Reasons for accepting or refusing HIV services among tuberculosis patients at a TB-HIV integration clinic in Malawi

SETTING: In Malawi, human immunodeficiency virus (HIV) prevalence among newly registered tuberculosis (TB) patients is 60-70%. In 2008, an integrated TB-HIV clinic was established at a central hospital in Zomba. Despite the integration of TB-HIV activities and improved HIV service uptake, unacceptably high proportions of HIV-positive TB patients are still not receiving antiretroviral therapy (ART).
OBJECTIVE: To identify factors that motivate or discourage TB patients from accepting HIV services.
DESIGN: Retrospective analysis of patients registered for TB treatment (not yet on ART) between April 2008 and March 2009; qualitative interviews of 99 patients on TB treatment.
RESULTS: Of 1773 newly registered TB patients who were not already on ART at the time of TB registration, 86% accepted HIV testing and counselling. Among HIV-positive TB patients, 38% started ART during or after anti-tuberculosis treatment. Young adults aged 15-24 years were least likely to initiate ART. Motivation for accepting ART during TB treatment included prospects of regaining good health and longer life, and counselling by health care providers. Barriers to ART uptake included not being offered ART, high CD4 count, drug stockouts and fear of drug toxicities/interactions.
CONCLUSION: Several factors that undermine uptake of ART have been highlighted; targeted measures urgently need to be addressed by TB-HIV programmes to overcome these barriers.