Mixed methods systematic review and metasummary about barriers and facilitators for the implementation of cotrimoxazole and isoniazid – preventive therapies for people living with HIV

Abstract

Background: Cotrimoxazole and isoniazid preventive therapy (CPT, IPT) have been shown to be efficacious therapies for the prevention of opportunistic infections and tuberculosis (TB) among people living with human immunodeficiency virus (HIV). Despite governments' efforts to translate World Health Organization recommendations into practice, implementation remains challenging. This review aimed to explore and compare CPT and IPT with respect to similarities and differences of barriers identified across high TB/HIV burden countries. A secondary objective was to identify facilitators for implementing both preventive therapies. Methods: We searched MEDLINE, Web of Science and SCOPUS databases for peer-reviewed literature published before September 2020. We extracted and synthesized our findings using Maxqda software. We applied framework synthesis in conjunction with metasummary to compare both therapies with respect to similarities and differences of barriers identified across seven health system components (in line with the modified WHO's Framework for action). Protocol registration: PROSPERO (CRD42019137778). Findings: We identified four hundred and eighty-two papers, of which we included forty for review. Although most barrier themes were identical for both preventive therapies, we identified seven intervention-specific themes. Like for CPT, barriers identified for IPT were most frequently classified as 'service delivery-related barriers' and 'patient & community-related barriers'. 'Health provider-related barriers' played an additional important role for implementing of IPT. Most facilitators identified referred to health system strengthening activities. Conclusions: For researchers with limited working experience in high TB/HIV burden countries, this review can provide valuable insights about barriers that may arise at different levels of the health system. For policymakers in high TB/HIV burden countries, this review offers strategies for improving the delivery of IPT (or any newer therapy regimen) for the prevention of TB. Based on our findings, we suggest initial and continuous stakeholder involvement, a focus on the efficient use and reinforcement of existing resources for health.

Preventive Measures and Potential Risk Factors for Toxoplasmosis among ART Clients in Sunyani Municipality.

“…Several other studies pooled together in a systematic review on several continents also identified age to be associated with adherence to other interventions which are also normally given to HIV patients (Müller & Velez Lapão, 2021).This study found a statistically significant relationship between age and adherence to both ART and co-trimoxazole preventive therapy (CPT) in the bivariate analysis as was revealed in other studies such as that of B. Addo et al, 2018 in Ashanti region which also found older age to be more likely associated with non-adherence to ART.…”

“…However, religious beliefs may affect coping mechanisms and could in turn influence the acceptability for and adherence to any form of long term treatment. Living with family members who offer the necessary support may impact positively on adherence as compared to living alone whereby the impetus for taking medications may sometimes be lacking (Müller & Velez Lapão, 2021). In the same way, living with a stigmatizing and unsupportive family may equally impact negatively on adherence to treatment, as was shown in one study in an African country where some respondents reported that they had ever experienced instances where their family members deliberately discarded their medications (Müller & Velez Lapão, 2021).…”

“…Living with family members who offer the necessary support may impact positively on adherence as compared to living alone whereby the impetus for taking medications may sometimes be lacking (Müller & Velez Lapão, 2021). In the same way, living with a stigmatizing and unsupportive family may equally impact negatively on adherence to treatment, as was shown in one study in an African country where some respondents reported that they had ever experienced instances where their family members deliberately discarded their medications (Müller & Velez Lapão, 2021). Similarly, ambiguous family relationship was seen in one study to reduce adherence among adolescents living in homes without their natural parents (MacCarthy et al, 2018).…”

“…Co-trimoxazole preventive therapy (CPT) is the cornerstone of prevention against toxoplasmosis in the population of HIV infected individuals, and has been found in some studies to be highly effective, reaching 100 percent protection for regular users (Kirk et al, 1999;Bamba et al, 2017). It is a simple relatively inexpensive intervention requiring only a single dose per day, but is inarguably an absolute necessity in this population as it wards off not only opportunistic infections such as cerebral toxoplasmosis but also demonstrates some protection against malaria (Müller & Velez Lapão, 2021) which is a common disease that often causes significant morbidity and mortality in people living on the African continent and other tropical regions of the world. Even though concerns about resistance to this medication have been expressed in some parts of the world, it continues to be a cornerstone preventive therapy for most patients who can tolerate it (Müller & Velez Lapão, 2021).…”

“…It is a simple relatively inexpensive intervention requiring only a single dose per day, but is inarguably an absolute necessity in this population as it wards off not only opportunistic infections such as cerebral toxoplasmosis but also demonstrates some protection against malaria (Müller & Velez Lapão, 2021) which is a common disease that often causes significant morbidity and mortality in people living on the African continent and other tropical regions of the world. Even though concerns about resistance to this medication have been expressed in some parts of the world, it continues to be a cornerstone preventive therapy for most patients who can tolerate it (Müller & Velez Lapão, 2021). Majority of ART clients in this study reported that they were undergoing routine chemoprophylaxis (against opportunistic infections, which include cerebral toxoplasmosis) with co-trimoxazole at the time of the data collection, and had been on them for varying durations.…”