LTBI and TB: Treatment Barriers
By Tiffany Hirokawa
For Asian, Asian Americans (A/AAs), Native Hawaiians, and Pacific Islanders (NH/PIs), tuberculosis (TB) and latent TB infection (LTBI) disproportionately impacts these communities. A/AAs accounted for nearly 36% and NH/PIs accounted for nearly 2% of all U.S. TB cases in 2021. To address the disproportionate impact of LTBI/TB, community health centers (CHCs) play a pivotal role as essential safety net providers serving the frontlines of prevention and treatment for at-risk communities. However, CHCs face substantial barriers in implementing and conducting LTBI/TB screening, testing, and treatment for their patient populations often as a result of limited funding and staffing, unclear/non-applicable TB guidelines, provider and patient educational barriers, and sociocultural patient barriers.
The Tuberculosis Elimination Alliance’s limited blog series, “Addressing LTBI and TB at Community Health Centers Serving Asian, Asian Americans, Native Hawaiians, and Pacific Islanders,” aims to shed a light on the impact of LTBI and TB on A/AA and NH/PI communities and the community health center providers that serve them. Learn about TB/LTBI basics, the critical role CHCs play in community care, and the importance of providing resources and support to TB/LTBI providers.
Similar to testing coverage, patients face a multitude of barriers to treatment both financially and socially. For example, LTBI as an asymptomatic infection (no presentation of symptoms) along with the possibility that active TB may never develop*, patients often see no need to undergo LTBI treatment. Additionally, for individuals with co-existing conditions such as hepatitis B which is prevalent among A/AA communities, involving high rates for liver cancer, some TB treatment regimes may worsen health outcomes among these individuals due to the potential for hepatotoxicity. This, in turn, hinders treatment completion. Moreover, sociocultural barriers (e.g., transportation, cost) further impede LTBI and TB treatment completion. As mentioned previously, factors such as transportation to and from appointments, patients’ proximity to a pharmacy for necessary medications, affordable coverage for medications, in-language providers and community health personnel, culturally and linguistically conscious education materials, ability to take time off of work for treatment, and stigma all limit and determine a patients’ ability to complete and benefit from treatment. Current interventions, for example, virtual directly observed therapy (eDOT), although emerging as an enabler for treatment completion, disregards folks with no internet access or access to phones, computers, or other mobile devices. Therefore, there needs to be further efforts to support health centers’ enabling services and guidelines that account for all diverse patient needs, challenges, and backgrounds.
Additionally, not only do health centers and patients face educational and structural barriers to screening, testing, and treatment, but also the overarching TB stigma that exists within A/AA and NH/PI communities. From the 2022 LTBI/TB needs assessment, in discussion with one health center respondent from the Pacific Islands, we discussed the prevalent TB stigma among the community. In his words, he explained the stigma saying, “the reaction of the community is not so friendly. People really express their concern, they do not want to be associated with the patient or their family because the mindset or mentality that it’s a deadly disease, it’s easily spread from person to person…It’s really at the level of fear and concern of transmission or the spread of the disease.” To further combat misconceptions surrounding LTBI and TB transmission and treatment, awareness building and culturally and linguistically conscious education are necessary to encourage widespread screening, testing, and treatment for A/AA and NH/PI communities. Given limited focus on the impact of TB stigma within A/AA and NH/PI communities, additional research is needed to further explore TB stigma as a barrier among A/AA and NH/PI communities.
Overall, this blog series aimed to provide foundational context to better understand the barriers experienced by both patients and health centers in LTBI/TB screening, testing, and treatment. We hope this series can inform an upcoming needs assessment project which explores the LTBI and TB experiences of 20 A/AA and NH/PI health centers in serving their diverse patient populations. TB disease, often tarnished by misconceptions that it is a forgotten relic of the past or a “foreign” disease outside our borders, serves as a prime example for the multitude of social, educational, and structural barriers posed against its eradication. Although tainted by stigma within many A/AA and NH/PI communities, internal community efforts must push for TB awareness in pursuit of resolving TB inequities. Furthermore, if a community health center lacks the capacity to support TB screening, testing, education, and treatment for at-risk populations, this further perpetuates TB transmission and prevalent misconceptions. For community health centers lacking an on-site TB specialist, facing provider educational barriers in knowing who should be screened for LTBI/TB, funding limitations for targeted and general TB testing, and so on, TEA aims to support CHCs by advocating for updated and comprehensive guidelines and recommendations that holistically address the diverse needs of health centers and the patients they serve.
Stay tuned for the release of the upcoming LTBI/TB needs assessment which will be featured on the AAPCHO website to learn more about the needs and best practices of 20 A/AA and NH/PI-serving community health centers’ LTBI and TB protocols and practices!
For additional LTBI and TB resources, please visit TEA’s updated resource page today! If you have any questions about the content above, please contact tea@aapcho.org or visit tbeliminationalliance.org for more information.
Want to get involved? Become a local TEA partner today! We invite state and local TB control programs, community-based organizations, and community health centers to consider becoming a TEA partner today.
We also encourage you to apply to our upcoming mini-grant cycle. For the 2022–2023 TEA Mini-Grant Program, TEA will be offering up to fifteen (15) Mini-Grants to organizations serving A/AA- and NH/PI communities to enhance LTBI/TB community engagement and education, provider education, and quality improvement. Deadline to apply is Friday, August 5 by 5:00pm local time. Learn more from the RFP: https://bit.ly/TEA22RFP
For more information, please visit www.tbeliminationalliance.org and contact tea@aapcho.org today!
*Individuals with LTBI are at increased risk for developing active TB disease
