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.

Declining tuberculosis notification trend associated with strengthened TB and expanded HIV care in Swaziland.

This retrospective observational review documents the efforts of the Swaziland National Tuberculosis (TB) Control Programme between 2004 and 2014. The objective is to describe the disparity between actual declines in case notification and increases in estimated incidence. The review of policies and practices shows the most influential factors associated with the decrease in TB case notification to be an increase in access to antiretroviral therapy for co-infected TB patients, the general success of TB and human immunodeficiency virus service integration in the country and improvements in implementation of all components of directly observed treatment, active case finding, and rapid diagnosis using new technologies.

Cette étude d'observation rétrospective documente les efforts du programme de lutte contre la tuberculose (TB) du Swaziland entre 2004 et 2014. L'objectif est de décrire la disparité entre un réel déclin dans la déclaration des cas et une augmentation de l'incidence estimée. La revue des politiques et des pratiques montre que les facteurs les plus influents associés au déclin de la déclaration des cas de TB sont liés à une augmentation de l'accès aux antirétroviraux pour les patients tuberculeux co-infectés, au succès d'ensemble de l'intégration des services pour la TB et ceux pour le virus de l'immunodéficience humaine dans le pays et aux améliorations dans la mise en œuvre de tous les composants du traitement sous observation directe, de la recherche active des cas et d'un diagnostic rapide grâce aux techniques nouvelles.

Con el presente análisis observacional retrospectivo se documentan las iniciativas emprendidas por el Programa de Control de la Tuberculosis (TB) de Swazilandia del 2004 al 2014. El objetivo del estudio fue describir la discrepancia existente entre la disminución en la notificación de casos de TB y el aumento en las estimaciones de incidencia de la enfermedad. El análisis de las políticas y las prácticas puso de manifiesto que los factores que más influyen sobre la disminución de la notificación de casos de TB es un aumento en el acceso al tratamiento antirretrovírico por parte de los pacientes coinfectados por el virus de la inmunodeficiencia humana y la TB, el éxito general de la integración de los servicios que se ocupan de ambas enfermedades en el país y los progresos en la aplicación de todos los componentes del tratamiento directamente observado, la búsqueda activa de casos y el diagnóstico rápido mediante nuevas tecnologías.