Routine implementation of isoniazid preventive therapy in HIV-infected patients in seven pilot sites in Zimbabwe

Abstract

Setting: Seven pilot sites in Zimbabwe implementing 6 months of isoniazid preventive therapy (IPT) for people living with the human immunodeficiency virus (PLHIV). Objectives: To determine, among PLHIV started on IPT, the completion rates for a 6-month course of IPT and factors associated with non-adherence. Design: A retrospective cohort study. Results: Of 578 patients, 466 (81%) completed IPT. Of the 112 patients who failed to complete IPT, 69 (60%) were lost to follow-up, 30 (27%) stopped treatment with no documented reasons, 8 (7%) developed toxicity/adverse reactions, 5 (5%) were documented as having drug stock-outs and the remainder transferred out or refused to continue treatment. Currently being on antiretroviral therapy (ART) (aOR 0.09, 95%CI 0.03-0.28) and receiving a 2 month supply of isoniazid at the start of treatment were associated with a lower risk of not completing IPT, while missing clinic visits prior to starting IPT (aOR 5.25, 95%CI 2.10-13.14) was associated with a higher risk of non-completion. Conclusion: IPT completion rates in seven pilot sites of Zimbabwe were comparatively high, showing that IPT roll-out in public health facilities is feasible. Enhanced adherence counselling or active tracing among pre-ART patients and those with a history of loss to follow-up may improve IPT completion rates, along with synchronising IPT and ART resupplies. Public Health Action IPT in Zimbabwe 56the WHO-recommended four-symptom TB screening checklist. 11 If PLHIV present with any of the four symptoms, they are considered to be presumptive TB cases and sputum specimens are collected for smear microscopy or Xpert ® MTB/RIF (Cepheid, Sunnyvale, CA, USA) testing. Those patients negative on Xpert or smear microscopy and who have no other symptoms or signs of extra-pulmonary or smear-negative pulmonary TB, including chest radiography if necessary, are not recorded as having active TB. During the pilot phase, PLHIV who were not diagnosed with active TB were offered adherence counselling and were started on a daily oral dose of isoniazid (INH, 5 mg/kg body weight for adults or 10 mg/kg body weight for children) plus a daily low dose of pyridoxine (25 mg/day) for a 6-month period, regardless of their ART status. It was recommended that patients receive regular supplies of INH every month until completion of their prophylactic treatment. 10 During clinic visits, patients were assessed through self-reporting and pill counts for adherence and screened for TB. Patients found to have active TB were taken off IPT and treated according to the national TB guidelines. 11 Data on TB status (screened with no TB signs/not screened/ presumptive TB case/active TB), IPT status (yes/no), IPT quantity dispensed and reasons for starting or stopping IPT were integrated into the individual patient opportunistic infection (OI) ART care booklets and the pre-ART or ART registers, depending on the patients' ART status. This information was updated during each clinical review visit. For easier tracing of all clients enrolled on IPT, ...

Prevalence of drug-resistant tuberculosis in Zimbabwe: A health facility-based cross-sectional survey

“…First, there is need to improve early and universal access to DST (in Zimbabwe and elsewhere in SADC) for at least rifampicin, in line with the WHO End TB strategy (STOP TB Partnership 2015). Second, since isoniazid prophylactic therapy (IPT) has been scaled up in Zimbabwe with !20,000 PLHIV having been started on IPT by December 2015 and IPT completion rates of !89% have been attained (Takarinda et al 2017(Takarinda et al , 2019, and within the context of South African isoniazid-mono resistance of [4.9%, 95% CI: 4.1%-5.8%)],(National Institute for Communicable Diseases 2014) estimating the prevalence of and continued monitoring of isoniazid mono-resistance should be prioritized in Zimbabwe. Third, although sample size was small and should be interpreted as hypothesis-generating, we noted an increased risk of RR-TB among older children and adolescents, and warrants additional studies examining the determinants of childhood RR-TB in Zimbabwe.…”

Determinants of Isoniazid Preventive Therapy Completion among People Living with HIV Attended Care and Treatment Clinics from 2013 to 2017 in Dar es Salaam Region,Tanzania. A cross-sectional analytical study

“…WHO recommends the completion of at least six months IPT for the successful prevention of active tuberculosis among PLHIV (4,10). Globally, six-month IPT completion has been reported to range from 39-99% (28)(29)(30)(31)(32)(33)(34)(35)(36)(37), and in Tanzania studies reported 65%-98% of those who initiated IPT, completed the six month treatment course (6,20,(38)(39)(40). Most epidemiological studies have shown that IPT completion reduces the risks of mortality among PLHIV (8,26,41)…”

Barriers to the implementation of isoniazid preventive therapy for tuberculosis in children in endemic settings: A review

“…Education is an important issue but it is not the only impediment faced by health‐care workers trying to deliver IPT to children in TB‐endemic settings. Some health‐care centres lacked the equipment to rule out active TB, which they saw as necessary to initiating IPT, while others encountered supply chain difficulties in procuring sufficient isoniazid to provide patients . The labour‐intensive preparation of paediatric doses was reported as placing additional strain on already stretched staffing arrangements in some areas although child‐friendly dispersible formulations are now becoming available in most countries through the Global Development Fund .…”

“…The labour‐intensive preparation of paediatric doses was reported as placing additional strain on already stretched staffing arrangements in some areas although child‐friendly dispersible formulations are now becoming available in most countries through the Global Development Fund . Centres also often eschewed from recommending monthly monitoring, as advised by the WHO, complicating efforts to track and encourage adherence . The lack of prioritisation for IPT by government in some areas, adds another layer of difficulty to the effective implementation of these programmes, particularly in resource‐poor regions where health systems are in need of broad strengthening across multiple areas…”