Characterizing tuberculosis diagnosis and the associations with economic instability and employment discrimination among women living with HIV across 11 countries in sub-Saharan Africa: a cross-sectional study.

INTRODUCTION

Tuberculosis (TB) is the leading cause of death among people living with HIV. Global estimates among people living with HIV demonstrate that more incident cases and more deaths due to TB occur among women than men. Simultaneously, women experience higher levels of under and unpaid work compared to men. Given that poverty is an established determinant for TB, the aim of this study is to characterize the role of HIV-related employment discrimination and legal protections on TB outcomes for women living with HIV.

METHODS

The People Living with HIV Stigma Index 2.0 study was implemented in 11 countries across sub-Saharan Africa, including Angola, Benin, Burkina Faso, Cote D'Ivoire, Ghana, Kenya, Mauritania, Nigeria, Lesotho, Togo and Zimbabwe. Study design and implementation were led by networks of people living with HIV in each country between 2020 and 2022. Interviewer-administered questionnaires were used to collect self-reported socio-behavioural measures among cisgender adult women living with HIV. Multilevel logistic regression models were used to estimate associations between economic instability and employment discrimination exposures and recent TB diagnoses in the context of varying discrimination protections for women living with HIV.

RESULTS

Among 10,718 participants, 7.5% (n = 807) reported a recent TB diagnosis. Among women in countries without non-discrimination protections, recent TB diagnosis was negatively associated with current employment (aOR: 0.72; 95% CI: 0.62, 0.85) compared to no employment; and positively associated with being refused employment or income due to HIV status (aOR: 1.80; 95% CI: 1.36, 2.39) and ever being refused promotion (aOR: 2.00; 95% CI: 1.37, 2.91) compared to those who have not reported these experiences. Among women in countries with non-discrimination protections, recent TB diagnosis was associated with lower current employment (aOR: 0.72; 95% CI: 0.56, 0.92) but not associated with employment discrimination.

CONCLUSIONS

The presence of social protections may modify the associations between employment discrimination and TB diagnosis. Employment discrimination was associated with TB diagnosis in settings without social protections but not in settings with those protections in place-highlighting a potential vulnerability among people living with HIV in settings without non-discrimination protections. Given the role of poverty in driving TB epidemics, social protections focused on employment, economic instability and opportunity may support TB prevention and control.