Structural barriers to implementing recommended tuberculosis preventive treatment in primary care clinics in rural South Africa

ABSTRACT

The World Health Organization (WHO) recommends tuberculosis preventive treatment (TPT) in people with HIV (PWH), yet implementation remains poor, especially in rural communities. We examined factors influencing TPT initiation in PWH on antiretroviral therapy (ART) in rural South Africa using the Promoting Action on Research Implementation in Health Services (PARiHS) framework to identify contextual factors and facilitation strategies to successfully implement TPT. Patient and clinical factors were extracted from medical records at two primary healthcare clinics (PHCs). Among 455 TPT eligible indivdiuals, only 263 (57.8%) initiated TPT. Patient-level characteristics (older age and symptoms of fever or weight loss) were significantly associated with TPT initiation in bivariate analysis, but PHC was the only independent correlate of TPT initiation (aOR: 2.24; 95% CI: 1.49–3.38). Clinic-level factors are crucial targets for implementing TPT to reduce the burden of HIV-associated TB. Gaps in knowledge of HCW, staff shortages, and non-integrated HIV/TB services were identified barriers to TPT implementation. Evidence-based strategies for facilitating TPT implementation that might be under-prioritized include ongoing reprioritization, expanding training for primary care providers, and quality improvement strategies (organisational changes, multidisciplinary teams, and monitoring and feedback). Addressing contextual barriers through these facilitation strategies may improve future TPT implementation in this setting.

KEYWORDS:

• Implementation
• HIV
• rural health
• tuberculosis
• prevention

Acknowledgments

We would like to acknowledge the healthcare providers at COSH and the PHCs in Msinga sub-district for their dedication to patient care. We would also like to acknowledge the staff from the nongovernmental organisation, Philanjalo, for their continued support of the Msinga community and public health research to improve patient outcomes. The study was funded by Yale University’s Wilbur Downs International Health Fellowship (DC), NIAID K23AI089260 (SS), Gilead Foundation #157201 (SS, AM, LA), CDC #1U01GH000524 (SS, AM, LA), Doris Duke Foundation #2015216 and Irene Diamond Foundation #2006078 (SS, LA).

Author contributions

DC, AM, SS conceived of and designed the study.

DC collected the data.

DC, SS analyzed the data.

DC, LA, AM, SS, FA, ED contributed to the writing and/or revising of the manuscript.

Disclosure statement

The spouse of SS worked part time at Amgen Pharmaceuticals October 2015 - October 2018. No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Centers for Disease Control and Prevention: [Grant Number 1U01GH000524]; Doris Duke Charitable Foundation: [Grant Number 201516]; Gilead Foundation: [Grant Number 157201]; National Institute of Allergy and Infectious Diseases: [Grant Number K23AI089260]; Yale University Wilbur Downs International Health Fellowship: [Grant Number N/A]; Irene Diamond Foundation: [Grant Number 2006078].