Acceptance and completion of rifapentine-based TB preventive therapy (3HP) among people living with HIV (PLHIV) in Kampala, Uganda—patient and health worker perspectives

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 acceptance and completion of 3HP treatment from the perspective of people living with HIV (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 the 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 of acceptance and completion of 3HP treatment among PLHIV were fear of contracting TB, awareness of being at risk of getting TB, willingness to take TPT, trust in health workers, and the perceived benefits of directly observed therapy (DOT) and self-administered therapy (SAT) 3HP delivery strategies. Barriers included inadequate understanding of TPT, fear of potential side effects, concerns about the effectiveness of 3HP, and the perceived challenges of DOT or SAT. Among health workers, perceived facilitators included knowledge that TB is a common cause of mortality for PLHIV, fear of getting TB, and trust in the health workers by PLHIV, the advantages of once-weekly 3HP dosing, and the benefits of DOT and SAT 3HP delivery strategies. Health worker-reported barriers for PLHIV included inadequate understanding of TB and benefits of TPT, TB-associated stigma, potential side effects pill burden, and challenges of DOT and SAT 3HP delivery strategies. Lack of experience in the use of digital technology to monitor patient care was identified as a health worker-specific barrier. Identified intervention functions to address the facilitators or barriers included education, persuasion, environmental restructuring, enablement, and training. Conclusions Using a formative qualitative and comprehensive theoretical approach, we identified key barriers, facilitators, and appropriate interventions, including patient education, enhancing trust, and patient-centered treatment support that could be used to optimize the delivery of 3HP to PLHIV in our setting. These interventions are likely generalizable to other clinical interventions in similar populations in sub-Saharan Africa and other TB high-burden settings.

Completion of isoniazid–rifapentine (3HP) for tuberculosis prevention among people living with HIV: Interim analysis of a hybrid type 3 effectiveness–implementation randomized trial

“…Importantly, the results reported here were achieved with the use of facilitated delivery strategies. The strategies were designed using an implementation science-based approach to target key barriers to 3HP acceptance and completion, and local stakeholders were involved in the design process to maximize acceptability and scale up potential [14][15][16][17]. The final analysis of results from the full trial is needed to determine whether one of the strategies is more or less effective than the others.…”

“…Briefly, eligible participants who provide written informed consent are randomized to 1 of 3 optimized delivery strategies for receiving 3HP. The delivery strategies were designed to address barriers to 3HP acceptance and completion identified in formative research [15][16][17] and with involvement of local stakeholders including PLHIV, clinicians, and clinic/program leadership to maximize acceptability and feasibility.…”

Optimizing delivery strategies for 3HP TB preventive treatment in Tanzania: A qualitative study on acceptability of family approach in HIV care and treatment centers

“…This shows that receiving support from a family member and SMS reminders was acceptable to the majority. Perceived TB risk is also reported as a facilitator for 3HP acceptance in other studies in Africa(20,21).…”

Clinical characteristics and morbidity among hospitalized adults with advanced HIV disease in Uganda during ‘test and treat’ era

“…It is not uncommon for TB and cryptococcosis to occur in the same patient [ 40 ]. TPT is further limited by high pill burden and poor medication adherence, thus, shorter regimens such as one month of Isoniazid and Rifapentine are preferred in the advanced HIV disease population [ 41 , 42 ]. System barriers such as drug stock outs, clinician knowledge gaps, and insufficient TB‐dedicated staff also contribute to the low TPT uptake in Uganda [ 41 ].…”