This study found a low level of knowledge about HIV transmission and prevention among newly diagnosed TB patients in San Juan de Lurigancho. This main finding of the study, taken into account along with the low percentage of regular condom use in TB patients puts this population at risk to acquire HIV and other sexually transmitted diseases.
In addition, two important findings in our study should be pointed out. First, we observed a decrease in the level of knowledge on HIV transmission and prevention by age. This finding can be explained by a “cohort effect” . Younger participants had more access to and had higher chances of receiving education on this topic compared with older participants. At the beginning of the HIV epidemic in the 1980s and early 1990s, information about HIV prevention was not widely available for all, therefore, youth at that time were unlikely to be exposed to adequate information for HIV prevention. However, despite more opportunities to exposure to HIV prevention information among younger populations in Peru, the reported median age of HIV infection is around 20 years old in Peru . Second, an increase in the level of knowledge was observed with level of education in this study. A systematic review showed that most educated people had a lower risk of HIV infection. This review found that the HIV prevalence dropped more consistently in this group compared with less educated people .
Some studies have shown the importance of offering HIV counseling to TB patients [16, 17]. HIV testing was offered to all TB patients in the study area for free. However, at a national level, the percentage of TB patients with known HIV status has been decreasing over recent years (35%, 29% and 21% for 2009, 2010 and 2011, respectively) . The NTP provides regular preventing activities for TB among TB patients and their relatives, but it is necessary to implement more collaborative activities between the NTP and HIV programs, to improve the detection and prevention of HIV infection among TB patients at a national level. WHO remarks the importance of the integration of both programs in prevention and treatment , especially in settings with limited resources. For example, experiences in Malawi and South Africa showed that local integrated programs could operate successfully . One systematic review showed that the referral model (where TB patients are referred to HIV service for HIV diagnosis, and vice versa) could be the less complex model, but still have the risk of failure in the referral process (the patient does not attend the appointment for several factors) . The referral model is currently in place in Peru. The lower cost of this model compared to a fully-integrated model is a potential advantage, but it has to be weighted against the big weakness of losing referrals (only 21% of TB patients know their HIV status in Peru despite of free access). There is also a lack of information of programmatic and logistic issues of integrated TB-HIV services in settings without high HIV prevalence such as Peru (most of the studies are based in African countries) [21–23]. As the evidence shows, the integration of these programs cannot be performed with a unique recipe for all settings.
The importance of HIV testing and counseling is not only to promptly identify HIV infected patients, but also provides the opportunity to talk about HIV prevention . In the case of TB patients in Peru, because they are a generally young population and share similar demographic characteristics with vulnerable populations for HIV infection, HIV counseling and testing activities at the time of TB testing can provide the opportunity to address the potential lack of HIV knowledge among these vulnerable populations.
Some public health programs (such as NTP or pregnancy program) in Peru provide free HIV counseling and free HIV testing to benefit their patients as described before. In recent years, the Peruvian Government, non-governmental organizations, academic institutions, and international initiatives, such as the Global Fund have developed activities to provide information about HIV prevention to different populations in the country . As a result of these and other initiatives, the level of knowledge on HIV prevention among women increased from 18.9% in 2000 to 68.2% in 2011, based on information from the National Survey for Demography and Family Health (ENDES 2011) .
Other studies have shown a similar level of knowledge as in our study among people seeking HIV counseling in a referral hospital in Lima . However, a comparison of these studies with the information provided in our study is difficult to make. Reasons for that include different questionnaires used to evaluate level of knowledge and no detailed evaluation of factors associated with the level of knowledge in these studies [10–12, 25]. At a more global level, there is a lack of information about the level of HIV knowledge among TB patients. One study in China reported only 1.7% level of knowledge about HIV among 2300 TB patients , and another study in Afghanistan showed that 23.3% of tuberculosis patients knew about HIV . No studies on this topic are available from Latin America.
This study has several limitations; one of these is selection bias. Efforts were made to minimize this bias using intensive enrolment of study subjects during TB clinic attention hours. In addition, HIV carries a stigma in our population, and some of the questions, especially the questions regarding sexual practices, may be affected by information bias (specifically recall bias). Another limitation of this and other similar studies is the lack of a standardized tool for evaluating level of HIV knowledge, which makes comparison across studies difficult.