UCSF

Background: Tuberculosis (TB) is one of the leading causes of infectious disease deaths worldwide. Despite effective and widely available treatment, in 2022, an estimated 10.6 million people were infected with TB and 1.3 million people died from TB.1 TB is also the leading cause of death among people living with HIV (PLHIV), causing 167,000 deaths worldwide in 2022 and highlighting the importance of the TB/HIV “syndemic.”2 Both TB and HIV have long been recognized as diseases that disproportionately impact the impoverished who primarily reside in resource limited settings. To break out of the cycle of poverty and disease, interventions to minimize socioeconomic vulnerability, termed social protection interventions, are now a key pillar of the World Health Organization (WHO) End TB Strategy, the 2023 United Nations General Assembly High-level meeting commitments for TB-affected individuals and households, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the United Nations’ Sustainable Development Goals (SDGs). However, there are significant gaps in understanding the impact of, and barriers to access social protection interventions among people with TB and or HIV in high burden, low income countries (LICs). Further, key information about how to operationalize social protection in LICs is lacking. Objectives: To address the aforementioned gaps, this study used a multimethod approach that uses published research and programmatically available data to quantify the extent to which social protection interventions improve TB treatment success and HIV viral load suppression, as well as empirical data collection to inform the design of policies and strategies that may improve the uptake of social protection for TB and HIV affected individuals and communities. The three aims of this dissertation were to quantify the effect of social protection interventions on TB treatment and socioeconomic outcomes (Aim 1), to estimate the association between socioeconomic characteristics and HIV treatment outcomes, as well as outcomes pertaining to antenatal care among pregnant and lactating women with HIV in Zimbabwe (Aim 2), and to describe barriers and facilitators to accessing social protection interventions among PLHIV both with TB and at risk for acquiring TB (Aim 3). Methods: For Aim 1, we conducted a systematic review and meta-analysis to evaluate if people with TB who had been recipients of social protection interventions demonstrated an improvement in TB treatment or socioeconomic outcomes when compared to people with TB who had not been recipients of social protection interventions. For Aim 2, we used generalized estimating equations to quantify the association between sociodemographic characteristics and various clinical outcomes among pregnant and lactating women with HIV in Zimbabwe. Lastly, for Aim 3, we conducted in depth, semi-structured interviews with 25 PLHIV (with and without TB) in Zimbabwe to assess barriers and facilitators to accessing social protection interventions. Results: Our systematic review and meta-analysis yielded 46 articles for inclusion. Our meta-analysis demonstrated that recipients of social protection interventions had 2.12 times the odds of TB treatment success (defined as cure or completion of treatment) compared to individuals who were not recipients of these interventions (95% CI 1.7, 2.6). Our findings also suggested improved economic outcomes, such as lower rates of catastrophic costs (total costs in excess of 20% of annual household income), among recipients of social protection interventions. Using generalized estimating equations, we found that in Zimbabwe, pregnant and lactating women with HIV experience many forms of poverty and socioeconomic vulnerability. Intimate partner violence was significantly associated with HIV viral load non-suppression across several models. Additionally, dissaving, or negative financial coping strategies, was associated with delayed presentation to antenatal care. Lastly, the semi-structured interviews provided key insights into barriers and facilitators accessing social protection interventions. These barriers included lack of knowledge about existing social protection interventions, limited reach of social protection interventions, and limited sustainability of social protection interventions. Conclusions: When implemented effectively, social protection interventions can significantly improve TB treatment outcomes for at-risk individuals. Pregnant and lactating women with HIV are particularly vulnerable to the co-occurring effects of HIV and poverty, but additional research is needed to better understand how to target social protection interventions to support at-risk populations effectively. Lastly, PLHIV with and without TB in Zimbabwe experience a range of socioeconomic vulnerabilities, but encounter multiple barriers to accessing social protection interventions. Efforts must be made to improve access to social protection among vulnerable populations to optimize their potential benefit.