Evaluation of the uptake of tuberculosis preventative therapy for people living with HIV in Namibia: a multiple methods analysis

Abstract

Background In 2016, Namibia had ~ 230,000 people living with HIV (PLHIV) and 9154 new tuberculosis (TB) cases, including 3410 (38%) co-infected cases. TB preventative therapy (TPT), consisting of intensive case finding and isoniazid preventative therapy, is critical to reducing TB disease and mortality. Methods Between November 2014 and February 2015, data was abstracted from charts of PLHIV enrolled in HIV treatment. Fifty-five facilities were purposively selected based on patient volume, type and location. Charts were randomly sampled. The primary outcome was to estimate baseline TPT in PLHIV, using nationally weighted proportions. Qualitative surveys were conducted and summarized to evaluate TPT practices and quantify challenges encountered by health care workers (HCW). Results Among 861 PLHIV sampled, 96% were eligible for TPT services, of which 87.1% were screened for TB at least once. For PLHIV eligible for preventative therapy (646/810; 82.6%), 45.4% (294/646) initiated therapy and 45.7% (139/294) of those completed therapy. The proportion of eligible PLHIV completing TB screening, initiating preventative therapy and then completing preventative therapy was 20.7%. Qualitative surveys with 271 HCW identified barriers to TPT implementation including: lack of training (61.3% reported receiving training on TPT); misunderstandings about timing of TPT initiation (46.7% correctly reported TPT should be started with antiretroviral therapy); and variable screening practices and responsibilities (66.1% of HCWs screened for TB at every encounter). Though barriers were evident, 72.2% HCWs surveyed described their clinical performance as very good, often placing responsibility of difficulties on patients and downplaying challenges like staff shortages and medication stock outs. Conclusions In this study, only 1 in 5 eligible PLHIV completed the TPT cascade in Namibia. Lack of training, irregularities with TB screening and timing of TPT, unclear prescribing and recording responsibilities, and a clinical misperception may have contributed to suboptimal programmatic implementation. Addressing these challenges will be critical with continued TPT scale-up.

The latent tuberculosis cascade-of-care among people living with HIV: A systematic review and meta-analysis

“…Integration of HIV and TPT care was a facilitator for multiple steps in 7 studies [ 18 , 38 , 72 , 74 , 76 , 79 , 82 ]. Barriers were reported by 12 studies [ 18 , 21 , 24 , 34 , 58 , 66 , 70 , 72 , 74 , 78 , 80 , 81 ], primarily at the initial steps of identification and testing and the final steps of initiating and completing TPT. Nonintegrated TB and HIV care was a barrier for at multiple steps [ 34 , 81 ].…”

“…Pill burden, fear of adverse events, and stocks out of LTBI drugs were also reported as barriers for starting and completing TPT [18,34,72,74,78]. [18,38,72,74,76,79,82] • Fragmentation of care of HIV and TB patients [34,81] • Testing and TPT were implemented by TB programs that were not familiar with the care of HIV patients [66] • Stigma of HIV patients receiving care in TB clinics [72,74] • Lack of information, motivation, and support to HCW [21,80,81] • Too much workload [81] Identification • Participation of staff in the design of TPT implementations strategy [70] • Patient education material [70] • HIV testing for household contacts of infectious TB disease [38,71] • Community HCWs initiating contact [71] • TB/HIV care in antenatal care services [73,75] • Creation of a TB/HIV integration officer and a TB screening officer [76] • Task shifting TB screening to primary care [76] • None Identified Initial testing • Theoretical training on TST [18,24] • TST training [18,24,70] • Extra consultation room [18] • TB screening by "lay counselor" [18] • TB screening done by physicians [24] • TB nurse dedicated for administration of TST [24] • TB counseling at the moment of HIV diagnosis…”

Completion of isoniazid–rifapentine (3HP) for tuberculosis prevention among people living with HIV: Interim analysis of a hybrid type 3 effectiveness–implementation randomized trial

“…Access to TPT has improved recently, with 3.5 million PLHIV receiving TPT in 2019 [1]. However, in many settings, less than half of those initiating TPT with the standard 6-month course of daily isoniazid complete treatment [4][5][6]. Safer, shorter TPT regimens are now available, including a 12-dose weekly regimen of isoniazid-rifapentine (3HP) [7][8][9].…”

Addressing TB-related mortality in adults living with HIV: a review of the challenges and potential solutions

“… 26 A retrospective study from Namibia evaluating TPT uptake in PLHIV found that only 20% of eligible patients completed the TPT cascade of care. 27 A cross-sectional study from Zambia also found low TPT completion rates with only 38% of the 25% of eligible PLHIV who initiated TPT completing treatment. 28 …”

“… 84 Improving the efficiency of healthcare systems and effective training on TPT may also allow for better implementation of TPT and reduced TB mortality in PLHIV. 27 , 28 …”