The social implications of participant choice on adherence to Isonaizid Preventive Therapy (IPT): A follow-up study to high completion rates in Eswatini.

BACKGROUND: Eswatini (formerly Swaziland) has one of the highest rates of TB and HIV co-disease in the world. Despite national efforts to improve service delivery and prevent TB and HIV transmission, rates remain high. A recent prospective, observational study of integrated, patient-selected IPT delivery showed extraordinary improvements in IPT adherence, running counter to previous assumptions. This prompted the need to understand contextual and unseen study factors that contributed to high rates of adherence. OBJECTIVE: To investigate high rates of IPT adherence rates among people living with HIV who participated in an observational study comparing modes of IPT delivery. METHODS: Community-based participatory research guided the development of in-person administration of semi-structured questionnaires. Observational and field note data were analyzed. Qualitative data were analyzed using content analysis. RESULTS: We interviewed 150 participants and analyzed responses from the 136 who remembered being given a choice of their IPT delivery method. Fifty-seven percent were female and the median age was 42. Nearly 67% of participants chose to receive facility-based IPT. High rates of self-reported IPT treatment adherence were linked to four key concepts: 1) adherence was positively impacted by community education; 2) disclosure of status served to empower participant completion; 3) mode of delivery perceptions positively impacted adherence; and 4) choice of treatment delivery seen as helpful but not essential for treatment completion. DISCUSSION: Achieving higher rates of IPT adherence in Eswatini and similar rural areas requires community-engaged education and outreach in coordination with care delivery systems.

Integrated and patient-selected care facilitates completion of isoniazid preventive therapy in Eswatini.

SETTING: Five human immunodeficiency virus (HIV) care facilities in Eswatini. OBJECTIVE: To identify critical factors that enabled persons living with HIV to successfully complete a 6-month course of isoniazid preventive therapy (IPT) provided through a choice of facility-based or community-based delivery, coordinated with antiretroviral therapy (ART) refills. DESIGN: This was a mixed methods, retrospective cross-sectional study. RESULTS: Between June and October 2017, we interviewed 150 participants who had completed IPT in the previous year. Fourteen participants did not recall being offered a choice, and were excluded from the analysis. Of the remaining 136, 56.6% were female and 64.7% chose facility-based care; the median age was 42.5 years. Most participants reported that having a choice was important to their treatment completion (87.7%) and that linking IPT and ART refills facilitated undergoing IPT (98.5%). Participants were knowledgeable about the benefits of IPT and valued the education received from their providers. Participants also reported a high rate of IPT disclosure (95%) to friends and family members. CONCLUSION: Offering patients a choice of IPT delivery, linking IPT with ART refills, emphasizing patient education and engagement with healthcare workers, and supporting disclosure of IPT are critical factors to enabling IPT completion. These interventions should be incorporated throughout Eswatini and in similar high tuberculosis and HIV burden settings.

High completion rates of isoniazid preventive therapy among persons living with HIV in Swaziland.

SETTING: Five human immunodeficiency virus (HIV) care facilities in Swaziland. OBJECTIVE: To assess adherence and treatment completion of a 6-month course of isoniazid preventive therapy (IPT) provided to HIV-infected patients through a self-selected model of facility-based, community-based or peer-supported IPT delivery coordinated with antiretroviral refills. DESIGN: Prospective cohort study. RESULTS: Between February and August 2015, we enrolled 908 patients, with follow-up until February 2016. Most were female (66.2%), with a median age of 38 years (interquartile range 31-45). Most (n = 797, 87.8%) chose facility-based delivery, 111 (12.2%) selected community-based delivery, and none selected peer-supported delivery. Adherence was high in both cohorts; among those with available data, 794 (94.8%) reported taking at least 80% of their IPT (P > 0.05). Twenty-two patients screened positive for tuberculosis (TB) at any visit; all had TB excluded and most continued IPT. In total, 812 (89.4%) patients completed treatment: 711 (89.2%) were on facility-based and 111 (91.0%) on community-based IPT (P > 0.05). No confirmed treatment failures occurred. Few patients discontinued IPT (6.3%) or were lost to follow-up (4.1%). CONCLUSION: Self-selected IPT delivery aligned with HIV care achieved high rates of adherence and treatment completion. This model may improve outcomes by simplifying clinic visits and conferring agency to the patient, and may be readily implemented in similar high TB-HIV burden settings.

Barriers to tuberculosis care delivery among miners and their families in South Africa: an ethnographic study.

SETTING: South African miners suffer the highest tuberculosis (TB) rates in the world. Current efforts to stem the epidemic are insufficient. Historical legacies and persistent disease burden demand innovative approaches to reshape health care delivery to better serve this population. OBJECTIVE: To characterize social and behavioral health determinants for successful TB care delivery and treatment from the perspective of miners/ex-miners, health care workers and policy makers/managers. DESIGN: We conducted applied ethnography with 30 miners/ex-miners, 13 family/community members, 14 health care providers, and 47 local policy makers/managers in South Africa. RESULTS: Miners/ex-miners felt health care delivery systems failed to meet their needs. Many had experienced unnecessary physical and psychological harm due to limited health education about TB, minimal engagement in their own care, lack of trust in providers, and a system that did not value their experience. Stigma and fear associated with TB result in denial of symptoms and delays in care seeking. Health care providers and policy makers/managers felt discouraged by system constraints in providing optimal care. CONCLUSION: Our findings describe long-term effects of perpetual TB misinformation and stigma resulting from fear and disempowerment among miners and their families/communities. To reduce the TB burden, there is an urgent need to co-design a care delivery system with miners to better meet their needs.

Ending neglect: providing effective childhood tuberculosis training for health care workers in Tanzania.

SETTING: Health care facilities in Dar es Salaam, Pwani, and Arusha, Tanzania. OBJECTIVE: To assess health care worker (HCW) knowledge and practices 1 year after specialized training in childhood tuberculosis (TB). DESIGN: Using a standardized survey, we interviewed a convenience sample of HCWs providing both general and specialized care to children. RESULTS: We interviewed 117 HCWs in TB clinics, maternal and child health clinics, human immunodeficiency virus (HIV) clinics, out-patient departments, and pediatric in-patient wards at 12 facilities. A total of 81 HCWs (62% of nurses, 74% of clinicians) reported having attended the national childhood TB training course. Most HCWs responded correctly to questions on childhood TB diagnosis, treatment, and TB-HIV co-management, regardless of training history. Most HCWs reported that they routinely obtain chest radiographs, HIV testing, and a TB contact history when evaluating children for TB. Less than half of HCWs reported routinely obtaining sputum for mycobacterial culture or performing a tuberculin skin test. Three times as many trained as untrained HCWs reported having ever prescribed isoniazid preventive therapy (IPT) to a child (P < 0.05). CONCLUSION: In general, levels of childhood TB knowledge were high and practices were in accordance with national guidance. Specific gaps in diagnosis, treatment and use of IPT were identified for future focused training.

Contexte : Structures de soins de santé à Dar es Salam, Pwani et Arusha, Tanzanie.Objectif : Evaluer les connaissances et pratiques du personnel de santé (HCW) un an après une formation spécifique à la tuberculose de l'enfant (TB).Schéma : Grâce à une enquête standardisée, nous avons interviewé un échantillon de complaisance de HCW offrant des soins à la fois généraux et spécialisés à des enfants.Résultats : Nous avons interviewé 117 HCW dans des dispensaires de TB, des centres de santé maternelle et infantile, des dispensaires pour le virus de l'immunodéficience humaine (VIH), des consultations externes et des services de pédiatrie dans 12 établissements. Un total de 81 HCW (62% d'infirmières, 74% de cliniciens) a affirmé avoir bénéficié de la formation nationale relative à la TB de l'enfant. La majorité a répondu correctement aux questions relatives au diagnostic de la TB de l'enfant, à son traitement et à la prise en charge conjointe de la TB et du VIH, quels que soient les antécédents de formation. La plupart ont dit demander en routine des radiographies pulmonaires, un test VIH et une recherche de contacts tuberculeux lors de l'évaluation des enfants. Moins de la moitié des HCW a affirmé recueillir des crachats en routine pour une culture mycobactérienne ou réaliser un test cutané à la tuberculine. La prescription de thérapie préventive par isoniazide (IPT) a été faite trois fois plus souvent par des HCW formés que par ceux qui ne l'avaient pas été (P < 0,05).Conclusion : En général, les connaissances en matière de TB de l'enfant étaient élevées et les pratiques conformes aux directives nationales. L'étude a identifié des lacunes spécifiques en matière de diagnostic, de traitement et d'utilisation de l'IPT afin de mieux cibler les futures formations.

Marco de referencia: Los establecimientos de atención de salud de Dar es-Salaam, Pwani y Arusha en Tanzania.Objetivo: Evaluar los conocimientos y las prácticas de los profesionales de salud (HCW) un año después de haber recibido una capacitación especializada sobre la tuberculosis (TB) de la infancia.Método: Se administró una encuesta normalizada a una muestra de conveniencia de los HCW que prestan atención general y especializada a los niños.Resultados: Se entrevistaron 117 HCW de los consultorios de TB, salud maternoinfantil, atención de la infección por el virus de la inmunodeficiencia humana (VIH) y de los servicios de atención ambulatoria y hospitalización pediátrica en 12 establecimientos. Ochenta y un HCW refirieron haber asistido al programa nacional de capacitación sobre la TB en la infancia (62% del personal de enfermería y 74% del personal médico). La mayoría de los HCW respondió de manera correcta a las preguntas sobre el diagnóstico y el tratamiento de la TB y la atención integrada de la TB-VIH, independientemente de las capacitaciones recibidas. La mayoría de los interrogados refirió la solicitud sistemática de radiografías de tórax, pruebas diagnósticas del VIH y el interrogatorio sobre los antecedentes de contacto con casos de TB cuando examinaba niños con presunción clínica de TB. Menos de la mitad de los HCW declaró la obtención corriente de muestras de esputo para cultivo de micobacterias o la práctica de la prueba cutánea de la tuberculina. Fue tres veces más frecuente que los HCW que habían recibido una capacitación, hubiesen recetado en alguna ocasión el tratamiento preventivo con isoniazida (IPT) a un niño en comparación con HCW sin antecedentes de capacitación (P < 0,05).Conclusión: En general, se observó un buen conocimiento de la TB de la infancia y las prácticas fueron conformes con las directrices nacionales. Se pusieron en evidencia algunas deficiencias en materia de diagnóstico, tratamiento y aplicación del IPT, sobre las cuales se centrará la atención en los futuros programas de capacitación.

Effectiveness of a sports-based HIV prevention intervention in the Dominican Republic: a quasi-experimental study.

Previous observational and quasi-experimental studies in sub-Saharan Africa have suggested the effectiveness of youth-targeted HIV prevention interventions using sport as an educational tool. No studies have yet assessed the effect of similar programs in the Caribbean. A quasi-experimental trial was conducted to assess the effectiveness of a sports-based intervention in six migrant settlements in the Puerto Plata Province of the Dominican Republic. A total of 397 structured interviews were conducted with 140 adolescents prior to, immediately following, and four months following 10-hour interventions using the Grassroot Soccer curriculum. Interview responses were coded, aggregated into composite scores, and analyzed using logistic regression, adjusting for baseline differences as well as age, sex, community, and descent. At post-intervention, significant differences were observed between groups in HIV-related knowledge (adjOR = 13.02, 95% CI = 8.26, 20.52), reported attitudes (adjOR = 12.01, 95% CI = 7.61, 18.94), and reported communication (adjOR = 3.13, 95% CI = 1.91, 5.12). These differences remained significant at four-month follow-up, though declines in post-intervention knowledge were observed in the Intervention group while gains in knowledge and reported attitudes were observed in the Control group. Results suggest that this sports-based intervention could play a valuable role in HIV prevention efforts in the Caribbean, particularly those targeting early adolescents. Further evaluation of sports-based interventions should include indicators assessing behavioral and biological outcomes, longer-term follow-up, a larger sample, randomization of study participants, and strenuous efforts to minimize loss-to-follow-up.

Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality.

BACKGROUND: Disseminated tuberculosis (TB) is a major cause of death in patients with the acquired immune-deficiency syndrome (AIDS), but its pathogenesis and clinical features have not been defined prospectively. METHODS: Human immunodeficiency virus (HIV) infected adults with a CD4 count ≥ 200 cells/µl and bacille Calmette-Guérin scar underwent immunologic evaluation and subsequent follow-up. RESULTS: Among 20 subjects who developed disseminated TB, baseline tuberculin skin tests were ≥15 mm in 14 (70%) and lymphocyte proliferative responses to Mycobacterium tuberculosis were positive in 14 (70%). At the time of diagnosis, fever ≥2 weeks plus ≥5 kg weight loss was reported in 16 (80%) patients, abnormal chest X-rays in 7/17 (41%), and positive sputum cultures in 10 (50%); median CD4 count was 30 cells/µl (range 1-122). By insertion sequence (IS) 6110 analysis, 14 (70%) blood isolates were clustered and 3/8 (37%) concurrent sputum isolates represented a different strain (polyclonal disease). Empiric TB treatment was given to eight (40%) patients; 11 (55%) died within a month. CONCLUSIONS: Disseminated TB in HIV occurs with cellular immune responses indicating prior mycobacterial infection, and IS6110 analysis suggests an often lethal combination of reactivation and newly acquired infection. Control will require effective prevention of both remotely and recently acquired infection, and wider use of empiric therapy in patients with advanced AIDS and prolonged fever.

Virilization during pregnancy with spontaneous resolution postpartum: a case report and review of the English literature.

The incidence of gestational hyperandrogenism secondary to ovarian pathology is low. However, when the condition does exist, diagnosis should be made with minimally invasive modalities. It is important to provide appropriate medical/surgical intervention without disturbing the pregnancy iatrogenically or causing unnecessary maternal morbidity. This case report adds to the existing radiographic data concerning this rare obstetrical condition. Presented is a review of the English literature on virilizing ovarian tumors during pregnancy, and a discussion of an approach to managing these tumors when they occur during pregnancy.