Facility and patient barriers in the implementation of isoniazid preventive therapy for people living with HIV attending Care and Treatment Centers, Songea Municipality, Tanzania.

INTRODUCTION: isoniazid preventive therapy for people living with HIV is an essential public health intervention in low-income countries with high tuberculosis and HIV burden. Despite available evidence that it is efficacious, its implementation is still low in many countries. This study was designed to determine its implementation coverage and explore barriers for suboptimal implementation in Songea municipality in Tanzania. METHODS: a cross-sectional descriptive study design using both quantitative and qualitative approaches of data collection was employed. A review of 2148 records of people living with HIV eligible for isoniazid preventive therapy (IPT) was done to determine its implementation coverage. Twenty-one (21) in-depth interviews and 5 observations were conducted to explore barriers in the implementation. Quantitative data was analyzed using Statistical Package for the Social Science (SPSS) for windows version 20 statistical software. Descriptive statistics (frequencies and percentage) were employed and data were visualized using tables and bar graphs. All interviews were audio-recorded and analyzed using thematic analysis approach. RESULTS: overall, isoniazid preventive therapy coverage at Songea municipality was estimated to be 45%. Insufficient drug supply and stock out, shortage of staff, lack of service privacy, long waiting time, drug side effects, pills burden, distance and cost of transport were the main reported barriers hindering full scale implementation of isoniazid preventive therapy. CONCLUSION: implementation of isoniazid preventive therapy in Songea municipality had low coverage. The study recommends that tuberculosis and HIV stakeholders must be part of the solutions by ensuring that the identified barriers are addressed.

To start or to complete? - Challenges in implementing tuberculosis preventive therapy among people living with HIV: a mixed-methods study from Karnataka, India.

Background: Isoniazid preventive therapy (IPT) has been shown to reduce the risk of tuberculosis (TB) among people living with HIV (PLHIV). In 2017, India began a nationwide roll-out of IPT, but there is a lack of evidence on the implementation and the challenges.Objectives: Among PLHIV newly initiated on antiretroviral therapy (ART) from January 2017 to June 2018, to: (i) assess the proportion who started and completed IPT and (ii) explore reasons for non-initiation and non-completion from health-care providers' and patients' perspectives.Methods: An explanatory mixed-methods study was conducted in two selected districts of Karnataka, South India. A quantitative phase (cohort analysis of routinely collected program data) was followed by a qualitative phase involving thematic analysis of in-depth interviews with providers (n = 22) and patients (n = 8).Results: Of the 4020 included PLHIV, 3780 (94%) were eligible for IPT, of whom, 1496 (40%, 95% CI: 38%-41%) were initiated on IPT. Among those initiated, 423 (28.3%) were still on IPT at the time of analysis. Among 1073 patients with declared IPT outcomes 870 (81%, 95% CI: 79%-83%) had completed the six-month course of IPT. The main reason for IPT non-initiation and non-completion was frequent drug stock-outs. This required health-care providers to restrict IPT initiation in selected patient subgroups and earmark six-monthly courses for each patient to ensure that, once started, treatment was not interrupted. The other reasons for non-completion were adverse drug effects and loss to follow-up.Conclusion: The combined picture of 'low IPT initiation and high completion' seen in our study mirrors findings from other countries. Drug stock-out was the key challenge, which obliged health-care providers to prioritize 'IPT completion' over 'IPT initiation'. There is an urgent need to improve the procurement and supply chain management of isoniazid.

Isoniazid Preventive Therapy among Children Living with Tuberculosis Patients: Is It Working? A Mixed-Method Study from Bhopal, India.

Objective: We assessed uptake of isoniazid preventive therapy (IPT) among child contacts of smear-positive tuberculosis (TB) patients and its implementation challenges from healthcare providers' and parents' perspectives in Bhopal, India. Methods: A mixed-method study design: quantitative phase (review of programme records and house-to-house survey of smear-positive TB patients) followed by qualitative phase (interviews of healthcare providers and parents). Results: Of 59 child contacts (<6 years) of 129 index patients, 51 were contacted. Among them, 19 of 51 (37%) were screened for TB and one had TB. Only 11 of 50 (22%) children were started and 10 of 50 (20%) completed IPT. Content analysis of interviews revealed lack of awareness, risk perception among parents, cumbersome screening process, isoniazid stock-outs, inadequate knowledge among healthcare providers and poor programmatic monitoring as main barriers to IPT implementation. Conclusion: National TB programme should counsel parents, train healthcare providers, simplify screening procedures, ensure regular drug supply and introduce an indicator to strengthen monitoring and uptake of IPT.

Health system challenges: An obstacle to the success of isoniazid preventive therapy.

BACKGROUND: The researchers identified infection with HIV as the strongest risk factor in the reactivation of latent tuberculosis (TB) infection or progression to active disease. Isoniazid preventive therapy (IPT) is one of the interventions recommended by the World Health Organization and the South African (SA) National Department of Health to prevent progression to active TB disease in people living with HIV. Adherence to IPT is therefore the responsibility of healthcare clients and clinicians. OBJECTIVES: To describe the incidence of TB among clients who received IPT, rates of completing and not completing IPT among those who started it, and the reasons for non-completion. METHODS: A quantitative, non-experimental, descriptive retrospective cohort study was undertaken. The clinic records of 104 HIV-positive adults receiving care at a clinic in SA who started IPT between 1 July 2010 and 30 November 2011 were analysed. RESULTS: Sixty-six of 104 study respondents (63.5%) completed the IPT course. None of the respondents who completed IPT was diagnosed with TB, and 86.8% of the respondents who did not complete the programme did so because of the poor quality of healthcare they received, and not by their own choice. CONCLUSION: The study results strengthened the findings of similar local and international studies that IPT is advantageous in the prevention of TB. The finding that so many patients did not complete the programme as a result of drug dispensing or prescription problems is alarming, and revealed a major shortcoming in the healthcare system.

Barriers in the implementation of isoniazid preventive therapy for people living with HIV in Northern Ethiopia: a mixed quantitative and qualitative study.

BACKGROUND: Isoniazid preventive therapy is a key public health intervention for the prevention of tuberculosis disease among people living with HIV. Despite the confirmed efficacy of isoniazid preventive therapy and global recommendations existing for decades, its implementation remains limited. In resource constrained settings, few have investigated why isoniazid preventive therapy is not implemented on full scale. This study was designed to investigate the level of isoniazid preventive therapy implementation and reasons for suboptimal implementation in Tigray region of Ethiopia. METHODS: A review of patient records combined with a qualitative study using in-depth interviews and focus group discussions was conducted in 11 hospitals providing isoniazid preventive therapy in the Tigray Region. The study participants were health providers working in the HIV clinics of the 11 hospitals in the province. Health providers were interviewed about their experience of providing isoniazid preventive therapy and challenges faced during its implementation. All conversations were audio-recorded. Record review of 16,443 HIV patients registered for care in these hospitals between September 2011 and April 2014 was done to determine isoniazid preventive therapy utilization. Data were collected from April to August 2014. RESULTS: Fifty health providers participated in the study. Overall isoniazid preventive therapy coverage of the region was estimated to be 20 %. Isoniazid stock out, fear of creating isoniazid resistance, problems in patient acceptance, and lack of commitment of health managers to scale up the program were indicated by health providers as the main barriers hindering implementation of isoniazid preventive therapy. CONCLUSION: Implementation of isoniazid preventive therapy in Tigray region of Ethiopia had low coverage. Frequent interruption of isoniazid supplies raises the concern of interrupted therapy resulting in creation of isoniazid resistance. Health managers, drug suppliers and partners working in HIV and tuberculosis programs should be committed to ensure an uninterrupted supply of isoniazid and full scale implementation of isoniazid preventive therapy to eligible people living with HIV.

Impact of a shortage of first-line antituberculosis medication on tuberculosis control - United States, 2012-2013.

Tuberculosis (TB) disease is treated in most cases with a regimen of several drugs taken for 6-9 months. Currently, 10 drugs are approved by the Food and Drug Administration (FDA) for treatment of TB. Of these, the four drugs that form the core for first-line treatment regimens are isoniazid (INH), rifampin, ethambutol, and pyrazinamide. In November 2012, the United States began to experience a severe interruption in the supply of INH. To assess the extent of the problem and its impact on TB control programs, a nationwide survey of programs was conducted in January 2013 by the National Tuberculosis Controllers Association (NTCA). The results indicated that the INH shortage was interfering with patient care and could contribute to TB transmission in the United States. This report summarizes the findings of that survey, which showed that 79% of the responding health departments reported difficulties with procuring INH within the last month, with 15% reporting that they no longer had INH and 41% reporting that they would no longer have a supply within 1 month of the survey. Because of local interruptions in INH supply, responding TB programs were changing INH suppliers (69%), prioritizing patients for treatment of latent TB infection (LTBI) (72%), delaying LTBI treatment (68%), and changing to alternative LTBI treatment regimens (88%). Potential solutions for alleviating the INH shortage and averting future shortages include maintaining a national supply of first-line drugs, sharing INH among jurisdictions, working with the World Health Organization's Global Drug Facility to obtain INH from foreign manufacturers, and strengthening reporting of shortages and impending shortages by drug suppliers to FDA.

Notes from the field: national shortage of isoniazid 300 mg tablets.

On November 16, 2012, the Illinois State tuberculosis (TB) program notified CDC's Division of Tuberculosis Elimination of a national shortage of 300 mg tablets of the antituberculosis medication isoniazid (INH). Subsequently, other state TB programs (e.g., California, Indiana, Maryland, New York, Virginia, and Wisconsin) reported difficulty obtaining INH 300 mg tablets. Other programs (e.g., San Diego) have experienced difficulties obtaining at least one of the commercially available anti-TB preparations containing the combination of rifampin and INH (IsonaRif [VersaPharm]).