Implementation and Operational Research

Costenaro, Paola; Massavon, William; Lundin, Rebecca; Nabachwa, Sandra; Fregonese, Federica; Morelli, Erika; Alowo, Agnes; Musoke, Maria Nannyonga; Namisi, Charles; Kizito, Susan; Bilardi, Davide; Mazza, Antonio; Cotton, Mark F.; Giaquinto, Carlo; Penazzato, Martina

doi:10.1097/qai.0000000000000806

Cited by 9 publications

(9 citation statements)

References 16 publications

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“…Among cohorts that did not receive LTBI tests, the cumulative TPT initiation and completion were similar if PLHIV were followed at HIV clinics or other clinics (S5 Fig [18,21,24,38,51,58,66,[70][71][72][73][74][75][76]78,79,82]. The most common facilitators were related to the initial steps (identification, initial LTBI testing, and completing LTBI testing) and to initiation and completion of TPT.…”

Section: Plos Medicinementioning

confidence: 96%

“…evaluated for TPT, and 40 (64%) of these cohorts were seen in HIV clinics. Twenty-one cohorts [17,[66][67][68][69][70][71][72][73][74][75][76][77][78][79] did not use LTBI tests, while 49 cohorts used LTBI tests; 22 used only TST, 12 used only IGRA, and 15 used either IGRA or TST. Among the 56 (80%) studies that reported the type of TPT regimen, mono-isoniazid regimens were the primary regimen prescribed in 50 cohorts (89%), and only one (2%) of the included cohorts primarily prescribed rifamycin-based short regimens (3 to months of rifampicin and isoniazid) [29].…”

Section: Plos Medicinementioning

confidence: 99%

“…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].…”

Section: Plos Medicinementioning

confidence: 99%

“…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…”

Section: Plos Medicinementioning

confidence: 99%

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

et al. 2021

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Background Tuberculosis preventive therapy (TPT) reduces TB-related morbidity and mortality in people living with HIV (PLHIV). Cascade-of-care analyses help identify gaps and barriers in care and develop targeted solutions. A previous latent tuberculosis infection (LTBI) cascade-of-care analysis showed only 18% of persons in at-risk populations complete TPT, but a similar analysis for TPT among PLHIV has not been completed. We conducted a meta-analysis to provide this evidence. Methods and findings We first screened potential articles from a LTBI cascade-of-care systematic review published in 2016. From this study, we included cohorts that reported a minimum of 25 PLHIV. To identify new cohorts, we used a similar search strategy restricted to PLHIV. The search was conducted in Medline, Embase, Health Star, and LILACS, from January 2014 to February 2021. Two authors independently screened titles and full text and assessed risk of bias using the Newcastle–Ottawa Scale for cohorts and Cochrane Risk of Bias for cluster randomized trials. We meta-analyzed the proportion of PLHIV completing each step of the LTBI cascade-of-care and estimated the cumulative proportion retained. These results were stratified based on cascades-of-care that used or did not use LTBI testing to determine eligibility for TPT. We also performed a narrative synthesis of enablers and barriers of the cascade-of-care identified at different steps of the cascade. A total of 71 cohorts were included, and 70 were meta-analyzed, comprising 94,011 PLHIV. Among the PLHIV included, 35.3% (33,139/94,011) were from the Americas and 29.2% (27,460/94,011) from Africa. Overall, 49.9% (46,903/94,011) from low- and middle-income countries, median age was 38.0 [interquartile range (IQR) 34.0;43.6], and 65.9% (46,328/70,297) were men, 43.6% (29,629/67,947) were treated with antiretroviral therapy (ART), and the median CD4 count was 390 cell/mm3 (IQR 312;458). Among the cohorts that did not use LTBI tests, the cumulative proportion of PLHIV starting and completing TPT were 40.9% (95% CI: 39.3% to 42.7%) and 33.2% (95% CI: 31.6% to 34.9%). Among cohorts that used LTBI tests, the cumulative proportions of PLHIV starting and completing TPT were 60.4% (95% CI: 58.1% to 62.6%) and 41.9% (95% CI:39.6% to 44.2%), respectively. Completion of TPT was not significantly different in high- compared to low- and middle-income countries. Regardless of LTBI test use, substantial losses in the cascade-of-care occurred before treatment initiation. The integration of HIV and TB care was considered an enabler of the cascade-of-care in multiple cohorts. Key limitations of this systematic review are the observational nature of the included studies, potential selection bias in the population selection, only 14 cohorts reported all steps of the cascade-of-care, and barriers/facilitators were not systematically reported in all cohorts. Conclusions Although substantial losses were seen in multiple stages of the cascade-of-care, the cumulative proportion of PLHIV completing TPT was higher than previously reported among other at-risk populations. The use of LTBI testing in PLHIV in low- and middle-income countries was associated with higher proportion of the cohorts initiating TPT and with similar rates of completion of TPT.

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Section: Plos Medicinementioning

confidence: 96%

Section: Plos Medicinementioning

confidence: 99%

Section: Plos Medicinementioning

confidence: 99%

Section: Plos Medicinementioning

confidence: 99%

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

et al. 2021

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“…The level of awareness among health care providers, interruption of INH supply, co-infection with HIV, lack of recording tools for IPT and distance from health facilities affect uptake of the service in different settings. The IPT initiation and completion rates reported in research settings ranged between 18–33% and 23–50% respectively [ 7 – 10 ]. Whereas the IPT initiation and completion rates reported in program implementation settings were between 21–58% and 13% respectively [ 11 – 12 ].…”

Section: Introductionmentioning

confidence: 99%

Uptake of Isoniazid Preventive Therapy among Under-Five Children: TB Contact Investigation as an Entry Point

et al. 2016

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A child’s risk of developing tuberculosis (TB) can be reduced by nearly 60% with administration of 6 months course of isoniazid preventive therapy (IPT). However, uptake of IPT by national TB programs is low, and IPT delivery is a challenge in many resource-limited high TB-burden settings. Routinely collected program data was analyzed to determine the coverage and outcome of implementation of IPT for eligible under-five year old children in 28 health facilities in two regions of Ethiopia. A total of 504 index smear-positive pulmonary TB (SS+) cases were reported between October 2013 and June 2014 in the 28 health facilities. There were 282 under-five children registered as household contacts of these SS+ TB index cases, accounting for 17.9% of all household contacts. Of these, 237 (84%) were screened for TB symptoms, and presumptive TB was identified in 16 (6.8%) children. TB was confirmed in 5 children, producing an overall yield of 2.11% (95% confidence interval, 0.76–4.08%). Of 221 children eligible for IPT, 64.3% (142) received IPT, 80.3% (114) of whom successfully completed six months of therapy. No child developed active TB while on IPT. Contact screening is a good entry point for delivery of IPT to at risk children and should be routine practice as recommended by the WHO despite the implementation challenges.

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Drop‐offs in the isoniazid preventive therapy cascade among children living with HIV in western Kenya, 2015–2019

et al. 2022

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Introduction Isoniazid preventive therapy (IPT) can reduce the risk of tuberculosis (TB) in children living with HIV (CLHIV), but data on the outcomes of the IPT cascade in CLHIV are limited. Methods We evaluated the IPT cascade among CLHIV aged <15 years and newly enrolled in HIV care in eight HIV clinics in western Kenya. Medical record data were abstracted from September 2015 through July 2019. We assessed the proportion of CLHIV completing TB symptom screening, IPT eligibility assessment, IPT initiation and completion. TB incidence rate was calculated stratified by IPT initiation and completion status. Risk factors for IPT non‐initiation and non‐completion were assessed using Poisson regression with generalized linear models. Results Overall, 856 CLHIV were newly enrolled in HIV care, of whom 98% ([95% CI 97–99]; n = 841) underwent screening for TB symptoms and IPT eligibility. Of these, 13 (2%; 95% CI 1–3) were ineligible due to active TB and 828 (98%; 95% CI 97–99) were eligible. Five hundred and fifty‐nine (68%; 95% CI 64–71) of eligible CLHIV initiated IPT; median time to IPT initiation was 3.6 months (interquartile range [IQR] 0.5–10.2). Overall, 434 (78%; 95% CI 74–81) IPT initiators completed. Attending high‐volume HIV clinics (aRR = 2.82; 95% CI 1.20–6.62) was independently associated with IPT non‐initiation. IPT non‐initiation had a trend of being higher among those enrolled in the period 2017–2019 versus 2015–2016 (aRR = 1.91; 0.98–3.73) and those who were HIV virally non‐suppressed (aRR = 1.90; 95% CI 0.98–3.71). Being enrolled in 2017–2019 versus 2015–2016 (aRR = 1.40; 1.01–1.96) was independently associated with IPT non‐completion. By 24 months after IPT screening, TB incidence was four‐fold higher among eligible CLHIV who never initiated (8.1 per 1000 person years [PY]) compared to CLHIV who completed IPT (2.1 per 1000 PY; rate ratio [RR] = 3.85; 95% CI 1.08–17.15), with a similar trend among CLHIV who initiated but did not complete IPT (8.2/1000 PY; RR = 4.39; 95% CI 0.82–23.56). Conclusions Despite high screening for eligibility, timely IPT initiation and completion were suboptimal among eligible CLHIV in this programmatic cohort. Targeted programmatic interventions are needed to address these drop‐offs from the IPT cascade by ensuring timely IPT initiation after ruling out active TB and enhancing completion of the 6‐month course to reduce TB in CLHIV.

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Implementation and Operational Research

Cited by 9 publications

References 16 publications

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

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

Uptake of Isoniazid Preventive Therapy among Under-Five Children: TB Contact Investigation as an Entry Point

Drop‐offs in the isoniazid preventive therapy cascade among children living with HIV in western Kenya, 2015–2019

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