0.05).
In our study, (Table V) we observed that the CD4 count prior to actually counselling was in the range of 223-450, and the CD4 count after counselling was in the range of 922-1449. (Fig.5) The relationship between health effective interventions and disease prognosis is significant. The significance is demonstrated by a P value of 0.0001 (P<0.05). Health education and intervention programmes may assist the patient in learning more about the disease and the complications that may arise if the disease is not treated. This knowledge will help the subjects to be excellent medication adherents, which will aim to decrease disease complications and increase the patient's CD4 count. This states that counselling and health consciousness programmes aid in disease treatment. Our study results that there is no significance between stigma and medication adherence, i.e., stigma is not a factor in medication adherence. However, there are more illiterates in our study, which may be due to lack of knowledge and awareness of the disease. When it comes to medication adherence in educated and uneducated subjects, there is no correlation between education and medication adherence in the subjects, which could be due to their awareness of the disease or panic.
During our work, we observed that illiterate subjects have more medication adherence. This could be due to their anxiety about their disease or maybe they were made aware about the disease and its complications during counselling, which may have improved their medication adherence. We also disclosed that there is greater medication adherence and that the subjects who do not adhere to their medicine are newly diagnosed.