Integrating Isoniazid Preventive Therapy into the Fast-Track HIV Treatment Model in Urban Zambia: A Proof-of -Concept Pilot Project

Abstract

IntroductionMost people living with HIV (PLHIV) who are established on treatment in Zambia receive multi-month prescribing and dispensing (MMSD) of antiretroviral therapy (ART) and are enrolled in less-intensive differentiated service delivery (DSD) models, such as Fast Track (FT), in which clients pick up ART every 3-6 months and make clinical visits to health facilities every 6 months. In 2019, Zambia introduced Isoniazid Preventive Therapy (IPT) with scheduled visits at 2 weeks and 1, 3, and 6 months. The asynchronous IPT and HIV appointment schedules were inconvenient and not client centered. In response, we piloted integrated MMSD/IPT in the FT HIV treatment model.MethodsWe implemented and evaluated a proof-of-concept pilot project at one purposively selected high-volume facility in Lusaka, Zambia between July 2019 and May 2020. We sensitized stakeholders, adapted training materials and standard operating procedures, and screened adults in FT for TB as per national guidelines. Participants received structured TB/IPT education, a 6-month supply of isoniazid and ART, an aligned 6th month IPT/MMSD clinic appointment, and phone appointments at 2 weeks and months 1-5 following IPT initiation. We used descriptive statistics to characterize IPT completion rates, phone appointment keeping, side effect frequency and Fisher’s exact test to determine if these varied by participant characteristics. Notes from monthly meetings and discussions were used to synthesize key lessons learned.Results1,167 clients were screened for eligibility and 818 (70.1%) were enrolled. Two thirds (66%) were female, median age was 42 years, and 56.6% had been on ART for ≥ 5 years. 738 (90.2%) completed a 6-month course of IPT and 66 (8.1%) reported IPT-related side effects. 539 clients (65.9%) attended all 7 telephone appointments. There were no significant differences in these outcomes by age, sex, or time on ART. Lessons learnt include the value of promoting project ownership, client empowerment, securing supply chain, adapting existing processes, and cultivating a collaborative structured learning environment.ConclusionsIntegrating multi-month dispensing and telephone follow up of IPT into the FT HIV treatment model is a promising approach to scaling-up TB preventive treatment among PLHIV, although limited by barriers to consistent phone access.

Isoniazid preventive therapy completion between July-September 2019: A comparison across HIV differentiated service delivery models in Uganda

“…Unlike our study, two systematic reviews of latent tuberculosis cascade-of-care among PLHIV found very low completion rates as low as 33.2% [ 18 ] and 18.8% [ 19 ], which were much lower than we found in our study. The higher IPT completion found in our study compared to the above two systematic reviews is an indicator of the high quality of the IPT program in Uganda [ 20 ], which followed the implementation of IPT Surge activities by the Uganda Ministry of Health with technical and financial support from development partners.…”

Integrating 3HP‐based tuberculosis preventive treatment into Zimbabwe's Fast Track HIV treatment model: experiences from a pilot study

“…These findings align with other studies, including one in urban Zambia designed to integrate 6 months of IPT into a Fast Track model, using monthly phone appointments with community healthcare workers (CHWs) who provided adherence counselling and monitored side effects [ 25 ]. TPT completion rates in this project were high (90.2%) although only 65.9% of clients participated in all phone appointments.…”

“…Another study in Pakistan integrated 3HP into prison systems and adverse events resulted in 8.6% of participants discontinuing 3HP [ 29 ]. In the Uganda study, 36% of those who completed IPT reported one or more side effects [ 13 ], while 8.1% of clients enrolled in the TPT study in Zambia reported side effects to CHWs during phone check‐ins [ 25 ].…”

“…However, in this proof‐of‐concept study, we found that remote check‐ins were not too time‐consuming (average 10 minutes each) and saved time for clients and HCPs overall. It may also be feasible to utilize CHWs to support remote check‐ins [ 25 ] and/or to use automated rather than manual SMS reminders. Additionally, participants were provided with airtime to participate in remote check‐ins.…”