Barriers to implementation of isoniazid preventive therapy in HIV clinics: a qualitative study

London School of Hygiene and Tropical Medicine, London, UK.
AIDS (London, England) (Impact Factor: 6.56). 11/2010; 24 Suppl 5:S45-8. DOI: 10.1097/01.aids.0000391021.18284.12
Source: PubMed

ABSTRACT Despite good evidence that isoniazid preventive therapy (IPT) reduces incidence of tuberculosis among people with HIV infection, implementation of IPT is low. This study aimed to describe barriers to IPT implementation from healthcare provider and patient perspectives in a donor-funded HIV care programme in Gauteng province, South Africa, in which IPT is recommended, but delivery is variable.
A qualitative study using in-depth interviews and a focus group discussion.
We conducted interviews with 22 clinic staff and 20 patients from 10 purposively selected HIV clinics, and a staff focus group discussion. Staff were questioned on their knowledge and experience of IPT, and asked about barriers to its use. Patients were asked for their opinions about taking IPT.
Healthcare workers reported the primary barrier to IPT use was lack of knowledge and experience. Prescribers were unaware of the benefits of IPT and unclear about guidelines. The belief that existing screening tools are inaccurate in HIV-infected individuals and the need to refer patients to separate clinics for tuberculosis screening also emerged as barriers. No patients had heard of IPT.
Barriers to the widespread use of IPT primarily derived from healthcare workers, in particular, lack of experience among physicians. In addition to overcoming operational barriers, a change in healthcare worker perception is needed if IPT is to be widely used; we suggest local clinical opinion leaders could help achieve this.

1 Follower
  • Source
    • "In America, international medical graduates were significantly less likely to prescribe PT to a recent converter and to believe that PT was protective against TB disease compared to American medical graduates (Hirsch-Moverman et al. 2006). In South Africa, it was found that HCWs lacked knowledge and experience of IPT (Lester et al. 2010). Qualitative investigation gives further insight. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Young children living with a tuberculosis patient are at high risk of Mycobacterium tuberculosis infection and disease. WHO guidelines promote active screening and isoniazid (INH) preventive therapy (PT) for such children under 5 years, yet this well-established intervention is seldom used in endemic countries. We review the literature regarding barriers to implementation of PT and find that they are multifactorial, including difficulties in screening, poor adherence, fear of increasing INH resistance and poor acceptability among primary caregivers and healthcare workers. These barriers are largely resolvable, and proposed solutions such as the adoption of symptom-based screening and shorter drug regimens are discussed. Integrated multicomponent and site-specific solutions need to be developed and evaluated within a public health framework to overcome the policy-practice gap and provide functional PT programmes for children in endemic settings.
    Tropical Medicine & International Health 08/2012; 17(10). DOI:10.1111/j.1365-3156.2012.03053.x · 2.30 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To describe the association between isoniazid preventive therapy (IPT) and mortality among individuals starting antiretroviral therapy (ART) in a workplace programme in South Africa where tuberculosis (TB) incidence is very high. ART-naive individuals starting ART from January 2004 to December 2007 were followed for up to 12 months. Deaths were ascertained from clinic and human resource data. The association between IPT and mortality was assessed using Cox regression. A total of 3270 individuals were included (median age 45; 93% men; median baseline CD4 cell count 155 cells/μl (interquartile range 87-221); and 45% with WHO stage 3/4]. Nine hundred twenty-two (28%) individuals started IPT either prior to or within 3 months of starting ART. Individuals who started IPT tended to have less advanced HIV disease at ART initiation. Two hundred fifty-nine (7.9%) deaths were observed with overall mortality rate 8.9 per 100 person-years [95% confidence interval (CI) 7.9-10.6]. The unadjusted mortality rate was lower among those who received IPT compared with those who did not [3.7/100 vs. 11.1/100 person-years, respectively, hazard ratio 0.34 (95% CI 0.24-0.49)]; this association remained after adjustment for age, baseline CD4 cell count, baseline WHO stage, year of ART start, and individual company (hazard ratio 0.51, 95% CI 0.32-0.80). In sensitivity analyses restricted to those with no previous history of TB (n = 3036) or with no TB symptoms at ART initiation (n = 2251), IPT remained associated with reduced mortality [adjusted hazard ratios 0.51 (95% CI 0.32-0.81) and 0.48 (95% CI 0.24-0.96), respectively]. Mortality was lower among individuals receiving IPT with or prior to ART start. These results support routine use of IPT in conjunction with ART.
    AIDS (London, England) 11/2010; 24 Suppl 5:S5-13. DOI:10.1097/01.aids.0000391010.02774.6f · 6.56 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: An abstract is unavailable. This article is available as HTML full text and PDF.
    AIDS (London, England) 11/2010; 24 Suppl 5(Suppl 5):S57-65. DOI:10.1097/01.aids.0000391023.03037.1f · 6.56 Impact Factor
Show more