| BackgroundThis study was conducted in Paynesville, Monrovia, Liberia. Liberia is situated on the west coast of Africa and covers a land surface area of about 111,370 km with an estimated population of 3.5 million people. The climate is tropical with significant variations between the dry and wet rainy seasons. The community of Paynesville is one of the key business communities in the suberg of Liberia's capitol, Monrovia and is home to nearly 304,745 inhabitants,278 households. Majority of inhabitants are youth who are engaged in petty street trading. The source population from which the sample of 400 respondents was drawn was 134,745. The national TB and HIV control programs are separate entities in Liberia like most countries in the world. Doubt, low knowledge, misconception and stigmatization are major challenges faced by both programs. It is not clear if both programs have areas of collaboration that could enhance program uptake and promote good outcomes. The issue of HIV remains a sensitive one due to high level of stigma and sometimes physical abuse muted against the victims. People still have doubt about the existence of HIV and do not accurately understand the synergistic relationship between HIV/TB as co-infections that facilitates the progression of each other. What a pity! What a lethal marriage! Infectious and communicable diseases share common characteristics that make them persist under conditions of poverty, resulting in clustering and overlap with different diseases of all kinds over the world especially in resource constrained countries. The two diseases under spot light, TB/HIV are considered the worse of disease burden that claimed so many lives and continued to lay waste on human populations. According to infectious disease surveillance report from Liberia, the prevalence of HIV is put at 8.2% nationwide with an upward trend expected. The prevalence proportion for HIV in adults (15-49years) is 1.7% and the estimated number of people living with AIDS is 35,000 for both adults and children (0-14) years. The TB estimated number of cases is 18,857 with TB case detection rate of 55% and TB DOTS treatment success rate of 76%. HIV infected with active TB rate is 4.9%. With the population growth rate of 3.7%, it is important for a study of this nature conducted to help educate the local people and advice policy makers so that they do not depend on their haphazard subjective judgment in their management task but base their decisions on results from well grounded scientific research findings.Objectives1.Determine the overall knowledge of the research subjects (15-49 years) in Paynesville about TB/HIV co infections.2.Determine the feasibility of the research subjects accepting PICT/VCT.3.Find out the kind of health practices they are engaged in that could increase or decrease their chances of contracting both diseases.4.Find out the perception of the research respondents towards people with TB/HIV as co infections.MethodsThe research design used in this study was a cross-sectional survey design. In this way, the data was just observed and described accordingly. The sample size was calculated using the Leslie Kish and Taro Yamane simplified formula for population proportion in sample size calculation when the reference population is known. Given that the source population (15-49 years) is known to be 134,584 subjects, it implies that n= N/1+N(e)2 with a result of approximately 400 subjects as sample size, where n=sample size, N= population proportion, and 95%CI with (e) as the level of precision at 0.05 assuming p= 0.5. The power of the research study was also set at 80%. The simple random sampling technique was used after the community was divided into four blocks based on proximity to get the target respondents. In a household, one adult person was selected randomly for the interview. To get the target study participants, households were visited repeatedly. If the respondent was not found on two successive visitations, the next household was included automatically to replace the absentee. The data collection instruments used was questionnaires coded with unique numbers to reflect the different communities in Paynesville. A 50-50 gender balance was attempted to avoid bias. It was also presumed that majority of the target population is largely to read and respond to a simple questionnaire under the tutelage of the well trained interviewers. Their answers to the questionnaire items related to HIV, TB and prejudice towards people with TB/HIV co infections were scored. Since the data scores departed from a normally distribution and skewed, they were divided into three quartiles or parts to select a statistical threshold based on their median. Decision rule that those whose knowledge assessment scores fell below the first 25th quartile exclusively had low knowledge, between the 25th to 75th quartiles inclusively as people with average knowledge, and those above the75th quartile as highly knowledgeable subjects based on the questionnaire items. The same procedure was repeated for TB and prejudice assessment towards people with TB/HIV co infection but the mean scores of the subjects was used as the mean as the cutoff point for prejudice assessment. Data generated from this study were double entered into epi-data version 3.1(Epi-data Norway,2008) and later transported to SPSS version 18(SPSS INC., Chicago, Illinois, U.S.A) as windows for analysis. To triangulate the findings, statistical software R version 2.12.1 was used. Data were displayed using tables, area plots, and side-by-side box and whiskers plots. Test statistics used were the Kruskal-Wallis ranked sum test, Wilcoxon's ranked sum test with continuity corrections, and the Pearson's product movement correlation.Results1.Table 1 showed that 199(49.75%) out of the 400 respondents were males while 201(50.25%) were females. For marital status,203(50.75%) were married, 95(23.75%) single,31(7.75%) underage,36(9.0%) cohabiting,16(4.0%) separated, 10(2.50%) divorced,3(0.75%) widows, and 6(1.50%) widowers. Considering their level of education,306(76.50%) were literate and 94(23.50%) illiterate. For occupation,71(17.75%) as students,189(47.25%) merchants,70(17.50%) casual laborers,22(5.50%) housewives,25(6.25%) civil servants,14(3.50%) farmers, 9(2.25%) had no jobs. For religion,286(71.50%) were Christians,92(23.00%) Muslims,5 (1.25%) pagans and 17(4.25%) for religions not mentioned. Their income was also viewed as a factor,121(30.25%) had no income,22(5.50%) less than 1000LD monthly,21(5.25%) earn 1000-2000LD,30(7.50%) 2005-4000LD, 56(14.00%) 4005-6000LD,90(22.50%) 6005-8000LD and 60(15.00%) above 80000LD monthly. For number of children, those without children recorded 131(32.75%),133(33.75%) for one child,97(24.25%) for two,29(7.25%) for three, and 1(0.25%) for four children. The observations 5 children and more were not recorded. However, the minimum age was (15years), median (34.5), mean (33.54), maximum (49) years and the mean age standard deviation (sd 10.4years).2. Their HIV knowledge was assessed based on academic standard, a total of twenty questionnaire items (Qs 11-26) were selected and scored. Two of the questions had 4points each for two correct answers. The total number of points as in all corresponding to a 100% was 44. A correct answer to each question meant the respondent would obtain two points and zero if the answer was incorrect. Decision rule that those who obtained HIV knowledge assessment scores below the first 25th quartile had low knowledge,25th to 75th quartile inclusively as average knowledge, and above 75th quartile as high knowledge. Accordingly,131(32.75%) attained scores that fell below25th quartile meaning low knowledge,201(50.25%) between25th to 75th quartile as average knowledge, and 68(17.00%) above 75th quartile as high knowledge. To compare if there was a difference in their individual educational status that impacted their HIV knowledge assessment scores, the Kruskal-Wallis ranked sum statistics was used with p<0.05.3.Figure 2 compared the respondents' individual income and their HIV knowledge. The Kruskal-Wallis ranked sum test was used with p<0.05. Their HIV knowledge was also compared with their occupation by use of Kruskal-Wallis ranked sum test with p<0.05.4.To find out if there was a relationship between their TB, HIV and prejudice assessment scores, the Pearson's product movement correlation statistics was employed. However, the relationship between their HFV and prejudice assessment scores showed a perfect correlation with the Pearson's product movement statistics and p<0.05.5.For TB knowledge assessment, twenty five questionnaire items were selected with each worth two points making a total of 50 points. Decision rule that those who obtained scores below the first 25th quartile got low knowledge,25th to 75th quartile inclusively as average knowledge and above 75th quartile as people with high TB knowledge. It was observed that 145(36.25%) obtained scores below the 25th quartile indicating low knowledge,171(42.75%) between 25th to 75th quartile inclusively as average knowledge and 84(21.0%) above 75th quartile as high knowledge. The Kruskal-Wallis ranked sum test was used to determine if there was a difference between their occupations and TB knowledge. Its p<0.05 indicating a significant difference. To compare if there was a difference with respect to their TB knowledge assessment scores by sex as a factor, its p< 0.001.6.To assess the level of prejudice the respondents havoc against people with TB/HIV co-infections, ten questionnaire items were selected with each worth two points making a total of twenty points. The mean was used as a cutoff point. The higher the individual's prejudice assessment scores, the more prejudice they havoc against people living with the dual epidemics. The result showed that 111(27.75%) had low prejudice while 289(72.25%) had high prejudice. The Krukal-Wallis ranked sum statistics was used to compare their occupations and prejudice assessment scores but its p<0.05. To compare their prejudice scores by sex as a factor, the Wilcoxon's ranked sum statistics with continuity correction was employed with p>0.05.7.Figure 8 and 9 assessed the perception of the respondents when asked if they are willing to take their TB/HIV test and if they support programs requiring such. Accordingly,286(71.75%) showed willingness for test,113(28.25%) are not willing to take the HIV test while 103(25.75%) admitted that they support testing programs and 297(74.25%) do not support such programs. The final area plot showed their health education information source. Accordingly,194(48.50%) watch TV,109(27.25%) listen to radio,22(5.5%) observe bill-boards,35(8.75%) from health centers,5(1.25%) from their schools,23(5.75%) from friends, and 12(3.00%) from health clubs.ConclusionThe low level knowledge on TB/HIV co-infection is implicated as key factor for the wide spread prejudice towards people living with TB/HIV co-infections, not willing to take their TB/HIV test, neither support programs that advocate individual testing in the co-infections. If the national TB/HIV control programs should meet their millennium development goals, they should collaborate with other partners and invest more in social mobilizations and education in various communities especially in rural areas. RecommendationsThat the Government of Liberia through the Ministry of Health and Social Welfare and other development partners:1.Strengthen existing services2.Reduce social stigma associated with TB/HIV through general health education3.Establish and improve linkage between TB/HIV programs nationwide.4.Increase availability of ART/ATT and decentralize TB/HIV services nationwide.5.Increase HIV surveillance among TB patients in the country.6.Substain political will.7.Invest in future researchCritical ReflectionFirst, the study was conducted in a predominantly urban setting and may not be reflective of the entire country. In addition, an assessment on the quality of health service for TB/HIV was not done to triangulate the research findings. TB/HIV co-infected subjects were not included in this study. This was the basis for recommending further research that will include more people from diverse background.
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