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: 5.55). 11/2010; 24 Suppl 5(Suppl 5):S45-8. DOI: 10.1097/01.aids.0000391021.18284.12
Source: PubMed


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.

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    • "own admission that they were unclear about its benefits. In a programme that has promoted IPT since its inception in 1999, this is even more remarkable, and policy clarification and dissemination of accurate information is required[16]. Prior to implementation of THRio, physician knowledge about the national recommendations for TB prevention in HIV patients was limited [17]. "
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    ABSTRACT: Introduction: Isoniazid preventive therapy (IPT) reduces the risk of active TB. IPT is a key public health intervention for the prevention of TB among people living with HIV and has been recommended as part of a comprehensive HIV and AIDS care strategy. However, its implementation has been very slow and has been impeded by several barriers. Objective: The Objective of the study is to assess the perceived barriers to the implementation of Isoniazid preventive therapy for people living with HIV in resource constrained settings in Addis Ababa, Ethiopia in 2010. Methods: A qualitative study using a semi-structured interviewed guide was used for the in-depth interview. A total of 12 key informants including ART Nurse, counselors and coordinators found in four hospitals were included in the interview. Each session of the in-depth interview was recorded via audio tape and detailed notes. The interview was transcribed verbatim. The data was analyzed manually. Results: the findings revealed that poor patient adherence was a major factor; with the following issues cited as the reasons for poor adherence; forgetfulness; lack of understanding of condition and patient non- disclosure of HIV sero-status leading to insubstantial social support; underlying mental health issues resulting in missed or irregular patient appointments; weak patient/healthcare provider relationship due to limited quality interaction; lack of patient information, patient empowerment and proper counseling on IPT; and the deficient reinforcement by health officials and other stakeholders on the significance of IPT medication adherence as a critical for positive health outcomes. Conclusion: Uptake of the implementation of IPT is facing a challenge in resource limited settings. This recalled provision of training/capacity building and awareness creation mechanism for the health workers, facilitating disclosure and social support for the patients is recommended.
    Full-text · Article · Jan 2014 · Pan African Medical Journal
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    • "In addition, we found that primary health clinics were less likely to offer ART compared to other facility types, suggesting that increased ART coverage as a result of decentralization remains an ongoing process. With regards to low IPT uptake, the persistence of known barriers to IPT implementation, including fear of the selection of INH-resistant TB [32], [33], could explain the slow IPT uptake among the selected facilities. "
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    ABSTRACT: Public Health Facilities in South Africa. To assess the current integration of TB and HIV services in South Africa, 2011. Cross-sectional study of 49 randomly selected health facilities in South Africa. Trained interviewers administered a standardized questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. We calculated and compared descriptive statistics by province and facility type. Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to Tb clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centers (p<0.001). As of February 2011, integration of TB and HIV services is taking place in public medical facilities in South Africa. Among these services, IPT in people living with HIV and ART in TB patients are the least available.
    Preview · Article · Mar 2013 · PLoS ONE
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    • "While ART roll-out has been expanding, implementation of IPT has been slow, impeded by barriers and challenges. This lack of implementation is in part due to fear of non-adherence [5]. "
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    ABSTRACT: Despite high rates of successful treatment TB incidence in South Africa remains high, suggesting ongoing transmission and a large reservoir of latently infected persons. Isoniazid preventive therapy (IPT) is recommended as preventive therapy in HIV-infected persons. However, implementation has been slow, impeded by barriers and challenges including the fear of non-adherence. The aim was to evaluate predictors of IPT non-completion. One hundred and sixty four antiretroviral therapy (ART)-naïve HIV-infected patients with tuberculin skin test ≥5 mm were recruited from Khayelitsha day hospital and followed up monthly. A questionnaire was used to collect demographic information. The overall completion rate was 69%. In multivariable analysis, there was a 29% decrease in risk of non-completion for every year after HIV diagnosis (OR 0.81; 95% C.I. 0.68-0.98). Self-reported alcohol drinkers (OR 4.05; 95% C.I. 1.89-9.06) also had a four-fold higher risk of non-completion, with a strong association between alcohol drinkers and smoking (χ(2) 27.08; p<0.001). We identify patients with a recent HIV diagnosis, in addition to self-reported drinkers and smokers as being at higher risk of non-completion of IPT. The period of time since HIV diagnosis should therefore be taken into account when initiating IPT. Our results also suggest that smokers and alcohol drinkers should be identified and targeted for adherence interventions when implementing IPT on a wider scale.
    Full-text · Article · Dec 2012 · PLoS ONE
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