Witkoppen Health and Welfare Centre, Johannesburg, South Africa.
Department of Epidemiology and Social Medicine (ESOC), University of Antwerp, Antwerp, Belgium.
PLoS One. 2019 Feb 14;14(2):e0212035. doi: 10.1371/journal.pone.0212035. eCollection 2019.
Isoniazid preventive therapy (IPT) is a key component of TB/HIV control, but few countries achieve high IPT coverage.
Using a behavioural COM-B design approach, the intervention consisted of a training on IPT guidelines and tuberculin skin testing (TST), identification of the optimal IPT implementation strategy by the health care workers (HCWs) of 3 primary care clinics, and a 2-month mentoring period. Using routine register data, TST and IPT uptake was determined 3 months before and 5 months after the intervention. Records were reviewed to identify factors associated with IPT initiation and HCW fidelity to the guidelines. A survey among HCWs was conducted to determine barriers to IPT.
Two clinics implemented TST-guided IPT for all clients receiving HIV care, one clinic decided against use of TST. According to routine register data, the proportion of clients initiating IPT increased substantially at the clinic not opting for TST (6% vs 36%), but minimally (34% vs 37% and 0.7% vs 3%) in the two other clinics. TST uptake did not increase (0 vs 0% and 0.5%). In addition to poor IPT uptake, HCW fidelity to investigation for TB and timing of IPT initiation was poor, with only 68% of symptomatic patients investigated and IPT initiation delayed to a median of 374 days post-ART initiation. In multivariate analysis, pregnancy (aOR 18.62, 95% CI 6.99-53.46), recent HIV diagnosis (aOR 3.65, 95% CI 1.73-7.41), being on ART (aOR 9.44, 95% CI 3.05-36.17), and CD4 <500 cells/mm3 (aOR 2.19, 95% CI 1.22-4.18) were associated with IPT initiation. Time needed to perform a TST, motivating patients to return for TST reading, and low IPT patient awareness were the main barriers to IPT implementation.
Despite using a behavioural intervention framework including training and participatory development of the clinic IPT strategy, HCW fidelity to the guidelines was poor, resulting in low TST coverage and low IPT uptake under primary care conditions. To achieve the benefits of IPT, health system level approaches including TST-free guidelines and sensitization are needed.
异烟肼预防治疗（IPT）是结核病/艾滋病控制的一个重要组成部分，但很少有国家能达到高IPT 覆盖率。
采用行为 COM-B 设计方法，该干预措施包括IPT 指南和结核菌素皮肤试验（TST）培训、3 家初级保健诊所的卫生保健工作者确定最佳 IPT 实施策略，以及为期 2 个月的指导期。使用常规登记数据，在干预前 3 个月和干预后 5 个月确定 TST 和 IPT 的采用情况。对记录进行审查，以确定与 IPT 开始相关的因素和 HCW 对指南的遵从性。对 HCW 进行了一项调查，以确定IPT 的障碍。
两家诊所对所有接受艾滋病毒护理的患者实施了 TST 指导的 IPT，一家诊所决定不使用 TST。根据常规登记数据，在不选择 TST 的诊所，开始 IPT 的患者比例大幅增加（6%对 36%），而在另外两家诊所则略有增加（34%对 37%和 0.7%对 3%）。TST 的采用率没有增加（0 对 0%和 0.5%）。除了 IPT 采用率低外，HCW 对结核病调查和 IPT 开始时间的遵从性也很差，只有 68%的有症状患者接受了调查，IPT 的开始时间延迟到抗逆转录病毒治疗（ART）开始后中位数 374 天。在多变量分析中，妊娠（优势比 18.62，95%置信区间 6.99-53.46）、近期 HIV 诊断（优势比 3.65，95%置信区间 1.73-7.41）、正在接受 ART（优势比 9.44，95%置信区间 3.05-36.17）和 CD4<500 个细胞/mm3（优势比 2.19，95%置信区间 1.22-4.18）与 IPT 的开始相关。进行 TST 所需的时间、激励患者返回进行 TST 阅读，以及 IPT 患者意识低是 IPT 实施的主要障碍。
尽管采用了包括培训和参与制定诊所 IPT 策略的行为干预框架，但 HCW 对指南的遵从性很差，导致 TST 覆盖率低，初级保健条件下 IPT 采用率低。要实现 IPT 的益处，需要采取包括无 TST 指南和宣传在内的卫生系统层面的方法。
