https://orcid.org/0000-0003-0309-1641
Figures
Abstract
Background
Household contact investigation (HCI) is an effective and widely used approach to identify persons with tuberculosis (TB) disease and infection globally. Despite widespread recommendations for the use of HCI, there remains poor understanding of the impact on and value of contact investigation for participants. Further, how HCI as a practice impacts psychosocial factors, including stigma and possible unintended disclosure of illness among persons with TB, their families, and communities, is largely unknown.
Methods
This exploratory qualitative study nested within a randomized trial (ClinicalTrials.gov: NCT04520113, 17 August 2020) was conducted in South Africa to understand the impacts of HCI on index patients living with TB and their household contact persons in two rural districts in the Limpopo province (Vhembe and Capricorn) and Soshanguve, a peri-urban township in Gauteng province. People with TB and household members of people with TB were recruited to participate in in-depth interviews and focus group discussions using semi-structured guides. We explored individual, interpersonal, and community-level perceptions of potential impacts of household contact investigation to elucidate their perceptions of HCI. Thematic analysis identified key themes.
Results
Twenty-four individual interviews and six focus group discussions (n = 39 participants) were conducted. Participants viewed HCI as an effective approach to finding TB cases, helpful in educating households about TB symptoms and reducing barriers to health-related services. At the interpersonal level, HCI aided people with TB in safely disclosing their TB status to family members and facilitated family and social support for accountability. The introduction of HIV testing during HCI was reported by some participants as making household members slightly uncomfortable, decreasing interest in household members being tested for TB. HCI negatively impacted community-level TB and HIV-related stigma due to healthcare worker visibility at home.
Citation: Mlambo LM, Milovanovic M, Hanrahan CF, Motsomi K, Morolo MT, Mohlamonyane MM, et al. (2026) The impact of ethical implications intertwined with tuberculosis household contact investigation: A qualitative study. PLoS One 21(3): e0306848. https://doi.org/10.1371/journal.pone.0306848
Editor: Takalani Grace Tshitangano, University of Limpopo, SOUTH AFRICA
Received: June 24, 2024; Accepted: October 22, 2025; Published: March 30, 2026
Copyright: © 2026 Mlambo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: De-identified transcripts are not publicly available, per the Johns Hopkins School of Public Health Institutional Review Board-approved informed consent form used for the study. Requests for data may be made to the Johns Hopkins School of Public Health Institutional Review Board, bsph.irboffice@jhu.edu.
Funding: This research was funded by the United States National Institutes of Health, National Insititute of Allergy and Infectious Diseases (Principal Investigator DWD; R01AI14768). https://www.nih.gov. The funder had no role in the the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: HCI, Household Contact Investigation; TB, Tuberculosis; HIV, Human Immunodeficiency Virus; WHO, World Health Organization
Background
The World Health Organization (WHO) has proposed an ambitious strategy to end the global TB epidemic by 2035 [1]. To meet this goal, urgent attention is needed to factors that may influence the success of routine programmatic approaches, such as screening of household members of people diagnosed with TB.
Identifying people with TB and those at substantial risk of TB infection remains essential for global health and development [1,2]. In the South African context, most people with TB are diagnosed passively by presentation at health facilities [3]. However, persistent barriers contribute to clinic attendance: being asymptomatic (e.g., subclinical or early TB disease) [3], lack of knowledge about TB or TB symptoms [4,5], financial costs [6], transport availability, and facility proximity [7,8]. A common approach to ensuring contact persons access TB screening and are linked to care is household contact investigation (HCI) [9]. Though approaches may vary by setting, HCI typically involves healthcare workers visiting the home of a newly diagnosed person with TB and screening and/or testing household members for TB symptoms. Literature from both within and beyond the South African context demonstrates that HCI is effective across high TB burden settings in increasing TB case notification and TB detection, and decreasing mortality as well as TB prevalence [10,11]. However, HCI may cause potential ethical challenges. Though scant, there is some evidence that HCI may increase stigma, discrimination, and blame for people with TB; a better understanding of these challenges can help ensure that any potential harms are mitigated [12–14].
In South Africa, TB screening in the home setting, though often associated with psychosocial and logistical challenges, may reduce barriers to testing other household members [15,16]. As HCI is increasingly prioritized in high-burden settings like South Africa [17–19], understanding the ethical implications associated with HCI is critical to ensuring that TB researchers and program planners alike address the less tangible benefits and potentially harmful impacts of HCI. Therefore, the goal of this study was to use qualitative methodology to explore how stigma, confidentiality, and disclosure manifest in the context of HCI and impact people diagnosed with TB, their household members, and interpersonal relationships within the household and community in rural and peri-urban settings in South Africa.
Methods
Study setting and design
A qualitative, exploratory study was conducted to understand the impacts of HCI, focusing on ethical factors among people living with TB and their household members in Gauteng and Limpopo provinces, South Africa. Focus group discussions (FGDs) and in-depth interviews (IDIs) were used to collect data on both individual and group-level perceptions. This study was nested within a larger randomized trial of two novel TB HCI intervention approaches: the Kharituwe trial. The two novel TB HCI interventions included 1) HCI on holidays in rural areas and 2) HCI on evenings and weekends in urban areas compared to the standard HCI (during working hours). The trial was conducted among people with active TB and their household members in 12 hospitals across Vhembe and Capricorn districts in Limpopo Province, plus 33 clinics and two hospitals in Soshanguve and surrounding areas (a mix of urban and peri-urban communities spanning the borders of Gauteng and North West provinces). Eligibility and recruitment procedures for the trial are described elsewhere [20].
Participant recruitment and sample
Potential participants aged 18 years and older were purposively selected from among Kharituwe trial participants and approached by study staff in-person during routine study or clinic visits to consider study participation and, if interested, informed consent, which was obtained before being interviewed in either a focus group or an interview, with attention to ensuring a balance of recruitment between sites as well a balance of gender and age within the sample.
Data collection
For interviews, the study team developed a semi-structured interview guide to elicit individual-level perceptions and insights on the experiences with and ethics of HCI (Supplementary File 1). Interview guides were structured to explore the following domains in the context of HCI: TB/HIV disclosure preferences, perceived stigma/blame associated with testing for TB or having a new TB diagnosis, community stigma or blame resulting from HCI; right to privacy; the relative importance of household contact investigation when weighed against potential negative impacts; willingness to participate in household contact investigation; family and household dynamics; duty to others health within the household; and beliefs about TB/HIV confection. For focus groups, the study team developed a facilitator guide to elicit discussions on community-level perceptions and norms regarding the ethics of household contact investigation (Supplementary File 2). Focus group guides were structured to explore the following domains: methods for reducing TB-related stigma among people with TB and their families; belief as to whether contact investigation should be mandatory/optional/not performed; and relative stigma of TB and HIV and the risk of stigmatizing people for either TB or TB and HIV by offering HIV testing as part of HCI.
From June 12th, 2021, to February 23rd, 2022, we conducted 24 IDIs among people living with TB (n = 12) and people living in their households (n = 12), plus six FGDs with people living with TB (n = 15) and TB household contact persons (n = 24). Both interview and FGD guides were piloted internally with both study staff and volunteers from within the broader staff at each site. Additionally, the first interviews (n = 2/site) and focus groups (n = 1/site) conducted with participants were reviewed by N.S.W., and feedback on quality and approach was provided and discussed with data collection teams. All individuals recruited for IDIs consented to participate. For FGDs, n = 8/25 people living with TB who initially expressed interest in participating did not arrive at the scheduled focus group time and were therefore not consented and did not participate, and n = 1/25 household contacts recruited did not attend/consent. IDIs and FGDs were conducted in English, Tshivenda, Sepedi, Tsonga, or Setswana languages and facilitated by experienced qualitative interviewers and focus group leaders who received additional training on the study aims and data collection instruments. All IDIs and FGDs were conducted in a confidential space at either the local health facility or study offices.
Analysis
A senior researcher conducted thematic analysis (author M.M.) experienced in qualitative methodologies, and a junior researcher author L.M.M., with support from author N.S.W.. A list of initial codes was generated by M.M and reviewed by N.S.W based on the study aim and questions from the semi-structured interview and focus group discussion guides. New codes were developed during analysis in response to emerging themes. This strategy allowed for an inductive and deductive approach to coding and analysis. Two South African analysts (L.M.M. and M.M.) reviewed the codebook to ensure agreement before coding, and it was re-assessed throughout the coding process. Both analysts had knowledge about the study but were not part of the parent study or data collection process.
The codebook and transcripts were imported into ATLAS.ti© analytical software for coding. Coding was done by L.M.M. with regular discussion with the study team regarding data interpretation. Codes were connected and sorted into identified themes and summarised into a tabular format with participant quotes. Two analysts (L.M.M and M.M) reviewed the tables to refine themes further. The analysts practiced reflexivity throughout the analysis by discussing and acknowledging their position and experiences as South African TB researchers and their experiences with and perceptions of HCI. Findings were examined by data collection method (IDIs, FGDs) and location but are not differentiated as such here unless noted because of consistency across these categories.
Final themes were reviewed and discussed by the entire analysis team to provide a deeper understanding of the contribution of each theme to the overall research goals [21]. A social-ecological model was used to situate the results and demonstrate the multilevel ethical factors intertwined with HCI for individuals, households, and communities [22,23].
Ethics statement
The study was approved by the Human Research Ethics Committee at the University of the Witwatersrand (Ethics reference: 1909111B), the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health (IRB reference: 11124), and by the District Research Committee (NHRD reference: LP_2022-12-005 and GP_202002_005). All participants provided written informed consent before enrolment.
Results
Thematic analysis was used to derive key themes from the FGDs (n = 6) and the IDIs (n = 24). The key themes are presented within the social-ecological model to understand the range of ethical factors intertwined with the implementation of HCI within the individual, community, household, and interpersonal levels. HCI had a positive impact on the individual and interpersonal level, providing education and access to health services as well as aided disclosure of TB status and social support. Within household and community levels, HCI decreased interest in testing for HIV and increased TB and HIV-related stigma.
IDI participants included ten men and 14 women with a median age of 32 (IQR 29,55) years. Focus group discussion participants were 20 men and 19 women with a median age of 43 (IQR 30,60) years. Participants included 27 people diagnosed with TB and 36 household members (participant demographics are presented in S1 File). Overall, people with TB and household members of people with TB described varied perceptions of the impact of HCI in the context of critical ethical considerations. Participants discussed the largely positive role of HCI in health service delivery and access, and in reducing fear by delivering information about TB and transmission prevention at the household level. By contrast, participants also noted the negative impact HCI has concerning the perceptions of concurrent TB and HIV testing as well as TB and HIV-related stigma. Fig 1 presents key themes within the social-ecological model.
Individual level
HCI as a means of reducing barriers for individuals accessing services.
According to participants, HCI was viewed positively, playing a pivotal role in ensuring that people with TB and their household members receive timely access to care and TB-related services. People with TB and their household members described HCI as cost-saving, reassuring, and less time-consuming than seeking TB screening through the clinic.
“I think it’s important that they often come and check on us because some people don’t like going to the clinic; from what I have seen, it’s difficult because we almost lost a person… I think it’s good because at home, we will be thinking that he [household member with a TB diagnosis] is the one who is sick and we are not sick. So he is the one who needs to get help, but when they came at home they were also able to assist us and we got assistance. Because they are also saving us transport to go to the clinic for all of us to go and get tested.” –FGD, Household member, Capricorn
HCI was considered impactful by many participants because it reached key groups like older adults or individuals who might be sick but for various reasons (e.g., unaware of TB symptoms, perceived their illness as minor, or feared being seen by the community at the clinic) were hesitant to seek care. Therefore, HCI was perceived as one of the most beneficial programs within the health system to reduce barriers to accessing TB-related screening and health services.
“...There are many people who are sick and sometimes they might be thinking that it’s just a minor cough but only to find that it is TB, so when these ones come and collect our sputum that’s very important because they will be able to come back with results and then the person will survive from TB or whatever disease they will find there.” IDI, Person with TB, Capricorn
Increased individual TB knowledge and reduced fear.
Both people with TB and household member participants noted that at the level of the individual, HCI provided direct knowledge about TB and taught household members how to live with someone who has TB, which could, in turn, positively impact interpersonal relationships and potentially minimize within-household discrimination. A participant described how HCI provided reassurances to people with TB and their household members who had concerns about transmitting or contracting TB:
“The house visits also motivate your family… Because you are bringing education to them, so that they know that this person is our patient, and what you need to know is that you must live with this person like this, and like that… And you as well, as they have explained to you that you need to do this and that so that you don’t infect others…” – FGD, Person with TB, Soshanguve
Interpersonal level
Interpersonal relationships: duty, responsibility, disclosure, and support.
Many participants, both people with TB and household members, described the importance of family health and how HCI influenced communication and actions among household members. First, some participants described the knowledge that HCI visits would be conducted as a catalyst for the disclosure of TB status to the family. However, others reported disclosing their status to their family members regardless of whether a HCI visit was made. Importantly, disclosing one’s TB status was believed to undoubtedly alleviate the stress of suffering alone because “a secret sometimes kills.” Second, many participants emphasized that knowing HCI would take place helped people with TB consider household safety and their role in decreasing the likelihood of TB transmission to others. Third, participants strongly expressed that the person with TB had a responsibility to disclose to others and play a role in the prevention of TB and screening for household members, which HCI facilitated:
“…You either protect this household people that live with a person with TB too. As they say, prevention is better than cure. If they don’t have TB, then they have to know that they don’t have TB. And then if they have, they can be tested for that too.”- IDI, Person with TB, Soshanguve
Despite the perceived beneficial role that HCI played in facilitating disclosure of TB status, some participants noted that disclosure could also result in discrimination within the household. Most participants viewed a person with TB rejecting HCI for their household as the result of either unawareness of the infectiousness of TB or associated with fear of negative household or community perceptions. For many participants, HCI as an approach was described as something that strongly enhanced a sense of responsibility for the household and personal health.
Some people with TB felt that HCI could often reduce household members’ concerns about TB infection by providing the necessary health information, thus facilitating a cohesive and supportive space in which to care for persons living with TB.
“We are the ones that benefit. Like you are teaching us about TB. They are also telling us [about TB] at the clinics as well, but they only telling us half [of the information], right? Like with you guys, you encourage [educate] us, on how to live, what to eat…How to live with the people we live with in the household.”- IDI, Household member, Capricorn
Participants felt that the motivation to disclose TB status and subsequent counseling received from HCI helped increase the level of family support offered to people with TB by empowering household members to hold people with TB accountable for adhering to treatment, assist with the collection of medication, and provide support through the provision of meals.
Household level
Household access to HIV testing during HCI.
HIV testing is a standard service often offered as part of the care package during a HCI visit. Participant perceptions of the HCI approach were intertwined with feelings about HIV testing. Both people with TB and household members described how HIV testing being linked to HCI could negatively impact a household’s decision to participate in HCI:
“…TB currently; when you go test for it, they automatically test your HIV status… I think a person who is not ready for that. If they haven’t fallen sick, hasn’t had any symptoms… that is what could make them say they aren’t ready for [HIV testing]…So, you find that even if they want to check/test for TB only, they will say that they also going to test me for [HIV]-… So, I am not ready...” – IDI, Person with TB, Soshanguve
Fear and acceptance: multifaceted within the household.
Participants felt that household members who would be less comfortable with the HCI approach also feared “knowing the truth” regarding their HIV status. Despite the noted challenge concerning the impact of offering HIV testing on TB screening/testing uptake, most participants acknowledged the importance of testing for HIV. Further, many participants also described that HIV testing as part of HCI may offer privacy, discretion, and convenience as described by a household member of a person with TB:
“When they say ‘can we also check you on this’ they are not only helping themselves but they are also helping you. That’s why you have to agree so that you can know where you stand, yes.” – FGD, Household member, Capricorn
Community level
The role of community stigma.
Most participants considered HCI an important approach for finding new cases of TB and recognized the importance of identifying people with TB in their households or communities; however, nearly all participants raised concerns about community perception and potential stigma. Descriptions of stigma primarily focused on the community, as opposed to stigmatization within the household. Overall, HCI was perceived to contribute to or exacerbate illness-related stigma because healthcare workers visiting households in marked cars and typically wearing uniforms were viewed as demonstrating to neighbors or other community members that someone within the household was sick. Many participants described being seen by others with healthcare workers visiting the household as potentially distressing because this might change a person’s ‘social identity’, labeling them as someone with an illness.
“…like when they come, we know that obviously, it’s those people wearing like obviously maybe those blue things or whatever… Yes, that uniform of theirs… They can see that “oh it means that in there, like when they [the healthcare workers] go there each and every day–… it means there is someone who is ill in there [at that particular house]” … So, people are ashamed because of that thing…” – IDI, Household member, Soshanguve
Overlapping stigma: HIV and TB.
Within discussions of stigma, participants described two distinct but overlapping types of potential stigma: 1) HIV-related stigma, noting that people with TB were sometimes believed to have HIV because of known high co-occurrence and overlapping symptoms such as loss of weight and coughing, and 2) TB-related stigma. Several participants described how their communities were uninformed about TB, including the medical journey from TB diagnosis to treatment and the likelihood of being cured. Participants strongly emphasized that HCI could play a role in educating people about TB and HIV.
“…Just judging…So automatically, when they see you coughing or see that you have lost weight or you have TB, they say ‘oh well she/he says it is TB, but she/he knows what it goes together with [HIV]’…it depends on people’s understanding about that thing [TB and HIV]…A person who doesn’t understand, who has little knowledge, is going to combine them…But one who has full knowledge and a lot, won’t combine them…The thing about when we get to the homes, we have to educate people…” – FGD, Person with TB, Soshanguve
Overall, participants noted that the stigma driven by HCI may isolate people and households with TB because fear of TB and HIV-related stigma is pervasive in communities.
Discussion
The findings from this qualitative study demonstrate that HCI, a recommended approach to identifying people with TB, has ethical considerations for implementation that operate across levels of influence when framed in the context of a social-ecological model for people impacted by TB. HCI is perceived as having largely positive impacts at the household level, but potential negative implications concerning community and HIV stigma. HCI fosters social support, reduces barriers to screening and healthcare engagement, and may facilitate the disclosure of TB diagnosis. However, the HCI approach is perceived as a potential driver of health-related stigma within the community. Overall, HCI as a programmatic approach has impacts beyond identifying and screening individuals for TB, spanning the interpersonal, household, and community levels.
At the individual level, traditional or “passive” identification of people with TB (e.g., relying on individuals to go to the clinic for screening or care) presents challenges, including access to the health facility for timely identification of TB symptoms [3]. A study in South Africa on healthcare access found that most individuals, particularly those living in low-income communities, postponed seeking healthcare due to distance from facilities and travel costs [7]. Many participants in our study felt HCI had an essential role for the individual because it reduced noted structural and economic barriers to TB screening. Both persons with TB and household members highlighted how HCI, compared to clinic-based care, helps avoid long queues [5] and alleviates travel costs, [7,8] thus improving the timely screening of TB and supporting the use of HCI in high-burden TB settings.
In our study, at the individual and household level, participants emphasized the utility of HCI in educating households, including household members and people with TB, on TB symptoms, treatment, and transmission. A study conducted in Free State, South Africa, found that educating people with TB about the disease positively influenced treatment adherence [4]. Additionally, household TB knowledge is crucial for understanding TB infectivity and supporting prevention behavior [17]. In Uganda, TB knowledge helped people with TB understand and make informed decisions, including protecting themselves and their close contacts from TB transmission [24]. People with TB have reported experiencing stigma and withheld support within the household [25]; in our study, participants described how HCI facilitated the sharing of TB diagnosis with close contacts despite the potential stigma. HCI also provides both education and reassurance to household members and people with TB, which may help mitigate household-level stigma [6,25]. In this case, decision-makers must balance the need to educate and counsel persons with TB and reduce barriers to testing their close contacts against the potential unintended adverse effects of increasing community-level stigma [13].
Stigma continues to obstruct the fight against TB amongst communities, including the implementation of interventions such as HCI [26]. For example, studies conducted in South Africa assessing the level of vulnerability and stigma experienced by people with TB found that TB interventions (both passive case finding and contact tracing) were often hampered because of factors such as negative community perceptions, the anticipated HIV-TB stigma and the association of TB with dirt [26,27]. Similar to other studies conducted in South Africa [3], our findings support evidence that people with TB and household members have mixed feelings about healthcare workers conducting household visits; specific concerns included the use of marked cars, uniforms that identify visiting healthcare workers, and neighbor perceptions that there is a sick person in the household. Ultimately, screening programs can unintentionally disclose the identity of people with TB [28], and while participants in our study described the benefits of HCI within their household as significant, concerns about community stigma – both HIV and TB-related – tempered enthusiasm for the approach. TB and HIV stigma ultimately remain significant yet are under-addressed problems in TB programming. Given that HCI programs potentially play a direct role in increasing stigma in communities for people with and affected by TB, stigma-mitigating interventions are crucial to prevent shame and discrimination. Such interventions can include educating and providing psychosocial interventions (e.g., psychosocial support groups or TB clubs) targeted towards communities, healthcare workers, and people living with TB; training healthcare workers on sensitivity and stigmatization; and considering policy interventions to measure and reduce TB stigma [23,26,29].
In line with other studies in high TB and HIV burden settings, our findings demonstrate that stigma among people with TB may be driven by the assumption that all individuals with TB are also living with HIV [26,27,30]. In South Africa, efforts to integrate TB and HIV screening have led to the use of cost-effective methods like HCI to identify more individuals with both TB and HIV, reduce transmission, and improve clinical outcomes [31,32]. While this is a critical approach given that an estimated 71% of people diagnosed with TB in South Africa also have HIV [33], HIV-associated stigma may negatively impact the uptake of TB services [14,34]. A study conducted in Eastern Cape, South Africa, reported that people with TB were often assumed to be living with HIV, which impacted TB treatment adherence and care by discouraging people from going to the clinic for care and complete treatment [30]. Importantly, we found that the association between TB and HIV was a factor that could influence a household’s decision to accept or reject HCI because of the provision of HIV testing. While integrated screening intends to reduce the burden of both TB and HIV, participants described significant HIV stigma concerns and the pressure driven by HCI to test for HIV. These findings demonstrate that, while offering HIV testing with HCI in high co-burden settings is a reasonable approach from a disease prevention standpoint [35], the impact of this practice on HCI uptake remains poorly understood. Filling this knowledge gap will allow screening programs to make informed decisions about the provision of HIV testing as part of HCI and ensure HCI programs are people-centered.
Limitations
This study has limitations. First, South Africa is among the top 30 high-burden HIV/TB countries; thus, these findings may not generalize to settings with high TB burden but low HIV prevalence. Second, participants were sampled from a parent contact investigation study, which may have influenced opinions of the HCI approach compared to individuals with no exposure to HCI. However, as HCI is a commonly used approach in South Africa, study participants’ views may not differ significantly from those of individuals not engaged in research. Finally, we did not find differences across the geographical areas (urban vs. rural) as expected, which may be the product of implementing a set of standardized questions that were not necessarily site-specific. However, we explored data across participant types and data collection methods (FGDs and IDIs), strengthening the rigor of our findings.
Conclusion
HCI as an approach has varying impacts on people with TB, their families, interpersonal relationships, and communities. This qualitative study suggests that HCI is broadly acceptable with perceived positive impacts on household health and TB knowledge, TB status disclosure, and social support for people with TB. However, the intersection of HCI and TB and HIV-related stigma is of critical importance to individuals impacted by TB and has been largely unaddressed in HCI implementation to date. The provision of HIV testing, in particular, may have negative consequences on the uptake of TB screening and needs to be better understood. If HCI is to be scaled up, more significant efforts should be made to ensure concerns about community stigma and HIV testing are addressed.
Acknowledgments
The authors thank the participants for their time and valuable insights. We thank C Ramsammy and J Coetzee for their help refining themes.
References
- 1.
WHO. Global tuberculosis report 2022. https://wwwwhoint/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022. 2022.
- 2. Lönnroth K, Castro KG, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, et al. Tuberculosis control and elimination 2010–50: cure, care, and social development. The Lancet. 2010;375(9728):1814–29.
- 3. Kerrigan D, West N, Tudor C, Hanrahan CF, Lebina L, Msandiwa R, et al. Improving active case finding for tuberculosis in South Africa: informing innovative implementation approaches in the context of the Kharitode trial through formative research. Health Res Policy Syst. 2017;15(1):42. pmid:28558737
- 4. Moodley N, Saimen A, Zakhura N, Motau D, Setswe G, Charalambous S, et al. “They are inconveniencing us” - exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: perspectives from patients and clinicians in the Free State Province, South Africa. BMC Public Health. 2020;20(1):454. pmid:32252703
- 5. Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S, et al. Inequities in access to health care in South Africa. J Public Health Policy. 2011;32 Suppl 1:S102-23. pmid:21730985
- 6. Furin J, Loveday M, Hlangu S, Dickson-Hall L, le Roux S, Nicol M, et al. “A very humiliating illness”: a qualitative study of patient-centered Care for Rifampicin-Resistant Tuberculosis in South Africa. BMC Public Health. 2020;20(1):76. pmid:31952494
- 7. Gordon T, Booysen F, Mbonigaba J. Socio-economic inequalities in the multiple dimensions of access to healthcare: the case of South Africa. BMC Public Health. 2020;20(1):289. pmid:32131787
- 8. McLaren ZM, Ardington C, Leibbrandt M. Distance decay and persistent health care disparities in South Africa. BMC Health Serv Res. 2014;14:541. pmid:25367330
- 9. Fox GJ, Barry SE, Britton WJ, Marks GB. Contact investigation for tuberculosis: a systematic review and meta-analysis. Eur Respir J. 2013;41(1):140–56. pmid:22936710
- 10. Velen K, Shingde RV, Ho J, Fox GJ. The effectiveness of contact investigation among contacts of tuberculosis patients: a systematic review and meta-analysis. Eur Respir J. 2021;58(6):2100266. pmid:34016621
- 11. Morrison J, Pai M, Hopewell PC. Tuberculosis and latent tuberculosis infection in close contacts of people with pulmonary tuberculosis in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis. 2008;8(6):359–68. pmid:18450516
- 12. Huprich SK, Fuller KM, Schneider RB. Divergent ethical perspectives on the duty-to-warn principle with HIV patients. Ethics Behav. 2003;13(3):263–78. pmid:14680008
- 13.
Organization WH. Ethics guidance for the implementation of the End TB strategy. World Health Organization. 2017.
- 14. Levin L, Irving K, Dikgang M, Punwasi J, Isaacs M, Myer L. TB patients’ perspectives on integrated TB/HIV services in South Africa. Trop Doct. 2006;36(3):173–5. pmid:16884629
- 15. Kliner M, Knight A, Elston J, Humphreys C, Mamvura C, Wright J, et al. Development and testing of models of tuberculosis contact tracing in rural southern Africa. Public Health Action. 2013;3(4):299–303. pmid:26393050
- 16. Medina-Marino A, de Vos L, Bezuidenhout D, Denkinger CM, Schumacher SG, Shin SS, et al. “I got tested at home, the help came to me”: acceptability and feasibility of home-based TB testing of household contacts using portable molecular diagnostics in South Africa. Trop Med Int Health. 2021;26(3):343–54. pmid:33289194
- 17. Ayakaka I, Ackerman S, Ggita JM, Kajubi P, Dowdy D, Haberer JE, et al. Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach. Implement Sci. 2017;12(1):33. pmid:28274245
- 18. Shapiro AE, Variava E, Rakgokong MH, Moodley N, Luke B, Salimi S. Community-based targeted case finding for tuberculosis and HIV in household contacts of patients with tuberculosis in South Africa. Am J Respiratory Critical Care Medicine. 2012;185(10):1110–6.
- 19. Vella V, Racalbuto V, Guerra R, Marra C, Moll A, Mhlanga Z, et al. Household contact investigation of multidrug-resistant and extensively drug-resistant tuberculosis in a high HIV prevalence setting. Int J Tuberc Lung Dis. 2011;15(9):1170–5, i. pmid:21943840
- 20. Machavariani E, Nonyane BAS, Lebina L, Mmolawa L, West NS, Dowdy DW, et al. Perceived stigma among people with TB and household contacts. Int J Tuberc Lung Dis. 2023;27(9):675–81. pmid:37608483
- 21. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.
- 22. Yakob B, Ncama BP. A socio-ecological perspective of access to and acceptability of HIV/AIDS treatment and care services: a qualitative case study research. BMC Public Health. 2016;16:155. pmid:26880423
- 23. Foster I, Galloway M, Human W, Anthony M, Myburgh H, Vanqa N, et al. Analysing interventions designed to reduce tuberculosis-related stigma: A scoping review. PLOS Glob Public Health. 2022;2(10):e0000989. pmid:36962638
- 24.
James A. Measuring TB stigma in Kampala, Uganda. Yale University. 2020.
- 25. Kallon II, Colvin CJ. A qualitative exploration of continuity of TB care in clinics after discharge from hospitals in Cape Town, South Africa. BMC Health Serv Res. 2022;22(1):1489. pmid:36474237
- 26. DeSanto D, Velen K, Lessells R, Makgopa S, Gumede D, Fielding K, et al. A qualitative exploration into the presence of TB stigmatization across three districts in South Africa. BMC Public Health. 2023;23(1):504. pmid:36922792
- 27. Murray EJ, Bond VA, Marais BJ, Godfrey-Faussett P, Ayles HM, Beyers N. High levels of vulnerability and anticipated stigma reduce the impetus for tuberculosis diagnosis in Cape Town, South Africa. Health Policy Plan. 2013;28(4):410–8. pmid:22945548
- 28. Fox GJ, Dobler CC, Marks GB. Active case finding in contacts of people with tuberculosis. Cochrane Database Syst Rev. 2011;2011(9):CD008477. pmid:21901723
- 29. Nuttall C, Fuady A, Nuttall H, Dixit K, Mansyur M, Wingfield T. Interventions pathways to reduce tuberculosis-related stigma: a literature review and conceptual framework. Infect Dis Poverty. 2022;11(1):101. pmid:36138434
- 30. Møller V, Erstad I. Stigma associated with tuberculosis in a time of HIV/ AIDS: Narratives from the Eastern Cape, South Africa. South African Review of Sociology. 2007;38(2):103–19.
- 31. Gilbert JA, Long EF, Brooks RP, Friedland GH, Moll AP, Townsend JP, et al. Integrating Community-Based Interventions to Reverse the Convergent TB/HIV Epidemics in Rural South Africa. PLoS One. 2015;10(5):e0126267. pmid:25938501
- 32. Gilbert JA, Shenoi SV, Moll AP, Friedland GH, Paltiel AD, Galvani AP. Cost-Effectiveness of Community-Based TB/HIV Screening and Linkage to Care in Rural South Africa. PLoS One. 2016;11(12):e0165614. pmid:27906986
- 33.
CDC. Global HIV and TB: South Africa. https://www.cdc.gov/globalhivtb/where-we-work/southafrica/southafrica.html. 2021.
- 34. Wouters E, van Rensburg AJ, Engelbrecht M, Buffel V, Campbell L, Sommerland N, 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(4):e045477. pmid:35383052
- 35. Albaugh NW, Nonyane BA, Mmolawa L, Siwelana T, Lebina L, Dowdy DW. Proportion and predictors of adult TB contacts accepting HIV testing during an active TB case finding intervention in South Africa. J Acquired Immune Deficiency Syndromes. 2020;85(5):525.