Outcomes of isoniazid preventive therapy among people living with HIV in Kenya: A retrospective study of routine health care data

Abstract

Introduction Isoniazid preventive therapy (IPT) taken by People Living with HIV (PLHIV) protects against active tuberculosis (TB). Despite its recommendation, data is scarce on the uptake of IPT among PLHIV and factors associated with treatment outcomes. We aimed at determining the proportion of PLHIV initiated on IPT, assessed TB screening practices during and after IPT and IPT treatment outcomes. Methods A retrospective cohort study of a representative sample of PLHIV initiated on IPT between July 2015 and June 2018 in Kenya. For PLHIV initiated on IPT during the study period, we abstracted patient IPT uptake data from the National data warehouse. In contrast, we obtained information on socio-demographic, TB screening practices, IPT initiation, follow up, and outcomes from health facilities' patient record cards, IPT cards, and IPT registers. Further, we assessed baseline characteristics as potential correlates of developing active TB during and after treatment and IPT completion using multivariable logistic regression. Results From the data warehouse, 138,442 PLHIV were enrolled into ART during the study period and initiated 95,431 (68.9%) into IPT. We abstracted 4708 patients’ files initiated on IPT, out of which 3891(82.6%) had IPT treatment outcomes documented, 4356(92.5%) had ever screened for TB at every clinic visit, and 4,243(90.1%) had documentation of TB screening on the IPT tool before IPT initiation. 3712(95.4%) of patients with documented IPT treatment outcomes completed their treatment. 42(0.89%) of the abstracted patients developed active TB,16(38.1%) during, and 26(61.9%) after completing IPT. Follow up for active TB at 6-month post-IPT completion was done for 2729(73.5%) of patients with IPT treatment outcomes. Sex, Viral load suppression, and clinic type were associated with TB development (p<0.05). Levels 4, 5, FBO, and private facilities and IPT prescription practices were associated with IPT completion (p<0.05). Conclusion IPT initiation stands at two-thirds of the PLHIV, with a high completion rate. TB screening practices were better during IPT than after completion. Development of active TB during and after IPT emphasizes the need for a keen follow up.

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

“…Our finding that CLHIV in high‐volume referral hospitals were almost three times less likely to initiate IPT is similar to a finding by Karanja et al. that people living with HIV (PLHIV) in level 4 and 5 hospitals were less likely to complete IPT compared to lower‐level facilities [ 11 ]. Such high‐volume hospitals have more complex service delivery models that challenge the integration of TB/HIV services [ 27 ].…”

“…Suboptimal or delayed IPT initiation in this study could be due to health system barriers, which have been documented in previous studies, including difficulties in ruling out active TB especially in CLHIV with respiratory symptoms [24], the fear of adverse reactions to isoniazid (INH) [22], poor health provider adherence to IPT guidelines [25], frequent INH stockouts and concerns about inducing resistance to INH [26]. Our finding that CLHIV in high-volume referral hospitals were almost three times less likely to ini-tiate IPT is similar to a finding by Karanja et al that people living with HIV (PLHIV) in level 4 and 5 hospitals were less likely to complete IPT compared to lower-level facilities [11]. Such high-volume hospitals have more complex service delivery models that challenge the integration of TB/HIV services [27].…”

“…Most studies from high burden settings evaluated the IPT cascade among under‐five children who are contacts of people with TB and reported IPT initiation rates ranging from 2.3% to 100% and completion rates ranging from 0% to 95% [ 10 ]. Previous studies that evaluated the IPT cascade in Kenya focused primarily on adults with HIV [ 9 , 11 , 12 ].…”

Burden of HIV and treatment outcomes among TB patients in rural Kenya: a 9-year longitudinal study.

“…Since rolling out the IPT in 2015 in Kenya, the uptake has increased to approximately two-thirds of all PLHIV and scaled up nationally [22]. IPT protects against TB among PLHIV [21], with the increased uptake, it is likely the incidence of TB among PLHIV would decline with time as observed in this study.…”

Increased uptake of tuberculosis preventive therapy (TPT) among people living with HIV following the 100-days accelerated campaign: A retrospective review of routinely collected data at six urban public health facilities in Uganda

“…In prospective research studies, many countries in sub-Saharan Africa (SSA) have shown similar success with TPT completion rates above 80%(7, 27, 28). In this report we show high completion rates of TPT in a program setting which can be attributed to, good coordination between the AIDS Control and National TB/Leprosy Programs, consistent supply of INH and vitamin B6, substantial support from partners like U.S President’s Emergency Plan for AIDS Relief (PEPFAR), United States Agency for International Development (USAID), Centers for Disease Control (CDC), among other, partner engagement, facility mentorship activities and improved reporting (16).…”