Factors associated with low tuberculosis preventive therapy prescription rates among health care workers in rural South Africa

ABSTRACT

Background

Despite extensive rollout of tuberculosis preventive therapy (TPT) in South Africa to reduce the incidence of tuberculosis among people living with HIV (PWH), rates of initiation and completion have remained suboptimal.

Objective

This study aimed to identify factors associated with low TPT prescription rates among health care workers (HCWs) in rural South Africa.

Methods

A cross-sectional study was conducted using an anonymous 39-item questionnaire guided by the Consolidated Framework for Implementation Research (CFIR). HCWs from a government district hospital and 14 primary healthcare clinics (PHCs) in the rural Msinga sub-district of KwaZulu-Natal were surveyed from November 2019 to January 2020. Self-reported data on prescription rates as well as knowledge, attitudes, beliefs, and practices regarding isoniazid preventative therapy, the current TPT regimen, were obtained. Factor analysis and logistic regression were used to determine associations with low prescription rates (< 50% of PWH) for TPT prescribers, and results were placed within CFIR-driven context.

Results

Among 160 HCWs, the median (IQR) age was 39 (33–46) years, 76% were women, 78% worked at a PHC, and 44% had experience prescribing TPT. On multivariable analysis, prescribers (n = 71) who believed their patients would not disclose TPT use to others were significantly less likely to prescribe TPT (aOR 4.19 95% CI 1.35–13.00; p = 0.01). Inadequate isoniazid supplies trended towards significance (aOR 10.10 95% CI 0.95–106.92; p = 0.06) in association with low prescription rates.

Conclusions

Strengthening HCW training to emphasize TPT prescription to all eligible PWH regardless of beliefs about patient disclosure and ensuring a consistent isoniazid supply at the health systems-level are both critical steps to enhancing TPT implementation in rural South Africa.

KEYWORDS:

• HIV
• implementation
• prevention
• rural health
• tuberculosis

Responsible Editor

Stig Wall

Responsible Editor

Stig Wall

Acknowledgments

We would like to acknowledge Dr. Gerald Friedland for his support. We thank the Department of Health of the Republic of South Africa for their support of this work and their dedication to patient care.

Disclosure statement

The authors declare they have no competing interests. SVS’s spouse worked for Merck pharmaceuticals 1997–2007 and retains company stock in his retirement account.

There is no conflict of interest regarding this manuscript, but it is included for full disclosure.

The data presented in this manuscript has been presented in part at the Infectious Disease Society of America annual meeting, Virtual, October 2020 and the Dissemination and Implementation in Health annual meeting, Virtual, December 2020.

Ethics and consent

This project was approved by the Yale University’s Human Investigation Committee and the University of KwaZulu-Natal Biomedical Research Ethics Committee.

Paper context

TB preventive therapy has been shown to reduce mortality among people living with HIV, independent of antiretroviral therapy. However, global implementation lags. Using a validated implementation science framework, this study demonstrates health care workers who believe their patients do not disclose use of TB preventive therapy were significantly less likely to prescribe it, which is modifiable. Therefore, strengthening health care worker training to facilitate prescribing preventive therapy to all eligible patients is critical to implementation efforts.

Supplementary material

Supplemental data for this article can be accessed here.

Additional information

Funding

This work was supported by the Doris Duke Charitable Foundation #2016178 (AA, KC) and #201516 (SVS); and the Yale International Downs Fellowship #731001 (JJ); and by NIH Fogarty Center #TW010540 (MG); and Yale School of Medicine Short-Term Research Fellowship (JBL); Fogarty International Center [#TW010540]; Yale School of Public Health Downs Fellowship [#731001].

Notes on contributors

Megan Grammatico

Amiya A. Ahmed – data acquisition, analysis, interpretation of data, drafting, final approval

Megan Grammatico - data acquisition, interpretation of data, drafting, final approval

Anthony P. Moll – design of work, interpretation of data, drafting, final approval

Sipho Malinga – data acquisition, final approval

Philile Makhunga – data acquisition, drafting, final approval

Salome Charalambous – interpretation of data, drafting, final approval

Joseph B. Ladines-Lim – analysis, drafting, final approval

Justin Jones – design of work, drafting, final approval

Koeun Choi – design of work, drafting, final approval

Sheela V. Shenoi – design of work, analysis, interpretation of data, drafting, final approval