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A cross-sectional survey of 271 day care center (DCC) members at 9 district hospitals was undertaken using an interviewer-administered questionnaire to assess the psychosocial and economic impact of the services provided by DCCs to people living with HIV/AIDS (PLWHA) and the costs of attending DCCs in Chiang Rai Province in Thailand. Data on the socioeconomic and demographic background of the participants, their reasons for attending DCCs, their medical services usage, the changes DCCs made on their lives, and the cost of attending DCCs were collected. "Receiving information" (37%) and "meeting friends" (32%) were the two most common reasons while fewer participants gave "physical examination" (6%) and "counseling" (0.4%) as their reasons for attending DCCs. Nearly half became more positive about their lives and 40% learned how to live with the disease. Through DCCs, 24% and 58% were receiving prophylaxis for tuberculosis and Pneumocystis carinii pneumonia respectively, and 15% were taking antiretrovirals. The majority (85%) lived with 30 minutes of DCCs, and incurred travel cost up to 30 Baht (1 USD approximately 40 Baht). The mean monthly income of those with jobs was 1,565 Baht and 42% lost wages when attending DCCs, more than half of whom were the main income earners in their families. In conclusion, DCCs benefit PLWHA through their educational and psychological support. However, they can be further utilized for their medical services. As an expansion of antiretroviral treatment is planned in Thailand, the DCCs' role should be fully explored and clearly defined. Minimizing economic and geographical barriers to access are some of the most immediate challenges.

Setting: Chiang Rai Hospital, Chiang Rai Province, the epicentre of the human immunodeficiency virus (HIV) in Thailand., Objective: To describe the health seeking behaviour among tuberculosis (TB) patients, to measure patient and provider delays and to analyse factors determining these delays., Design: All patients aged over 15 years with new smear-positive pulmonary TB detected in Chiang Rai Hospital (n = 557) were interviewed using a structured questionnaire., Results: The median patient delays for HlV-positive and HIV-negative patients and those whose HIV status was unknown were 10, 15 and 15 days respectively, while provider delays were respectively 7, 7.5 and 10 days. HIV-positive patients suffered more symptoms and had a shorter patient's delay. Risk factors of long patient delay (>21 days) included being HIV-negative, having no health insurance, hill tribe ethnicity, no previous visits to the hospital, and borrowing money for hospital visits. Multivariate logistic analysis suggested that being married or widowed and being HIV-positive led to the shortest patient delay. Provider delay was significantly longer in female patients than male patients., Conclusion: Although patient and provider delays were favourably short, certain specific groups require further attention. Hill tribe people should be targeted to improve accessibility to TB treatment. Active case-finding services for people known to be HIV-positive should be encouraged. The reasons for the longer provider delay in female patients require further investigation.

Focus groups were conducted in a high human immunodeficiency virus (HIV) prevalence area of Thailand to elicit perspectives of health staff and clients regarding the feasibility of directly observed therapy (DOT) for tuberculosis. Most participants perceived health centre-based DOT to be impractical for clients due to severe illness, travel inconvenience, and interference with employment. Most providers perceived home-based DOT to be difficult because of the inconvenience of travel, staff shortages and the high tuberculosis caseload. Most clients except HIV-negative tuberculous females considered home visits to be undesirable due to stigma. The preparedness of providers for home-based DOT might be improved through awareness building among staff about multidrug-resistant tuberculosis.

Objective: To elicit community perceptions about tuberculosis (TB) and the behaviour of TB patients in an area where significant public health attention has been focused on AIDS., Setting: Chiang Rai, Thailand, the epicentre of HIV/AIDS in this country., Design: Eleven focus group sessions with a cross-section of the population., Participants: Health centre staff, community members, persons having HIV, TB patients (with and without HIV infection), and male injecting drug users; five female groups and six male groups., Result: People had good knowledge of AIDS but they knew little about TB. Only a few female patients, whose husbands had died of TB and AIDS, recognized their symptoms as TB and immediately sought care. People defined persons losing weight, having fever and cough as AIDS rather than TB. This resulted in delay in seeking care and non-adherence to TB treatment in some patients who suspected they had AIDS, and feared AIDS detection. Most HIV-negative TB patients were also suspected by their relatives and neighbours of having AIDS. Most participants, except HIV-positive females, believed TB to be curable. Although less than AIDS, the community stigmatized TB patients because of it being contagious and easily transmitted through exhalations, foods and drinks and closeness to TB patients., Conclusion: In HIV/AIDS high endemic situation, increased awareness and stigmatization of AIDS and inadequate knowledge of TB can result in delay in seeking TB care and in treatment non-adherence.

Objective: To determine the level of and reasons associated with adherence to tuberculosis preventive therapy among asymptomatic HIV-infected individuals in northern Thailand., Design: A prospective cohort study with a 9-month follow-up., Methods: A total of 412 HIV-infected persons were enrolled in a tuberculosis preventive therapy programme in a hospital. A 9-month isoniazid regimen was prescribed. Adherence was determined by pill count. Participants who missed a scheduled appointment for more than a month were interviewed. Five focus group discussion sessions were held among those who successfully completed the therapy., Results: Of the 412 participants, 69.4% (286) completed the 9-month regimen. The adherence rate, defined as the proportion of those who took more than 80% of pills, was 67.5% (n = 278). Sex, source of participants and history of physical symptoms were associated with adherence. A significant portion of defaults took place at the beginning of the therapy. Out-migration, denial of HIV status, and perceived side effects of isoniazid were frequently cited as reasons for non-adherence. For those adhering participants, the acceptance of personal HIV status, concern about children and family, and a good health provider relationship were important reasons motivating adherence. Several reminder systems were developed by the participants., Conclusions: Although a isoniazid preventive therapy programme was shown to be feasible, further adjustments on the selection of participants, enrollment process, and follow-up system based on these findings are necessary to increase the adherence.