Integrated TB and HIV care for Mozambican children: temporal trends, site-level determinants of performance, and recommendations for improved TB preventive treatment

Abstract Background Pediatric tuberculosis (TB), human immunodeficiency virus (HIV), and TB-HIV co-infection are health problems with evidence-based diagnostic and treatment algorithms that can reduce morbidity and mortality. Implementation and operational barriers affect adherence to guidelines in many resource-constrained settings, negatively affecting patient outcomes. This study aimed to assess performance in the pediatric HIV and TB care cascades in Mozambique. Methods A retrospective analysis of routine PEPFAR site-level HIV and TB data from 2012 to 2016 was performed. Patients 0–14 years of age were included. Descriptive statistics were used to report trends in TB and HIV indicators. Linear regression was done to assess associations of site-level variables with performance in the pediatric TB and HIV care cascades using 2016 data. Results Routine HIV testing and cotrimoxazole initiation for co-infected children in the TB program were nearly optimal at 99% and 96% in 2016, respectively. Antiretroviral therapy (ART) initiation was lower at 87%, but steadily improved from 2012 to 2016. From the HIV program, TB screening at the last consultation rose steadily over the study period, reaching 82% in 2016. The percentage of newly enrolled children who received either TB treatment or isoniazid preventive treatment (IPT) also steadily improved in all provinces, but in 2016 was only at 42% nationally. Larger volume sites were significantly more likely to complete the pediatric HIV and TB care cascades in 2016 (p value range 0.05 to < 0.001). Conclusions Mozambique has made significant strides in improving the pediatric care cascades for children with TB and HIV, but there were missed opportunities for TB diagnosis and prevention, with IPT utilization being particularly problematic. Strengthened TB/HIV programming that continues to focus on pediatric ART scale-up while improving delivery of TB preventive therapy, either with IPT or newer rifapentine-based regimens for age-eligible children, is needed.

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Tuberculosis preventive treatment opportunities at antiretroviral therapy initiation and follow-up visits

Public Health Action ◽

10.5588/pha.19.0056 ◽

2020 ◽

Vol 10 (2) ◽

pp. 64-69

Author(s):

T. Agizew ◽

D. Surie ◽

J.E. Oeltmann ◽

M. Letebele ◽

S. Pals ◽

...

Keyword(s):

Antiretroviral Therapy ◽

Preventive Treatment ◽

Evaluation Study ◽

Hiv Care ◽

People Living With Hiv ◽

Control Effort ◽

Missed Opportunities ◽

Art Initiation ◽

A Prospective Study

Setting: Twenty-two clinics providing HIV care and treatment in Botswana where tuberculosis (TB) and HIV comorbidity is as high as 49%.Objectives: To assess eligibility of TB preventive treatment (TPT) at antiretroviral therapy (ART) initiation and at four follow-up visits (FUVs), and to describe the TB prevalence and associated factors at baseline and yield of TB diagnoses at each FUV.Design: A prospective study of routinely collected data on people living with HIV (PLHIV) enrolled into care for the Xpert® MTB/RIF Package Rollout Evaluation Study between 2012 and 2015.Results: Of 6041 PLHIV initiating ART, eligibility for TPT was 69% (4177/6041) at baseline and 93% (5408/5815); 95% (5234/5514); 96% (4869/5079); and 97% (3925/4055) at FUV1, FUV2, FUV3, and FUV4, respectively. TB prevalence at baseline was 11% and 2%, 3%, 3% and 6% at each subsequent FUV. At baseline, independent risk factors for prevalent TB were CD4 <200 cells/mm3 (aOR = 1.4, P = 0.030); anemia (aOR = 2.39, P < 0.001); cough (aOR = 11.21, P < 0.001); fever (aOR = 2.15, P = 0.001); and weight loss (aOR = 2.60, P = 0.002).Conclusion: Eligibility for TPT initiation is higher at visits post-ART initiation, while most cases of active TB were identified at ART initiation. Missed opportunities for TB further compromises TB control effort among PLHIV in Botswana.

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An urgent need for a paradigm shift in HIV testing for older children: A sine qua non condition to achieve an AIDS-free generation

10.1101/2020.06.22.20128363 ◽

2020 ◽

Author(s):

H.A. Yumo ◽

J.J.N. Ndenkeh ◽

I. Sieleunou ◽

D.N. Nsame ◽

P.B. Kuwoh ◽

...

Keyword(s):

Hiv Testing ◽

Pediatric Hiv ◽

Hiv Care ◽

Older Children ◽

Chi Square ◽

Treatment Services ◽

Art Initiation ◽

Testing Technology ◽

Chi Square Test ◽

Free Generation

AbstractBackgroundAchieving an AIDS-free generation requires effective pediatric testing and treatment services. While pediatric HIV testing has been more focused on children below 18 months through PMTCT, the yield of this approach remains unclear comparatively to testing children above 18 months through routine PITC. This study aimed at bridging this evidence gap and provide knowledge to guide pediatric HIV testing investments.Materials and MethodsParents visiting or receiving HIV care in three hospitals in Cameroon were invited to test their children for HIV. HIV testing was done using PCR and antibody rapid tests for children < 18 months and those ≥18 months, respectively. We compared HIV case detection and ART initiation between the two subgroups of children and this using Chi-square test at 5% significant level.ResultsA total of 4079 children aged 6 weeks-15 years were included in the analysis. Compared to children < 18 months, children group ≥18 months was 4-fold higher among those who enrolled in the study (80.3% vs 19.7%, p<0.001); 3.5-fold higher among those who tested for HIV (77.6% vs 22.4%, p<0.001); 6-fold higher among those who tested HIV+ (85.7% vs 14.3%, p=0.241) and 11-fold higher among those who enrolled on ART (91.7% vs 8.3%, p< 0.028).ConclusionsOur results show that 4 out of 5 children who tested HIV+ and over 90% of ART enrolled cases were children ≥ 18 months. Thus, while rolling out PCR HIV testing technology for neonates and infants, committing adequate and proportionate resources in antibody rapid testing for older children is a sine quo none condition to achieve an AIDS-free generation.

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Implementing TB preventive treatment within differentiated HIV service delivery models in global programs

Public Health Action ◽

10.5588/pha.20.0014 ◽

2020 ◽

Vol 10 (3) ◽

pp. 104-110

Author(s):

A. T. Boyd ◽

B. Moore ◽

M. Shah ◽

C. Tran ◽

H. Kirking ◽

...

Keyword(s):

Service Delivery ◽

Care Delivery ◽

Scale Up ◽

Preventive Treatment ◽

Hiv Care ◽

People Living With Hiv ◽

Emergency Plan ◽

The Us ◽

Living With Hiv ◽

Delivery Models

Global HIV program stakeholders, including the US President’s Emergency Plan for AIDS Relief (PEPFAR), are undertaking efforts to ensure that eligible people living with HIV (PLHIV) receiving antiretroviral treatment (ART) receive a course of TB preventive treatment (TPT). In PEPFAR programming, this effort may require providing TPT not only to newly diagnosed PLHIV as part of HIV care initiation, but also to treatment-experienced PLHIV stable on ART who may not have been previously offered TPT. TPT scale-up is occurring at the same time as a trend to provide more person-centered HIV care through differentiated service delivery (DSD). In DSD, PLHIV stable on ART may receive less frequent clinical follow-up or receive care outside the traditional clinic-based model. The misalignment between traditional delivery of TPT and care delivery in innovative DSD may require adaptations to TPT delivery practices for PLHIV. Adaptations include components of planning and operationalization of TPT in DSD, such as determination of TPT eligibility and TPT initiation, and clinical management of PLHIV while on TPT. A key adaptation is alignment of timing and location for TPT and ART prescribing, monitoring, and dispensing. Conceptual examples of TPT delivery in DSD may help program managers operationalize TPT in HIV care.

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Evaluation of routine Isoniazid Preventive Therapy among People Living with HIV for reducing Tuberculosis; a retrospective cohort study in Tanzania (2012-2016)

10.21203/rs.3.rs-19503/v1 ◽

2020 ◽

Author(s):

Werner Maokola ◽

Bernard Ngowi ◽

Lovett Lawson ◽

Michael Mahande ◽

Jim Todd ◽

...

Keyword(s):

Cohort Study ◽

Functional Status ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Scale Up ◽

Preventive Therapy ◽

Isoniazid Preventive Therapy ◽

Hiv Care ◽

People Living With Hiv ◽

Living With Hiv

Abstract Background: Isoniazid Preventive Therapy (IPT) reduced Tuberculosis (TB) among People Living with HIV (PLHIV). Despite this, uptake has been reported to be sub-optimal . We describe characteristics of visits in which PLHIV were screened TB negative (as the main source for IPT initiation), determine characteristics of visits in which PLHIV were initiated on IPT as well as determined factors associated with IPT initiation to inform program scale up and improve quality of service.Methods : Retrospective cohort study design which involved PLHIV enrolled into care and treatment clinics in Dar es Salaam, Iringa and Njombe regions from January 2012 to December 2016. The study aimed at evaluating implementation of IPT among PLHIV. Data analysis was conducted using STATA.Results: A total 173,746 were enrolled in CTC in the 3 regions during the period of follow up and made a total of 2,638,876 visits. Of the eligible visits, only 24,429 (1.26%) were initiated on IPT. In multivariate analysis, 50 years and more (aOR=3.42, 95% CI: 3.07-3.82, P<0.01), bedridden functional status individuals with bedridden functional status (aOR=4.56, 95% CI:2.45-8.49, P<0.01) and WHO clinical stage II had higher odds of IPT initiation (aOR=1.18, 95% CI:1.13-1.23, P<0.01). Furthermore, enrolment in 2016 (aOR=2.92, 95% CI:2.79-3.06, P<0.01), enrolment in hospitals (aOR=1.84, 95% CI:1.77-1.90, P<0.01), enrolment in public health facilities (aOR=1.82, 95% CI: 1.75-1.90, P<0.01) and been on care for more than one year (aOR=6.77, 95% CI: 5.25-8.73, P<0.000) were also more likely to be initiated on IPT. Enrollment in Iringa (aOR=0.44, 95% CI: 0.41-0.47, P<0.01) and good adherence (aOR=0.56, 95% CI 0.47-0.67, P<0.01) was less likely to be initiated on IPT.Conclusions: Our study documented low IPT initiation proportion among those who were enrolled in HIV care and eligible in the 3 regions during the study period. Variations in IPT initiation among regions signals different dynamics affecting IPT uptake in different regions and hence customized approaches in quality improvement. Implementation research is needed to understand health system as well as cultural barriers in the uptake of IPT intervention.

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Acceptance and Completion of Rifapentine-based TB Preventive Therapy (3HP) Among People Living with HIV (PLHIV) in Kampala, Uganda – Patient and Health Worker Perspectives.

10.21203/rs.3.rs-92783/v1 ◽

2020 ◽

Author(s):

Fred C. Semitala ◽

Allan Musinguzi ◽

Jackie Ssemata ◽

Fred Welishe ◽

Juliet Nabunje ◽

...

Keyword(s):

Side Effects ◽

Behavior Change ◽

Health Workers ◽

Scale Up ◽

Preventive Therapy ◽

Hiv Care ◽

People Living With Hiv ◽

Potential Barriers ◽

Behavior Change Interventions ◽

Living With Hiv

Abstract Background: A 12-dose, once-weekly regimen of isoniazid and rifapentine (3HP) is effective in preventing tuberculosis (TB) among people living with HIV (PLHIV). We sought to identify potential barriers to and facilitators of 3HP implementation from the perspective of PLHIV and health workers in a routine HIV care setting in Kampala, Uganda.Methods: We conducted semi-structured interviews with 25 PLHIV and 10 health workers at an HIV/AIDS clinic in Kampala, Uganda. For both groups, we explored their understanding and interpretations of TB and TB preventive therapy (TPT), and perceptions about social and contextual factors that might influence willingness of PLHIV to initiate and complete 3HP. We analyzed the data using an inductive thematic approach and aligned the emergent themes to the Behavior Change Wheel framework to identify sources of behavior and targeted behavior change interventions.Results: Facilitators for uptake and completion of 3HP among PLHIV were fear of contracting TB, awareness of being potentially at risk of getting TB, willingness to take TPT, trust in health workers, and the perceived benefits of DOT and SAT. Barriers included inadequate understanding of TPT, fear of potential side effects, concerns about effectiveness of 3HP as well as the perceived challenges of DOT or SAT. Among health workers, perceived facilitators included knowledge that TB is a common cause of mortality, fear of getting TB, patient trust in their health workers, potential for once-weekly dosing and the benefits of TPT delivery. Health workers perceived potential barriers for PLHIV as being: inadequate understanding of TB and TPT, TB associated stigma, potential side effects, pill burden and challenges of taking TPT. Additional barriers included a lack of experience among health workers with the use of digital technology to monitor patient care.Conclusions: Using a formative qualitative and comprehensive theoretical approach, we identified key sources of behavior that could be used to guide selection of appropriate intervention to optimize 3HP scale up among PLHIV in high burden settings.

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Successful implementation of isoniazid preventive therapy at a pediatric HIV clinic in Tanzania

BMC Infectious Diseases ◽

10.1186/s12879-020-05471-z ◽

2020 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Olivia F. Hunter ◽

Furaha Kyesi ◽

Amrit Kaur Ahluwalia ◽

Zeinabou Niamé Daffé ◽

Patricia Munseri ◽

...

Keyword(s):

Treatment Completion ◽

Preventive Therapy ◽

Pediatric Hiv ◽

Isoniazid Preventive Therapy ◽

Hiv Care ◽

Successful Implementation ◽

Completion Rates ◽

Community Based ◽

Symptom Screening ◽

Living With Hiv

Abstract Background In accordance with international guidance for tuberculosis (TB) prevention, the Tanzanian Ministry of Health recommends isoniazid preventive therapy (IPT) for children aged 12 months and older who are living with HIV. Concerns about tolerability, adherence, and potential mistreatment of undiagnosed TB with monotherapy have limited uptake of IPT globally, especially among children, in whom diagnostic confirmation is challenging. We assessed IPT implementation and adherence at a pediatric HIV clinic in Tanzania. Methods In this prospective cohort study, eligible children living with HIV aged 1–15 years receiving care at the DarDar Pediatric Program in Dar es Salaam who screened negative for TB disease were offered a 6-month regimen of daily isoniazid. Patients could choose to receive IPT via facility- or community-based care. Parents/caregivers and children provided informed consent and verbal assent respectively. Isoniazid was dispensed with the child’s antiretroviral therapy every 1–3 months. IPT adherence and treatment completion was determined by pill counts, appointment attendance, and self-report. Patients underwent TB symptom screening at every visit. Results We enrolled 66 children between July and December 2017. No patients/caregivers declined IPT. Most participants were female (n = 43, 65.1%) and the median age was 11 years (interquartile range [IQR] 8, 13). 63 (95.5%) participants chose the facility-based model; due to the small number of participants who chose the community-based model, valid comparisons between the two groups could not be made. Forty-nine participants (74.2%) completed IPT within 10 months. Among the remaining 17, 11 had IPT discontinued by their provider due to adverse drug reactions, 5 lacked documentation of completion, and 1 had unknown outcomes due to missing paperwork. Of those who completed IPT, the average monthly adherence was 98.0%. None of the participants were diagnosed with TB while taking IPT or during a median of 4 months of follow-up. Conclusions High adherence and treatment completion rates can be achieved when IPT is integrated into routine, self-selected facility-based pediatric HIV care. Improved record-keeping may yield even higher completion rates. IPT was well tolerated and no cases of TB were detected. IPT for children living with HIV is feasible and should be implemented throughout Tanzania.

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HIV-associated tuberculosis

International Journal of STD & AIDS ◽

10.1177/0956462421992257 ◽

2021 ◽

pp. 095646242199225

Author(s):

Yohhei Hamada ◽

Haileyesus Getahun ◽

Birkneh Tilahun Tadesse ◽

Nathan Ford

Keyword(s):

Scale Up ◽

Preventive Treatment ◽

Hiv Care ◽

Vulnerable Groups ◽

People Living With Hiv ◽

African Countries ◽

Timely Initiation ◽

Adequate Funding ◽

Tb Diagnostics ◽

Living With Hiv

Tuberculosis (TB) remains a leading cause of morbidity and mortality among people living with HIV. HIV-associated TB disproportionally affects African countries, particularly vulnerable groups at risk for both TB and HIV. Currently available TB diagnostics perform poorly in people living with HIV; however, new diagnostics such as Xpert Ultra and lateral flow urine lipoarabinomannan assays can greatly facilitate diagnosis of TB in people living with HIV. TB preventive treatment has been underutilized despite its proven benefits independent of antiretroviral therapy (ART). Shorter regimens using rifapentine can support increased availability and scale-up. Mortality is high in people with HIV-associated TB, and timely initiation of ART is critical. Programs should provide decentralized and integrated TB and HIV care in settings with high burden of both diseases to improve access to services that diagnose TB and HIV as early as possible. The new prevention and diagnosis tools recently recommended by WHO offer an immense opportunity to advance our fight against HIV-associated TB. They should be made widely available and scaled up rapidly supported by adequate funding with robust monitoring of the uptake to advance global TB elimination.

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Acceptance and Completion of Rifapentine-Based TB Preventive Therapy (3HP) Among People Living with HIV (PLHIV) in Kampala, Uganda – Patient and health Worker Perspectives.

10.21203/rs.3.rs-106899/v1 ◽

2020 ◽

Author(s):

Fred C Semitala ◽

Allan Musinguzi ◽

Jackie Ssemata ◽

Fred Welishe ◽

Juliet Nabunje ◽

...

Keyword(s):

Side Effects ◽

Behavior Change ◽

Health Workers ◽

Scale Up ◽

Preventive Therapy ◽

Hiv Care ◽

People Living With Hiv ◽

Structured Interviews ◽

Potential Barriers ◽

Living With Hiv

Abstract BackgroundA 12-dose, once-weekly regimen of isoniazid and rifapentine (3HP) is effective in preventing tuberculosis (TB) among people living with HIV (PLHIV). We sought to identify potential barriers to and facilitators of 3HP implementation from the perspective of PLHIV and health workers in a routine HIV care setting in Kampala, Uganda.MethodsWe conducted semi-structured interviews with 25 PLHIV and 10 health workers at an HIV/AIDS clinic in Kampala, Uganda. For both groups, we explored their understanding and interpretations of TB and TB preventive therapy (TPT), and perceptions about social and contextual factors that might influence willingness of PLHIV to initiate and complete 3HP. We analyzed the data using an inductive thematic approach and aligned the emergent themes to the Behavior Change Wheel framework to identify sources of behavior and targeted behavior change interventions.ResultsFacilitators for uptake and completion of 3HP among PLHIV were fear of contracting TB, awareness of being potentially at risk of getting TB, willingness to take TPT, trust in health workers, and the perceived benefits of DOT and SAT. Barriers included inadequate understanding of TPT, fear of potential side effects, concerns about effectiveness of 3HP as well as the perceived challenges of DOT or SAT. Among health workers, perceived facilitators included knowledge that TB is a common cause of mortality, fear of getting TB, patient trust in their health workers, potential for once-weekly dosing and the benefits of TPT delivery. Health workers perceived potential barriers for PLHIV as being: inadequate understanding of TB and TPT, TB associated stigma, potential side effects, pill burden and challenges of taking TPT. Additional barriers included a lack of experience among health workers with the use of digital technology to monitor patient care.Conclusions Using a formative qualitative and comprehensive theoretical approach, we identified key sources of behavior that could be used to guide selection of appropriate intervention to optimize 3HP scale up among PLHIV in high burden settings.

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Pediatric HIV Care Cascade in Southern Mozambique: Missed Opportunities for Early ART and Re-engagement in Care

The Pediatric Infectious Disease Journal ◽

10.1097/inf.0000000000002612 ◽

2020 ◽

Vol 39 (5) ◽

pp. 429-434

Author(s):

Sheila Fernández-Luis ◽

Tacilta Nhampossa ◽

Laura Fuente-Soro ◽

Orvalho Augusto ◽

Aina Casellas ◽

...

Keyword(s):

Pediatric Hiv ◽

Hiv Care ◽

Engagement In Care ◽

Missed Opportunities ◽

Hiv Care Cascade ◽

Care Cascade ◽

Pediatric Hiv Care

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Isoniazid preventive therapy use among adult people living with HIV in Zimbabwe

International Journal of STD & AIDS ◽

10.1177/09564624211014404 ◽

2021 ◽

pp. 095646242110144

Author(s):

Mayuko Takamiya ◽

Kudawashe Takarinda ◽

Shrish Balachandra ◽

Musuka Godfrey ◽

Elizabeth Radin ◽

...

Keyword(s):

Alcohol Use ◽

Scale Up ◽

Preventive Therapy ◽

Isoniazid Preventive Therapy ◽

Hiv Care ◽

People Living With Hiv ◽

Hazardous Alcohol Use ◽

Factors Associated ◽

Hazardous Alcohol ◽

Living With Hiv

We assessed the prevalence of isoniazid preventive therapy (IPT) uptake and explored factors associated with IPT non-uptake among people living with HIV (PLHIV) using nationally representative data from the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2015–2016. This was a cross-sectional study of 3418 PLHIV ZIMPHIA participants eligible for IPT, aged ≥15 years and in HIV care. Logistic regression modeling was performed to assess factors associated with self-reported IPT uptake. All analyses accounted for multistage survey design. IPT uptake among PLHIV was 12.7% (95% confidence interval (CI): 11.4–14.1). After adjusting for sex, age, rural/urban residence, TB screening at the last clinic visit, and hazardous alcohol use, rural residence was the strongest factor associated with IPT non-uptake (adjusted OR (aOR): 2.39, 95% CI: 1.82–3.12). Isoniazid preventive therapy non-uptake having significant associations with no TB screening at the last HIV care (aOR: 2.07, 95% CI: 1.54–2.78) and with hazardous alcohol use only in urban areas (aOR: 10.74, 95% CI: 3.60–32.0) might suggest suboptimal IPT eligibility screening regardless of residence, but more so in rural areas. Self-reported IPT use among PLHIV in Zimbabwe was low, 2 years after beginning national scale-up. This shows the importance of good TB screening procedures for successful IPT implementation.

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