ABSTRACT
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.
Subject(s)
Antitubercular Agents/administration & dosage , HIV Infections/epidemiology , Isoniazid/administration & dosage , Tuberculosis/prevention & control , Adolescent , Adult , Aged , Child , Child, Preschool , Cohort Studies , Eswatini/epidemiology , Female , Follow-Up Studies , Humans , Male , Mass Screening/methods , Medication Adherence , Middle Aged , Prospective Studies , Tuberculosis/diagnosis , Tuberculosis/epidemiology , Young AdultABSTRACT
INTRODUCTION AND BACKGROUND: Diagnostic tests for tuberculosis (TB) using sputum have suboptimal sensitivity among HIV-positive persons. We assessed health care worker adherence to TB diagnostic algorithms after negative sputum test results. METHODS: The XTEND (Xpert for TB-Evaluating a New Diagnostic) trial compared outcomes among people tested for TB in primary care clinics using Xpert MTB/RIF vs. smear microscopy as the initial test. We analyzed data from XTEND participants who were HIV positive or HIV status unknown, whose initial sputum Xpert MTB/RIF or microscopy result was negative. If chest radiography, sputum culture, or hospital referral took place, the algorithm for TB diagnosis was considered followed. Analysis of intervention (Xpert MTB/RIF) effect on algorithm adherence used methods for cluster-randomized trials with small number of clusters. RESULTS: Among 4037 XTEND participants with initial negative test results, 2155 (53%) reported being or testing HIV positive and 540 (14%) had unknown HIV status. Among 2155 HIV-positive participants [684 (32%) male, mean age 37 years (range, 18-79 years)], there was evidence of algorithm adherence among 515 (24%). Adherence was less likely among persons tested initially with Xpert MTB/RIF vs. smear [14% (142/1031) vs. 32% (364/1122), adjusted risk ratio 0.34 (95% CI: 0.17 to 0.65)] and for participants with unknown vs. positive HIV status [59/540 (11%) vs. 507/2155 (24%)]. CONCLUSIONS: We observed poorer adherence to TB diagnostic algorithms among HIV-positive persons tested initially with Xpert MTB/RIF vs. microscopy. Poor adherence to TB diagnostic algorithms and incomplete coverage of HIV testing represents a missed opportunity to diagnose TB and HIV, and may contribute to TB mortality.
