Let’s help female TB patients overcome barriers

Romi Singla

Pulmonary physician

GLOBALLY, 7 lakh women die of tuberculosis (TB) every year, nearly one-third of them in India. This disease kills more women than do all causes of maternal mortality. The death rate seems to be higher for women with TB than for men, and women are more often diagnosed with non-lung TB. However, in most low-income countries, twice as many men are diagnosed with tuberculosis as women.

This difference might indicate under-reporting, because access barriers are higher for women due to socio-cultural disempowerment, stigma, different patterns of healthcare use, or lack of financial resources.

The prevalence of TB is similar in males and females till adolescence, when it increases for the former. In high-prevalence countries, however, women of reproductive age have higher rates of progression to the disease than men in this age group.

Women wait up to twice as long to seek treatment as men experiencing the same symptoms. This may be because they have to stay at home looking after children, or are reluctant to use scarce family resources.

Women may need a chaperone when going for an appointment or may have to explain where they are going. So, the stigma around TB can make them reluctant to seek help, leading to delay in reaching the diagnosis stage. The whole family suffers when a mother/wife becomes sick or dies of TB. TB in women has an adverse effect on child survival and family welfare.

The greatest burden of tuberculosis is during the childbearing years. Tuberculosis during pregnancy has been associated with a six-fold increase in prenatal deaths and a two-fold risk of premature birth and low birth weight. Maternal tuberculosis is also an important risk factor for tuberculosis and mortality in infants, particularly in babies born to HIV-infected women.

A mother’s well-being is intimately linked to that of her children. TB may spread from mother to child during the latter’s development. Children may have to stay at home to care for their sick mother, while the father (if present) earns income for the family.

Genital TB, which is challenging to diagnose, has been identified as an important cause of infertility in high TB-incidence settings. Females with genital tuberculosis may suffer from infertility, menstrual disorders and chronic lower abdomen or back pain.

The socio-economic consequences of TB for women are exacerbated by later presentation, which leads to a poor prognosis. The stigma associated with TB causes women to be divorced or unlikely to get married. A study in India found that male TB patients expected their wives to care for them, but infected wives rarely received care. Thus, married women may try to hide their symptoms instead of seeking help.

Socio-economic factors also have an impact on TB control efforts, especially for women who grapple with poverty, low social status, lesser education (which impedes seeking diagnosis) and barriers to healthcare. 

Female employees form a large percentage of the workforce, particularly in certain industries. If TB remains unaddressed, these industries and others could suffer from absenteeism, high medical costs, lost productivity, and other negative consequences of having sick employees. Women may find it more difficult to comply with treatment once symptoms subside.

The HIV epidemic is also increasing the burden of TB for women, who seem to have a higher risk of developing TB during their reproductive years than that faced by men. Malnutrition and food insecurity can increase the risk of TB; other threats such as rising tobacco use and diabetes and stress among women also play a role.

TB treatment is safe during pregnancy and advanced diagnostics with latest treatment regimens are absolutely free in government hospitals/institutes. The need of the hour is to maximise the referral of TB suspects or their samples for testing to government institutes.

It is also important to keep government specialist doctors motivated enough through adequate remuneration of their services. Companies/NGOs can demonstrate leadership by formulating and supporting gender-sensitive workplace and community TB programmes.

To reduce delay in care-seeking among women, workplace programmes should emphasise education on TB symptoms and facilitate access to diagnostic services as soon as the symptoms manifest, paired with anti-stigma campaigns which encourage open dialogue.

Workplace policies guaranteeing that employees diagnosed with TB won’t be dismissed are an essential protection. Access to treatment should be supplemented by paid time off during the period of infection; ideally, workers should be permitted to obtain directly observed treatment during working hours.

Many companies offer worksite clinics for reproductive healthcare; these firms should make sure that these clinics include TB treatment as well as screening. Similarly, companies can integrate TB into existing workplace HIV/AIDS programmes, taking special note of TB’s impact on women with HIV. 

Women have unique susceptibilities and might encounter barriers to access appropriate care. Subgroups that require particular consideration include HIV-infected pregnant women, socially or culturally marginalised individuals, underweight and undernourished woman caretakers of TB patients, elderly and destitute women.

Those who focus their advocacy efforts on this important challenge would be seen as real leaders and champions not only of public health, but also of human rights and gender equity.