1 Wouters E, et al. BMJ Open 2022;12:e045477. doi:10.1136/bmjopen-2020-045477 Open access How the ‘HIV/TB co-epidemic–HIV stigma–TB stigma’ syndemic impacts on the use of occupational health services for TB in South African hospitals: a structural equation modelling analysis of the baseline data from the HaTSaH Study (cluster RCT) Edwin Wouters , 1,2 André Janse van Rensburg, 3 Michelle Engelbrecht, 2 Veerle Buffel , 1 Linda Campbell, 1 Nina Sommerland, 4 Asta Rau, 2 G Kigozi, 2 Josefien van Olmen, 5 Caroline Masquillier 1 To cite: Wouters E, van Rensburg AJ, Engelbrecht M, et al. How the ‘HIV/TB co- epidemic–HIV stigma–TB stigma’ syndemic impacts on the use of occupational health services for TB in South African hospitals: a structural equation modelling analysis of the baseline data from the HaTSaH Study (cluster RCT). BMJ Open 2022;12:e045477. doi:10.1136/ bmjopen-2020-045477 ► Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (http://dx.doi.org/10.1136/ bmjopen-2020-045477). Received 01 October 2020 Accepted 14 March 2022 For numbered affiliations see end of article. Correspondence to Professor Edwin Wouters; edwin.wouters@uantwerpen.be Original research © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT Introduction Tuberculosis (TB) has become an occupational health hazard in South African hospitals where healthcare workers (HCWs) are additionally confronted daily with HIV and its associated stigma, causing a syndemic. Early TB diagnosis and treatment are vital, but the uptake of these services through occupational healthcare units (OHUs) is low. The current study hypothesises that (1) the link between HIV and TB and (2) the perceived HIV stigmatisation by colleagues create (3) a double HIV–TB stigma which increases (4) internalised TB stigma and leads to (5) a lower willingness to use OHU services for TB screening and treatment. Design A cross-sectional study using the baseline data from the HIV and TB Stigma among Healthcare workers Study (HaTSaH Study). Setting Six hospitals in the Free State province of South Africa. Participants 820 HCWs of the six selected hospitals. Results The study results demonstrate that the co-epidemic (β=0.399 (screening model) and β=0.345 (treatment model)) combined (interaction effect: β=0.133 (screening) and β=0.132 (treatment)) with the persistent stigmatisation of HIV is altering the attitudes towards TB (β=0.345 (screening) and β=0.400 (treatment)), where the stigmatising views of HIV are transferred to TB—illustrating the syndemic impact. Our model demonstrated that this syndemic not only leads to higher levels of internal TB stigma (β=0.421 (screening) and β=0.426 (treatment)), but also to a lower willingness to use the OHU for TB screening (probit coefficient=−0.216) and treatment (probit coefficient=−0.160). Confidentiality consistently emerged as a contextual correlate of OHU use. Conclusions Theoretically, our results confirm HIV as a ‘syndemic generator’ which changes the social meaning of TB in the hospital context. Practically, the study demonstrated that the syndemic of TB and HIV in a highly endemic context with stigma impacts the intended use of occupational TB services. Trial registration number Pre-results of the trial registered at the South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. INTRODUCTION The tuberculosis (TB) epidemic has deeply affected sub-Saharan Africa, and especially South Africa, where it is the leading cause of death: 6.5% of deaths in the country in 2016 were attributable to TB. 1 According to WHO estimates, South Africa has the second highest incidence of TB worldwide (615 per 100 000 population in 2019) and—worryingly— approximately 14 000 cases of rifampicin- resistant or multidrug-resistant (MDR) TB. 2 It is evident that the TB epidemic puts the healthcare system—and healthcare workers (HCWs) in particular—under enormous strain, especially within the contexts of over- crowded health facilities and understaffing. Strengths and limitations of this study ► This is the first study to employ a large, quantita- tive dataset to disentangle the inter-relationships between the different elements of the described syndemic, namely the HIV/tuberculosis (TB) co- epidemic, HIV stigma and TB stigma. ► Structural equation modelling is used to optimally model the complex inter-relationships between HIV, TB and double HIV–TB stigma and the use of TB healthcare services. ► The use of cross-sectional data precludes any caus- al interpretations of the relationships. on January 31, 2024 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2020-045477 on 5 April 2022. Downloaded from