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

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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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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Urgent need to address the slow scale-up of TB preventive treatment in the WHO South-East Asia Region

The International Journal of Tuberculosis and Lung Disease ◽

10.5588/ijtld.20.0941 ◽

2021 ◽

Vol 25 (5) ◽

pp. 382-387

Author(s):

S. Satyanarayana ◽

V. Bhatia ◽

P. P. Mandal ◽

A. Kanchar ◽

D. Falzon ◽

...

Keyword(s):

High Risk ◽

East Asia ◽

Scale Up ◽

Preventive Treatment ◽

People Living With Hiv ◽

South East Asia ◽

High Level ◽

Almost All ◽

Living With Hiv ◽

East Asia Region

In September 2018, all countries made a commitment at the first ever United Nations High‐Level Meeting (UNHLM) on TB, to provide TB preventive treatment (TPT) to at least 30 million people at high‐risk of TB disease between 2018 and 2022. In the WHO South‐East Asia Region (SEA Region), which accounts for 44% of the global TB burden, only 1.2 million high‐risk individuals (household contacts and people living with HIV) were provided TPT (11% of the 10.8 million regional UNHLM TPT target) in 2018 and 2019. By 2020, almost all 11 countries of the SEA Region had revised their policies on TPT target groups and criteria to assess TPT eligibility, and had adopted at least one shorter TPT regimen recommended in the latest WHO TPT guidelines. The major challenges for TPT scale‐up in the SEA Region are resource shortages, knowledge and service delivery/uptake gaps among providers and service recipients, and the lack of adequate quantities of rifapentine for use in shorter TPT regimens. There are several regional opportunities to address these gaps and countries of the SEA Region must make use of these opportunities to scale up TPT services rapidly to reduce the TB burden in the SEA Region.

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Collect Once, Use Many Times: Attaining Unified Metrics for Tuberculosis Preventive Treatment for People Living With HIV

JMIR Public Health and Surveillance ◽

10.2196/27013 ◽

2021 ◽

Vol 7 (4) ◽

pp. e27013

Author(s):

Rena Fukunaga ◽

David Lowrance ◽

Adam MacNeil ◽

Teeb Al-Samarrai ◽

Joseph Cavanaugh ◽

...

Keyword(s):

Best Practice ◽

Data Communication ◽

Preventive Treatment ◽

World Health ◽

Management Approach ◽

People Living With Hiv ◽

Emergency Plan ◽

Strategic Information ◽

Persons Living With Hiv ◽

Living With Hiv

The World Health Organization (WHO) recommends providing tuberculosis preventive treatment (TPT) to all persons living with HIV and to all household contacts of persons with bacteriologically confirmed pulmonary tuberculosis disease. Regrettably, the absence of a harmonized data collection and management approach to TPT indicators has contributed to programmatic challenges at local, national, and global levels. However, in April 2020, the WHO launched the Consolidated HIV Strategic Information Guidelines, with an updated set of priority indicators. These guidelines recommend that Ministries of Health collect, report, and use data on TPT completion in addition to TPT initiation. Both indicators are reflected in the WHO’s list of 15 core indicators for program management and are also required by the US President’s Emergency Plan for AIDS Relief’s Monitoring, Evaluation, and Reporting (MER) guidance. Although not perfectly harmonized, both frameworks now share essential indicator characteristics. Aligned indicators are necessary for robust strategic and operational planning, resource allocation, and data communication. “Collect once, use many times” is a best practice for strategic information management. Building harmonized and sustainable health systems will enable countries to successfully maintain essential HIV, tuberculosis, and other health services while combatting new health threats.

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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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Barriers in accessing HIV care for Francophone African, Caribbean and Black people living with HIV in Canada: a scoping review

BMJ Open ◽

10.1136/bmjopen-2020-036885 ◽

2020 ◽

Vol 10 (8) ◽

pp. e036885

Author(s):

Pascal Djiadeu ◽

Abban Yusuf ◽

Clémence Ongolo-Zogo ◽

Joseph Nguemo ◽

Apondi J Odhiambo ◽

...

Keyword(s):

Systematic Review ◽

Black People ◽

Care Delivery ◽

Hiv Care ◽

Cochrane Library ◽

People Living With Hiv ◽

Inclusion Criteria ◽

Minority Communities ◽

French Speaking ◽

Living With Hiv

IntroductionIn 2001, 50%–55% of French-speaking minority communities did not have access to health services in French in Canada. Although Canada is officially a bilingual country, reports indicate that many healthcare services offered in French in Anglophone provinces are insufficient or substandard, leading to healthcare discrepancies among Canada’s minority Francophone communities.ObjectivesThe primary aim of this scoping systematic review was to identify existing gaps in HIV-care delivery to Francophone minorities living with HIV in Canada.Study designScoping systematic review.Data sourcesSearch for studies published between 1990 and November 2019 reporting on health and healthcare in Francophone populations in Canada. Nine databases were searched, including Medline, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the National Health Service Economic Development Database, Global Health, PsychInfo, PubMed, Scopus and Web of Science.Study selectionEnglish or French language studies that include data on French-speaking people with HIV in an Anglophone majority Canadian province.ResultsThe literature search resulted in 294 studies. A total of 230 studies were excluded after duplicates were removed. The full texts of 43 potentially relevant papers were retrieved for evaluation and data extraction. Forty-one studies were further excluded based on failure to meet the inclusion criteria leaving two qualitative studies that met our inclusion criteria. These two studies reported on barriers on access to specialised care by Francophone and highlighted difficulties experienced by healthcare professionals in providing quality healthcare to Francophone patients in Ontario and Manitoba.ConclusionThe findings of this scoping systematic review highlight the need for more HIV research on linguistic minority communities and should inform health policymaking and HIV/AIDS community organisations in providing HIV care to Francophone immigrants and Canadians.

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Policies, practices and barriers to implementing tuberculosis preventive treatment—35 countries, 2017

The International Journal of Tuberculosis and Lung Disease ◽

10.5588/ijtld.19.0018 ◽

2019 ◽

Vol 23 (12) ◽

pp. 1308-1313 ◽

Cited By ~ 3

Author(s):

D. Surie ◽

J. D. Interrante ◽

I. Pathmanathan ◽

M. R. Patel ◽

G. Anyalechi ◽

...

Keyword(s):

Scale Up ◽

Preventive Treatment ◽

Current Status ◽

National Guidelines ◽

Emergency Plan ◽

Immunodeficiency Virus ◽

The Us ◽

Control And Prevention ◽

Barriers To Implementation ◽

Hiv Programs

BACKGROUND: Tuberculosis preventive treatment (TPT) reduces the development of tuberculosis (TB) disease and mortality in people living with human immunodeficiency virus (HIV) infection. Despite this known effectiveness, global uptake of TPT has been slow. We aimed to assess current status of TPT implementation in countries supported by the US President's Emergency Plan for AIDS Relief (PEPFAR).METHODS: We surveyed TB-HIV program staff at US Centers for Disease Control and Prevention (CDC) country offices in 42 PEPFAR-supported countries about current TPT policies, practices, and barriers to implementation. Surveys completed from July to December 2017 were analyzed.RESULTS: Of 42 eligible PEPFAR-supported countries, staff from 35 (83%) CDC country offices completed the survey. TPT was included in national guidelines in 33 (94%) countries, but only 21 (60%) reported nationwide programmatic TPT implementation. HIV programs led TPT implementation in 20/32 (63%) countries, but TB programs led drug procurement in 18/32 (56%) countries. Stock outs were frequent, as 21/28 (75%) countries reported at least one isoniazid stock out in the previous year.CONCLUSION: Despite widespread inclusion of TPT in guidelines, programmatic TPT implementation lags. Successful scale-up of TPT requires uninterrupted drug supply chains facilitated by improved leadership and coordination between HIV and TB programs.

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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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Implementation of differentiated service delivery for paediatric HIV care and treatment: opportunities, challenges and experience from seven sub-Saharan African countries

Family Medicine and Community Health ◽

10.1136/fmch-2020-000393 ◽

2020 ◽

Vol 8 (3) ◽

pp. e000393

Author(s):

Rebecca Abelman ◽

Catharina Alons ◽

Jeni Stockman ◽

Ivan Teri ◽

Anna Grimsrud ◽

...

Keyword(s):

Service Delivery ◽

Children And Adolescents ◽

Care Delivery ◽

Hiv Care ◽

Differentiated Service ◽

Viral Load Suppression ◽

African Countries ◽

Care And Treatment ◽

Sub Saharan ◽

Living With Hiv

Differentiated service delivery (DSD) models for HIV often exclude children and adolescents. Given that children and adolescents have lower rates of HIV diagnosis, treatment and viral load suppression, there is a need to use DSD to meet the needs of children and adolescents living with HIV. This commentary reviews the concept of DSD, examines the application of DSD to the care of children and adolescents living with HIV, and describes national guidance on use of DSD for children and adolescents and implementation of DSD for HIV care and treatment in children and adolescents in Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)–supported programmes in seven sub-Saharan countries between 2017 and 2019. Programme descriptions include eligibility criteria, location and frequency of care delivery, healthcare cadre delivering the care, as well as the number of EGPAF-supported facilities supporting each type of DSD model. A range of DSD models were identified. While facility-based models predominate, several countries support community-based models. Despite significant uptake of various DSD models for children and adolescents, there was variable coverage within countries and variability in age criteria for each model. While the recent uptake of DSD models for children and adolescents suggests feasibility, more can be done to optimise and extend the use of DSD models for children and adolescents living with HIV. Barriers to further DSD uptake are described and solutions proposed. DSD models for children and adolescents are a critical tool that can be optimised to improve the quality of HIV care and outcomes for children and adolescents.

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