Knowledge and stigma of latent tuberculosis infection in Brazil: implications for tuberculosis prevention strategies

Abstract

Background: Tuberculosis (TB) elimination requires treatment of millions of persons with latent M. tuberculosis infection (LTBI). LTBI treatment acceptance depends on population-wide TB knowledge and low stigma, but limited data are available on the relationship between stigma and knowledge. We assessed knowledge of TB disease and LTBI throughout Brazil and examined their association with TB stigma and incidence. Methods: We performed a nationwide survey with multi-stage probability design through AmericasBarometer from April-May 2017; the sample was representative of Brazil at regional and national levels. Knowledge of and stigma toward TB were assessed by validated survey questions. Results: Survey-weighted responses of 1532 individuals suggest that 57% of the population knew LTBI can occur, and 90% would seek treatment for it. Regarding active TB, 85% knew TB symptoms, 70% reported they should avoid contact with someone with active TB, and 24% had stigma toward persons with TB (i.e., thought persons with tuberculosis should feel ashamed, or deserved their illness). In regression models adjusting for clinical and demographic variables, knowledge of LTBI was associated with increased stigma toward persons with TB (adjusted odds ratio [OR] = 2.13, 95% confidence interval [CI]: 1•25-3.63, for "should feel ashamed"; OR = 1•82, 95% CI: 1•15-2•89, for "deserve illness"). Adjusting for regional TB incidence did not affect this association. Conclusions: High proportions of this representative Brazilian population had knowledge of LTBI and were willing to seek treatment for it. However, such knowledge was associated with TB-specific stigma. Strategies to educate and implement treatment of latent tuberculosis must include efforts to decrease TB stigma.

Integrating interferon-gamma release assay testing into provision of tuberculosis preventive therapy is feasible in a tuberculosis high burden resource-limited setting: A mixed methods study

“…Similar to findings elsewhere in the Netherlands [26] and Brazil [27], TB stigma was a major barrier to LTBI services. Increased knowledge and awareness of LTBI led to an increase in expressed stigma [27].…”

“…Similar to findings elsewhere in the Netherlands [26] and Brazil [27], TB stigma was a major barrier to LTBI services. Increased knowledge and awareness of LTBI led to an increase in expressed stigma [27]. This was also the case in our setting were HHCs did not want the health worker teams to carry out any procedures from outside the house as they expressed fear of stigma from neighbors.…”

Possible sex difference in latent tuberculosis infection risk among close tuberculosis contacts

“…If replicated in other settings, a sex difference in LTBI would be informative from a health equity standpoint. TB disease stigma persists in Brazil, with higher stigmatization paradoxically among those with knowledge of LTBI ( Rebeiro et al ., 2020 ). Identifying and dismantling structural barriers that reinforce stigma can decrease the active TB disease burden – this can be achieved partly through early recognition, education, and treatment of LTBI.…”

Determinants of losses in the latent tuberculosis infection cascade of care in Brazil: a prospective multicenter cohort study

“…A Brazilian study [17] investigating stigma towards TB in the general population found that 57% of the participants knew that LTBI could occur, and 90% would seek treatment for it, suggesting that knowledge and stigma should not be an important barrier in our population. This factor should be better explored, along with other possible issues such as economic barriers for health care seeking, difficulties pertaining to absences from work and risk perception.…”