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The Tuberculosis Behavioral and Social Science Research Forum
Proceedings
Appendix C: TB Behavioral and Social Science Research
Gaps and Needs: Major Research Topics, Subtopics, and Research Questions
Major Research Topics, Subtopics, and Research
Questions
IV. Health Systems and Organizations
Influences of health systems and organizations on behavior focuses
on how structural, economic, and other organizational forces can
affect the views of individuals, small groups, and communities.
Examples include the availability, accessibility, and use of health
care services by individuals, and collaboration between and among
provider communities and other systems.
A. Organizational structure
The way in which the health care system is organized may play a
role in affecting both patient and provider behaviors. Whether the
system has a vertical or horizontal structure, whether services
are integrated with other health and social services or are part
of a collaborative network, and how the health care system is impacted
by other systems within a society may impact availability, delivery,
and acceptability of services.
1. Collaborations between provider communities and systems
There are many different social and behavioral determinants involved
in TB transmission, identification, and treatment success. Certain
factors that place individuals at high risk for TB, such as poverty,
substance abuse, and homelessness can be greatly impacted by the
availability and quality of social services. Both private and public
collaborations between and among existing social service agencies
and TB control efforts, as well as timely and appropriate social
service referrals for individuals with TB, may play an important
role in the efforts to successfully eliminate TB.
There are also a number of relevant collaborations between TB services
and other health-related entities that may need to be better understood
and cultivated. Given the high rate of TB/HIV co-infection among
certain populations, collaboration between or integration of TB
and HIV services may lead to better treatment outcomes and improved
satisfaction among persons receiving these services. Collaborations
with mental health and substance abuse services, homeless shelters,
and correctional facilities hold equal promise.
Forum participants identified the need to determine ways to
increase collaboration between TB programs and other health and
social service agencies for related conditions (e.g., HIV/AIDS,
mental health, and substance abuse) to improve TB diagnosis, case
management, and integration of services. Specific areas for increased
research include focusing on patients with multiple/varied needs,
U.S.-Mexico border issues, and collaboration with correctional systems,
Immigration and Customs Enforcement, and other agencies.
- What mix of TB and other services are most effective in different
communities, and what are the difficulties encountered in providing
such a mix? What mix is best for the patient and provider?
- What are some ways to develop collaborations with the justice
system (e.g., county jails)?
- What are some ways to increase U.S. (south of border) and Mexico/Central
America collaboration through the use of the government, health
care providers, academic institutions, and community agencies?
How should the community of origin be factored into this?
- What are the country specific TB prevention and control strategies
of Mexican, Central, and South American health departments and
communities?
- How can TB control and prevention partnerships be developed
between U.S. and Mexican local health departments, specifically
in Mexican communities?
- What are the barriers that health providers and health departments
face when doing TB control and education with labor and services
providers?
- What are some ways to identify and compare better methods on
increasing collaboration between TB control programs and other
health and social service agencies?
- How can coordination of care (i.e., systems of care) be
increased for patients with multiple health issues, such as
co-morbid conditions?
- How can coordination of mental health care with TB treatment
and adherence interventions be increased? How can patients
with mental health problems best receive care?
- What can be applied from HIV practices to TB with regard
to incorporating screening and care into jail settings?
- How can TB be integrated into HIV provider and community
planning group activities? What about substance abuse provider
activities?
- How can constraints, such as environmental ones, be overcome
in the implementation and provision of HIV counseling and
testing in TB programs and clinics?
- What specific interventions would positively impact the fact
that clients in correctional facilities are referred to the community
[health center] for follow-up of LTBI therapy?
- What strategies or models for collaboration lead to better
patient outcomes, not only for TB, but for a patient’s holistic
health? (Suggested methodology is to conduct operational research
using case studies.)
- Using an HIV case model, what type of comparison can be made
on the following: 1) an increase in the number of those who know
their TB status; and 2) the number who receive appropriate treatment?
2. Impact of sharing patient information
Patients who have other health and/or social issues such as TB/HIV
co-infection, diabetes, substance abuse, and mental health issues,
in addition to TB or LTBI, may have multiple providers. The sharing
of patient information becomes a crucial component in the provision
of proper and effective health care, especially as it relates to
a patient’s TB treatment regimen and follow-up care. Providers who
take a holistic approach to their patient’s health and who thus
have a complete picture of their patient’s health and well-being
are better equipped to make well-informed decisions that ensure
the most appropriate TB care and treatment.
Forum participants identified the need to focus upon the impact
of sharing (or not sharing) patient information on case management,
service coordination, and health outcomes among managing providers
in varying settings, such as health departments and correctional,
mental health, and substance abuse facilities.
- What is the impact of sharing and not sharing of patient information
on provider behavior and treatment outcome?
- Does the sharing of client records among managing providers
(e.g., county health departments, jail system, mental health facilities,
and substance abuse facilities) increase the quality of case management
for clients with TB?
- What are the key elements of a medical record that health providers
need to start and continue care?
- What type of retrospective analyses of clinical medical records
can be conducted to develop a patient profile? How can factors
and determinants be identified for patients who completed care
and for those who dropped out, based on their medical charts?
- What types of evaluation can be conducted on health data transfer
systems currently in place for TB?
B. Service delivery
The delivery of health services plays a major role in how patients
receive TB care and treatment. From an organizational perspective,
accessibility and acceptability of services, cost of services, and
quality of care can often delay or prevent a person from seeking
TB care and treatment. Through the use of patient-centered approaches
and effective case management, these systematic barriers can be
reduced or alleviated, resulting in improved provision of care and
better treatment outcomes.
1. Patient-centered approaches
Patient-centered approaches focus on bringing together compassion,
empathy, responsiveness, and resources to the needs, values, and
expressed preferences of individual patients. Effective patient-centered
care is essentially a partnership between the provider and the patient.
It involves determining individual patient needs and expectations
while ensuring that efforts are made to address those needs and
expectations by the health care provider(s).
Forum participants recognized the potential benefits of delivering
TB control services which embody a patient-centered approach, and
suggested that additional research is needed to identify, compare,
and standardize different methods and models for patient-centered
care.
- What are some patient-centered approaches that can be tested,
standardized, and replicated?
- What are some ways to develop and compare different methods
for conducting patient needs assessments?
- How are client-centered needs assessments best utilized in
developing client-centered interventions? Do we need to restructure
needs assessment tools to be holistic?
- How do we demonstrate the added value of patient-centered
TB treatment? How can this be applied to other services? What
are the synergistic influences of TB control programs on those
other services?
2. Case management
Quality case management is an important component of effective
TB care. It holds the potential to increase treatment adherence
and treatment outcomes by tailoring case management to the patient,
by making appropriate referrals to needed health and social services,
and helping to remove barriers to treatment success. However, little
empirical evidence exists that systematically confirms the effect
of the various types of case management practices. Part of the reason
for this may be that many case management practices are not standardized
and vary based on case management models and institutions.
Forum participants identified the need to determine the influences
of case management on multiple outcomes (e.g., treatment outcomes,
reduced homelessness, care for substance abuse, receipt of other
appropriate social and other health resources) as well as approaches
to strengthen case management practices.
- How can negative outcome expectations be overcome in order
to provide HIV counseling and testing in TB clinics?
- What is the impact of using case management strategies in homeless
shelters (and also jails) on multiple outcomes, including LTBI
adherence, reduced homelessness, and increased access to mental
health care and substance abuse treatment?
- Would the quality of case management improve if addressing
social needs was a standard part of the model?
- What types of demonstration projects can be used to apply case
management strategies that are effective with patients with active
TB to LTBI patients?
- What are some ways to conduct theory based experimental or
quasi-experimental studies that test specific methods to improve
efficiency and effectiveness of TB control programs?
3. Advantages and disadvantages of directly observed therapy
Directly observed therapy (DOT), in which a health care worker
or other qualified individual watches the patient swallow every
dose of the prescribed drugs, is an extremely effective strategy
for making sure patients take their medicines. DOT is strongly recommended
as part of a patient-centered case management plan because it is
difficult to reliably predict which patients will be adherent. Successful
treatment programs are dependent upon public health programs and
providers accepting responsibility for a patient’s care by ensuring
that DOT is appropriately administered.
As TB incidence declines and programs are turning their attention
to the treatment of LTBI, more TB programs are trying to use DOT
for LTBI patients. Data indicating low completion rates among patients
on treatment suggests the importance of determining the appropriate
use for DOT with LTBI patients.
Forum participants identified the need to conduct further research
on the effectiveness of varying DOT modalities for LTBI and TB,
such as clinic, home, or field-based DOT. Forum participants also
raised the need to identify patient-centered DOT strategies that
are most appropriate to the particular needs of patients, questioning
the one-size fits all mentality. Participants also focused on the
need to further delineate the usefulness of DOT in treating TB and
other co-morbid conditions, such as HIV.
- What are the most effective DOT strategies based on existing
research?
- How can DOT services be most cost effectively delivered?
- Given that directly observed preventive therapy (DOPT) is an
expensive modality, what are cost-effective models for achieving
treatment of LTBI?
- Does the initial education of the infected patient regarding
the use of DOPT affect the completion of treatment? Are factors,
such as advising not to use alcohol, initially emphasized? Is
the lack of a health department’s legal power to enforce LTBI
important to why clients drop out?
- What case control studies can be conducted to identify predictors
of persons who succeed and persons who fail in self-administered
programs for LTBI, and who may benefit from DOPT?
- What additional research is needed on DOT with regard to TB
treatment adherence? Are there parts of the DOT process that interfere
with adherence?
- What method, clinic-based versus home-based DOT for TB treatment,
works best and for which patients?
- Can changes be made to the DOT process that will aid in adherence
(e.g., increase in patient participation, feelings of control)?
- Is selective DOT a viable option? What components of DOT can
be delivered separately?
- What are some ways to test and evaluate different directly
observed therapy-short course (DOTS) “flavors” for appropriateness?
- How can patients be screened in terms of determining 1) what
basic needs will enable them to complete therapy, and 2) what
flavor of “DOTS” (e.g., observation, control, or medicine pick
up) works best for them?
- Is DOT for HIV and TB helpful in treating both diseases?
- How should a randomized clinical trial (RCT) of full vs. selective
DOT with a detailed protocol for patient management be conducted?
What specific components (e.g., home visits, clinic visits, or
self-management) are effective? What specific outcomes, such as
completion rate, failure and relapse rate, multi-drug resistance,
and cost-effectiveness, are important to measure?
4. Role of incentives and enablers
Research has shown that the use of incentives and enablers can
enhance patient acceptance as well as adherence to treatment for
both TB disease and LTBI.
Incentives and enablers help patients continue and complete treatment
and are widely used in facilities providing TB services. Incentives
and enablers are most beneficial when they are tailored to the patient’s
special needs and interests. Learning as much as possible about
individual patients through the use of patient-centered approaches
will help to identify their needs and better assist them in completing
treatment.
Forum participants identified the importance of further understanding
the barriers and facilitators that affect the initiation, duration,
and completion of treatment of LTBI and TB disease, and the role
that incentives and enablers can have in achieving TB treatment
goals, specifically for diverse populations such as foreign-born
persons and incarcerated or newly released prisoners.
- What are some ways to identify and distinguish basic needs
from incentives and their impact on treatment completion?
- What is the role and effectiveness of incentives in completion
of treatment, particularly with DOT and without DOT? What about
the use of DOPT?
- What incentives are effective with different foreign-born populations?
With African-Americans in the southeast? With the homeless?
5. Contact investigations
The contact investigation is an important component of TB prevention
and control efforts, as it is a process for identifying persons
exposed to someone with infectious TB, evaluating them for LTBI
and TB disease, and providing appropriate treatment for LTBI or
TB disease. In TB programs in the U.S., there is wide variability
in the way in which contact investigations are conducted. Furthermore,
the contact investigation can be sensitive for TB patients as they
are required to elicit personal information, such as who they interact
with, how often, and where. Little is known about the social and
emotional impact of these investigations on the individuals involved
and on the identification and follow-up of contacts.
Forum participants identified the need to determine ways to
improve contact investigations by, for example, gaining a better
understanding of patient and contact perceptions and being more
sensitive to involved parties to enhance contact investigation outcomes.
Finally, more research is needed with providers to examine their
perspectives on contact investigations.
- What are the perspectives of patients, contacts, and providers
of contact investigations? What are the problems associated with
contact investigations? How can the yield and patient satisfaction
with contact investigations be increased?
- How can contact investigations be improved? How can the process
be better explained and made less intrusive to patients? What
is the distinction between TB control and TB care? How can these
be differentiated, and what would it look like? How can the process
be made less punitive without jeopardizing public health?
- Why do some contacts not want to be examined? For patients
with TB disease who were unidentified but knew they were
contacts, what barriers did they encounter that prevented them
from getting tested?
- What are some ways to systematically collect data on TB control
and other programs in various settings, (e.g., prisons and homeless
shelters) during investigations of TB outbreaks in order to identify
“missed opportunities?”
6. Health communications
Health communications can be used to share information on TB with
the general public, local communities, patients and contacts, as
well as providers. Research has demonstrated that misconceptions
about TB and the stigma associated with the disease still abound,
suggesting the continuing need to increase knowledge and awareness
of TB through effective channels of communication. Further research
to better understand informational needs, identify appropriate and
effective media for channeling information, and testing health messages
related to many aspects of TB for a variety of audiences will enhance
the effectiveness of TB control efforts and hopefully mitigate the
stigma associated with TB.
Forum participants identified the need to identify specific
and tailored messages and messengers for improving communication
about LTBI and TB diagnosis and treatment among patients and providers,
as well as among family members and within the community.
- What messages do family members need to accept and support
the patient’s diagnosis?
- What type of message will increase the completion of LTBI treatment?
- How do we integrate messages with traditional health beliefs
of foreign-born patients and of the community?
- What are current media messages in TV news and programs, newspapers,
and magazines about TB and people with TB? Do these messages in
daytime/primetime programs, newspapers, and magazines need to
be improved or changed to be more effective?
- Regarding message acceptability, is there a difference in knowledge
and adherence behavior when the caregiver is matched with the
patient on race, gender, or both, particularly in generally segregated
communities?
- What is the role of peers and other messengers in the delivery
of health messages for patients, contacts, and providers?
- Does a core team approach, which includes former TB patients
who have successfully completed treatment, improve adherence and
treatment completion among persons from high-risk groups?
- How do opinion leaders change behavior of others? How can opinion
leaders improve translation of recommended treatment standards
to provider practice?
- What are the best places to advertise to high-risk groups?
- What specific educational interventions are most effective
in reaching clients in terms of type of delivery, type of message,
time entailed, messenger, and cost-effectiveness?
7. Special challenges of high risk settings and populations
a. HIV/TB
Co-infection of TB and HIV presents challenges for both patients
and the providers serving them. One challenge is related to the
potential lack of collaboration among TB and HIV programs. It is
important that TB providers offer HIV voluntary testing and counseling
to both TB patients and high risk contacts, and that HIV providers
offer TB screening and follow-up. Patients who have both TB and
HIV may also face challenges associated with the burden of taking
medicine for both diseases, as well as with the stigma associated
with both illnesses.
Forum participants identified the need to conduct research on
patient, provider, and agency barriers to the integration of voluntary
HIV testing and counseling in TB programs as well as the incorporation
of TB services in HIV/AIDS programs.
- How do the views of disease and patient agencies differ between
TB as a single disease and HIV/TB co-infection?
- Regarding HIV testing of persons with TB and LTBI, how can
we better understand why TB and LTBI clients resist testing for
HIV? What motivators can be used to get TB and LTBI clients to
get tested?
- How can the provision of HIV counseling and testing in TB programs
be improved?
- How can we help TB program managers and front line staff integrate
HIV volunteer counseling and testing (VCT) into their TB program
activities? What are the barriers and how can we reduce them?
- Is there a way that TB can be better integrated into HIV community
planning group activities?
- How can we overcome the environmental constraints to
implementing HIV counseling and testing in TB clinics? How
can we overcome the negative outcome expectations to providing
HIV counseling and testing in TB clinics?
- What survey research can we conduct in patient and provider
populations to assess discrimination, stigma, and treatment issues
among people with HIV/TB as well as people with TB in the home
environment, community and worksite?
- What are some effective models that can be used to increase
HIV testing of TB patients?
b. Homelessness, unstable housing, and mental health issues
TB control also faces significant challenges when dealing with
homeless populations or with individuals who may also be experiencing
mental health or substance abuse issues. These issues, combined
with a lack of stable housing, make TB screening and follow-up,
diagnosis, contact investigations, treatment initiation, adherence,
and completion of treatment extremely challenging.
Forum participants identified as important the need to assess
the TB knowledge, attitudes, and perceptions (KAP) as well as other
influences on behavior of homeless populations. Participants also
identified the need to consider using patient-centered case management
strategies to identify and address competing health and social issues
for this population.
- What are the TB KAP and influences of homeless people?
- What is the impact of using case management strategies in homeless
shelters (and also jails) on multiple outcomes, including LTBI
adherence, reduced homelessness, and increased access to mental
health care and substance abuse treatment?
- How do we address the impact mental illness and addictions
have on TB? (Suggested methodology is to conduct intervention
research.)
- What research is needed on mental health issues in regard to
client behavior? What are some effective interventions that address
mental health issues (co-morbidities) of people with TB?
c. High mobility jobs and
migrant labor
Given their mobility, migrant farm workers and other migrant populations
present unique challenges to TB prevention and control programs
with respect to diagnosis, treatment, continuity of care, and contact
investigations. U.S.-Mexico border issues, such as immigration and
frequency of border crossings, create additional challenges.
Forum participants suggested conducting descriptive and ethnographic
research using case studies as a possible method, among this special
population. This type of research might help to determine ways to
access migrant networks, mechanisms for tracking patients in a non-stigmatizing
way, and ways to increase completion of care.
- In what ways does TB affect migrant groups vs. the general
population?
- How can we “track” migrant TB patients so that we follow-up
on their treatment but don’t stigmatize them?
- What data sources can be utilized to identify sites with high
rates of migrant populations including Mexicans?
- What survey tools can be used to access migrant populations
within networks, such as employment settings, clinics, etc.?
- What descriptive research can be conducted that tracks a small
sample of mobile, high-risk populations?
- How can migrant “pockets” (i.e., locations with significant
populations) be identified?
- What types of ethnographic research studies using quantitative
and qualitative methods need to be conducted?
- How should patients be screened for disease? How can persons
with TB/LTBI be placed into care?
- How should patients in care be followed to completion?
(Suggested method: Interview patients at 18 months)
- How should the following be conducted with mobile or migrant
populations:
- Targeted testing for significant percentages of TB?
- Placing patients on TB treatment?
- Enrolling patients in Migrant Clinician Network’s TBNet
program?
- Following patients through to treatment completion?
- Following up with patients upon treatment completion, including
reviewing for ease of contact, ease of tracking, percentage
complete, and percentage lost?
d. Incarceration
Jails and prisons pose a unique challenge for TB prevention and
control. Efforts have been made to improve the relationships between
health department TB programs with jails and prisons to enhance
TB screening and follow-up among inmates and correctional personnel.
In addition, continuity of care can be a particular challenge for
TB patients who are incarcerated during treatment and who are later
released from prison or jail while on treatment.
Forum participants discussed the need to conduct further research
to identify ways to improve TB screening activities, as well as
adherence to and completion of treatment for incarcerated persons
and newly released prisoners. In addition, participants called for
further research to examine how screening and treatment for TB can
be incorporated into the diagnosis and treatment for other diseases
such as HIV.
- How can we provide demonstrations and conduct evaluations of
programs intended to improve TB testing and follow-up in jails?
- What ways can we improve adherence and completion of TB/LTBI
treatment among “hard to reach populations” (e.g., persons released
from jail)?
- How do we address TB for incarcerated populations returning
to the community?
- What specific interventions would increase referral of clients
in correctional facilities to community facilities such as health
centers for follow-up of LTBI therapy?
- How can we evaluate the use of incentives and educational based
interventions aimed at increasing adherence to LTBI and TB treatment
for persons being released from jail?
- What can we learn and apply from HIV to TB with regard to incorporating
screening and care into jail settings?
e. Substance use
Substance abusers are at increased risk for TB. Substance abusers
may have competing priorities that may prevent them from being diagnosed
with TB, accepting and adhering to treatment regimens, and identifying
contacts.
Forum participants identified the need to better understand
the TB knowledge, attitudes, and perceptions (KAP) of substance
abusers as well as determine the best ways to address these issues,
so that this population will receive the most effective TB care
and services.
- What are the TB KAP/influences of substance abusers?
- How can patients with substance abuse problems best receive
TB care? (Suggested methodology is a call for basic research)
f. Foreign born
Although TB case rates have steadily declined since 1992, TB in
foreign-born persons represents a significant challenge for TB control
efforts in the United States. In 2002, TB case rates among the foreign
born comprised 51% of reported TB cases in the United States.2
Foreign-born populations may have unique cultural characteristics,
practices, and circumstances related to their re-settlement and
adjustment to the U.S. that may influence their TB treatment and
care.
Forum participants identified the need to acknowledge, understand,
and incorporate different health-related cultural beliefs and practices
of foreign-born patients. Other issues that warrant exploration
included foreign-born persons’ perceptions of the U.S. health care
system and/or the providers who deliver care, determining the role
of gender and ethnic differences between patients and providers,
and identifying and addressing the wide range of barriers foreign-born
persons encounter when accessing services related to LTBI/TB diagnosis,
treatment initiation, adherence, completion, and follow-up.
- What are the effects of knowledge and attitudes among different
ethnicities and nationalities on LTBI treatment initiation, adherence,
and completion?
- What are the health education needs (and KAP) of newly arrived
immigrants and/or “transient” foreign-born persons (e.g., Latino
immigrants) with respect to TB transmission, treatment and adherence?
- Are immigrant males at higher risk of contracting TB due to
labor and environmental issues?
- What is the image of “public health centers” among foreign-born
persons? How does this image affect health-seeking behavior?
- What is the effect of stigma on foreign-born women with regard
to TB?
- What are the systematic (operational) issues regarding delays
in TB diagnosis? Are foreign-born TB patients (compared with U.S.-born)
more likely to have longer delays in seeking care? Are they likely
to have more or less access to health care providers than U.S.-born
persons?
- What are the effects of migration patterns on foreign-born
persons with regard to stigma, beliefs, social support, access
to care, and ensuring continuation and completion of treatment?
What happens at other end? How does a patient’s social support
structure change with his or her relocation?
- What are the barriers that immigrants face when accessing TB
prevention, case identification, education, treatment, and follow
up?
- Will educational materials, which address common misconceptions
towards TB, seen regionally throughout the world, increase treatment-seeking
behaviors among foreign-born persons?
- What factors predict adherence to treatment in Latino immigrants?
- What is the role of social support in LTBI adherence in Latino
immigrants?
- How do we best incorporate cultural beliefs and behaviors into
patient treatment plans, especially for Mexican and other foreign-born
populations?
- What incentives work with various foreign-born populations?
- How do we integrate messages with traditional health beliefs
of foreign-born patients and their community?
- What is the effect of new immigration policies on TB case identification,
follow up, treatment, and adherence, especially for Latino immigrants?
- What type of research is needed to maximize screening of new
and recent arrivals? How is access to these populations gained?
How can collaboration with Immigration and Customs Enforcement
(ICE) and other similar agencies that focus on foreign-born persons
be increased?
- What are some ways to help undocumented persons overcome their
fear of government agencies and institutions?
- What is the explanatory model of TB in Latino immigrants? (Beliefs
about health and sources of illness from Kleinman)
- What type of bottom-up education package can be used for educating
patients of different cultural groups about TB questions they
may have, such as on TB medication, while also being sensitive
to influences, such as the patient’s gender and age (e.g., family
generation)?
- What is the effect and cost-effectiveness of a cultural intervention
(e.g., educational intervention) on LTBI therapy adherence in
Latino immigrants?
- How is a foreign-born patient’s TB treatment-seeking behavior
in this country influenced by the policies and practices of his/her
home country? (Suggested methodology was to conduct a linked study
with the foreign-born TB patient’s country of origin focusing
also on the communities, providers/programs, policy makers, etc.)
g. Pediatrics
Children with LTBI and TB represent another population with unique
characteristics and needs. The diagnosis and treatment of children
is often dependent upon the role of the parent, primary care giver,
and other adults.
Forum participants felt it was important to conduct research
to test alternative models to increase LTBI and TB screening and
treatment among children.
- What provider behaviors can lead to more efficient LTBI diagnoses
in children? Can the tuberculin skin test (TST) be avoided for
low risk children? What tests should be conducted for the use
of new testing tools for children? How do we get providers to
use these screening tools, if effective?
- What alternative models can be used for delivery of LTBI treatment
among children? An example of an alternative model is the use
of school-based parent administers with and without prompts (e.g.,
phone call reminders).
Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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