Reasons for poor uptake of TB preventive therapy in South Africa

Abstract

BACKGROUND: South Africa has one the highest TB and HIV burdens globally. TB preventive therapy (TPT) reduces the risk of TB disease and TB-related mortality in adults and children living with HIV and is indicated for use in TB-exposed HIV-negative individuals and children. TPT implementation in South Africa remains suboptimal.METHODS: We conducted a pragmatic review of TPT implementation using multiple data sources, including informant interviews (n = 134), semi-structured observations (n = 93) and TB patient folder reviews in 31 health facilities purposively selected across three high TB burden provinces. We used case descriptive analysis and thematic coding to identify barriers and facilitators to TPT implementation.RESULTS: TPT programme implementation was suboptimal, with inadequate monitoring even in health districts with well-functioning TB services. Health workers reported scepticism about TPT effectiveness, deprioritised TPT in practice and expressed divergent opinions about the cadres of staff responsible for implementation. Service- and facility-level barriers included ineffective contact tracing, resource shortages, lack of standardised reporting mechanisms and insufficient patient education on TPT. Patient-level barriers included socio-economic factors.CONCLUSIONS: Improving TPT implementation will require radically simplified and more feasible systems and training for all cadres of health workers. Partnership with communities to stimulate demand driven service uptake can potentially facilitate implementation.

Tuberculosis contact tracing, Angola

“…Moreover, we believe that insufficient counselling of contacts and families, lack of isoniazid monotherapy, and lack of awareness of other drugs used for preventive treatment are limiting the start of preventive treatment for high-risk groups, especially children younger than 5 years. 24 Therefore, continuous training and support of local staff are necessary to increase tuberculosis diagnosis and encourage the initiation of preventive treatment in high-risk groups. 25 …”

Healthcare worker knowledge, attitudes, and beliefs regarding tuberculosis preventive therapy in rural South Africa: A content analysis using the consolidated framework for implementation research

“… 16 – 18 However, cascade indicators are being routinely used in TB care, though less in preventive therapy; potentially due to lack of quality reporting mechanisms. 25 – 28 Ultimately, shifting the priority from a treatment-focused approach to prevention – in nursing and medical education, and in point-of-care algorithms and documentation systems – is necessary to transform comprehensive TB care. This is especially critical as South Africa has recently released updated guidelines greatly expanding TPT eligibility.…”

Outcomes and Challenges in the Programmatic Implementation of Tuberculosis Preventive Therapy among Household Contacts of Pulmonary TB Patients: A Mixed-Methods Study from a Rural District of Karnataka, India

“…The HHC definitions were used and phrased in different ways, by different HCWs, in different contexts. A lack of clarity on the HHC definition can lead to ineffective contact tracing [ 18 ]. This lack of clarity contributes to either overestimation or underestimation of the number of HHCs in complex social settings.…”

“…Further, identification and evaluation of TB among contacts who have shifted residence (including pregnant women and migrants) requires the effort and coordination of HCWs in two or more geographical locations. The lack of a clear role definition for cadres of HCWs involved in the TPT cascade can result in implementation challenges [ 18 ]. Thus, the NTEP must additionally detail the process in which HCWs must be involved in HHC management, reporting and monitoring and addressing the communication gaps.…”