Abstract
Introduction
Myanmar faces significant challenges as one of the countries with the highest burden of tuberculosis (TB), HIV-associated TB, and drug-resistant TB in the Southeast Asia Region. 1 In 2021, approximately 167 000 TB cases and 22 000 TB-related deaths, including 2900 deaths among people with HIV, were reported in Myanmar. HIV infection, along with factors such as malnutrition and alcohol consumption, contributes significantly to the social determinants of TB. 2 The coinfection rate of HIV and TB stands at approximately 15%. 3 To achieve the goal of ending the TB pandemic and reducing mortality rates, rigorous control measures are essential, particularly in addressing the challenges posed by HIV coinfection.
Since 2005, provider-initiated HIV testing and counseling (PITC) activities have been implemented in Myanmar. 4 HIV-positive patients are referred to the nearest HIV centers for further case management without any charge. 5 This approach has resulted in an increase in the proportion of patients with TB with known HIV status, from 60% in 2014 to 74% in 2015. 6 However, various factors hinder HIV testing among some patients with TB, including geographical remoteness from health services, limited awareness about HIV testing, social stigma associated with HIV infection, and inadequate information about the HIV diagnostic process and results. 7 Consequently, the coverage of HIV testing among patients with TB remains low. The present study aims to assess the proportion of self-reported TB patients who have undergone HIV testing and identify associated factors.
Methods
Data Set From the Myanmar Demographic Health Survey 2015-16
The data employed in this study were sourced from de-identified secondary data compiled by the Myanmar Demographic Health Survey 2015-16 (MDHS 2015-16). 8 The survey encompassed a total of 17 622 respondents, among whom 459 individuals self-reported having TB and were eligible to participate in the present analysis.
Data Analysis
We employed both simple and multiple logistic regression models to explore the factors associated with HIV testing among self-reported TB patients. All statistical analyses were performed using STATA software (Version 15, STATA Corp., College Station, Texas). Weight factors and the “svyset” command were used to account for the complex multistage stratified cluster sampling design.
Results
In this study, 459 self-reported TB patients were analyzed (Table 1). Among them, a mere one-third (151, 32.9%) underwent HIV testing. Approximately two-fifths of those with a high uptake of HIV testing were men (40.4%); individuals aged 25 to 34 years (42.5%); those who were divorced, separated, or widowed (43.1%); individuals with a secondary level of education (40.4%); and those falling into the fourth or fifth wealth quintiles (39.2%). Moreover, nearly one-third resided in hilly regions (38.7%), lived in urban areas (36.6%), were employed in professional/technical/managerial level jobs (39.2%), and had regular access to mass media exposure at least once a week (34.9%). In addition, almost half exhibited a good level of knowledge about HIV (47.5%) (Table 2).
Characteristics of Self-Reported TB Patients (Age 15-49 Years), Myanmar Demographic and Health Survey 2015-16 (n = 459).
Composite measure that a person (1) knows about condom use and limiting sexual intercourse to one partner can prevent HIV, (2) knows that a healthy looking person can have HIV, and (3) rejects the two most common local misconceptions about the transmission of HIV, which in Myanmar are that HIV can be transmitted through mosquito bites and that a person can become infected with HIV by sharing food with someone who has AIDS.
Independent Predictors of HIV Testing Among Self-Reported TB Patients (Age 15-49 Years), Myanmar Demographic and Health Survey 2015-16. a
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; cOR, crude odds ratio; row %, row percentage.
Weighted estimates (for multistage survey design) for frequency, proportion, and odds ratio.
Composite measure that a person (1) knows about condom use and limiting sexual intercourse to one partner can prevent HIV, (2) knows that a healthy looking person can have HIV, and (3) rejects the two most common local misconceptions about the transmission of HIV, which in Myanmar are that HIV can be transmitted through mosquito bites and that a person can become infected with HIV by sharing food with someone who has AIDS.
During the logistic regression models, several factors were found to be associated with an increased likelihood of undergoing HIV testing. Being male (adjusted odds ratio [aOR]: 1.84, 95% CI [1.16, 2.94]), having a secondary education (aOR: 3.68, 95% CI [1.08, 12.57]), being married (aOR: 4.89, 95% CI [2.67, 8.95]) or divorced/separated/widowed (aOR: 6.43, 95% CI [2.48, 16.66]), and belonging to lower wealth quintiles (second—aOR: 3.00, 95% CI [1.12, 8.03]; third—aOR: 4.44, 95% CI [1.72, 11.47]; fourth—aOR: 4.10, 95% CI [1.51, 11.12]) were all associated with an increased likelihood of HIV testing (Table 2).
Discussion
Although the Myanmar National TB Program (NTP) has implemented PITC activities with support from various funding sources and expanded through the public-private mix approach to include HIV testing for patients with confirmed TB, there are certain groups that are often inaccessible to these services. Similarly, in this study, among the respondents who self-reported TB, only approximately one-third stated that they had undergone an HIV test. The result is almost consistent with another study conducted in Mandalay, Myanmar, which revealed that only 44.5% of patients with TB were aware of their HIV status. 3 This could potentially be attributed to the inadequacy of detailed health education about HIV testing and the explanation of blood test results. In Myanmar, the human resources in the health sector, especially in government hospitals and health centers, appear to be insufficient to cope with the overwhelming workload of caring for numerous patients on a daily basis. 9
The findings of the present study illuminate specific demographic and social characteristics, such as female gender, lack of formal education, and the poorest wealth quintiles, among self-reported TB patients who opted for a low uptake of HIV testing. Targeting these particular groups is crucial to increase awareness of HIV and emphasize the importance of testing. 10 This can be achieved through regular counseling sessions for patients, and potentially through mass media campaigns and group health talks targeting the entire at-risk population. Efforts should also focus on providing convenient channels for these individuals to access HIV testing. Furthermore, the establishment of an effective referral system between the NTP and the National AIDS Programme (NAP) is crucial to integrate diagnostic and treatment services for both diseases, ensuring early and comprehensive care for affected individuals. 5
The study recognizes several limitations to consider. First, the data used in the study are from the MDHS 2015-16 survey, which includes individuals regardless of their TB or disease status, limiting its representativeness for all patients with TB in Myanmar. Second, the challenges posed by the COVID-19 pandemic and political turmoil in Myanmar may affect the generalizability of the findings due to disruptions in health care and staffing. Lastly, the reliance on self-reported data through a questionnaire introduces the possibility of information bias, as individuals may respond based on their experiences or perceptions, potentially affecting the accuracy of the results.
Conclusion
The study findings highlight a significant gap in the proportion of self-reported TB patients in Myanmar who receive HIV testing. Certain subgroups, specifically educated married men with lower or middle wealth status, exhibit higher testing rates. Addressing the identified disparities between service providers and patients necessitates further investigation to improve service utilization among patients with TB.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
The DHS in Myanmar was conducted in accordance with rigorous ethical standards, following the necessary approval from the Ministry of Health. To uphold respondent confidentiality, the identities of all participants were strictly protected. The present study involved a secondary data analysis using the existing DHS data set, and therefore, no additional ethics approval was required for this specific study. The study title has been duly registered on the DHS program website, further ensuring transparency and accountability. Authorization to access and use the survey data sets was granted by the officials of the DHS program, underscoring the legitimacy and appropriateness of the data used in this study.
