Evaluation of the uptake of tuberculosis preventative therapy for people living with HIV in Namibia: a multiple methods analysis

Background In 2016, Namibia had ~ 230,000 people living with HIV (PLHIV) and 9154 new tuberculosis (TB) cases, including 3410 (38%) co-infected cases. TB preventative therapy (TPT), consisting of intensive case finding and isoniazid preventative therapy, is critical to reducing TB disease and mortality. Methods Between November 2014 and February 2015, data was abstracted from charts of PLHIV enrolled in HIV treatment. Fifty-five facilities were purposively selected based on patient volume, type and location. Charts were randomly sampled. The primary outcome was to estimate baseline TPT in PLHIV, using nationally weighted proportions. Qualitative surveys were conducted and summarized to evaluate TPT practices and quantify challenges encountered by health care workers (HCW). Results Among 861 PLHIV sampled, 96% were eligible for TPT services, of which 87.1% were screened for TB at least once. For PLHIV eligible for preventative therapy (646/810; 82.6%), 45.4% (294/646) initiated therapy and 45.7% (139/294) of those completed therapy. The proportion of eligible PLHIV completing TB screening, initiating preventative therapy and then completing preventative therapy was 20.7%. Qualitative surveys with 271 HCW identified barriers to TPT implementation including: lack of training (61.3% reported receiving training on TPT); misunderstandings about timing of TPT initiation (46.7% correctly reported TPT should be started with antiretroviral therapy); and variable screening practices and responsibilities (66.1% of HCWs screened for TB at every encounter). Though barriers were evident, 72.2% HCWs surveyed described their clinical performance as very good, often placing responsibility of difficulties on patients and downplaying challenges like staff shortages and medication stock outs. Conclusions In this study, only 1 in 5 eligible PLHIV completed the TPT cascade in Namibia. Lack of training, irregularities with TB screening and timing of TPT, unclear prescribing and recording responsibilities, and a clinical misperception may have contributed to suboptimal programmatic implementation. Addressing these challenges will be critical with continued TPT scale-up.

Mania induced by isoniazid preventive therapy during steroid treatment for rheumatoid arthritis and organising pneumonia

Isoniazid preventative therapy is widely used for latent tuberculosis infection. Isoniazid is highly effective but has many adverse effects, including neuropsychiatric. We describe the case of an 80-year-old woman with mania. She had received isoniazid preventative therapy during steroid treatment for rheumatoid arthritis and organising pneumonia for the previous 5 months. Her mania resolved after discontinuation of isoniazid. Adverse effects of isoniazid should be considered even if a long time has elapsed since the start of administration. Physicians other than infectious disease and respiratory specialists also must be aware of the adverse effects of isoniazid preventative therapy.

1883. Factors Associated with Stigma Toward Isoniazid-Preventative Therapy in a Rural Community of South Africa

Background Patients living with HIV should receive isoniazid-preventative therapy (IPT) in order to prevent tuberculosis (TB). In South Africa, IPT implementation has decelerated. Stigma is frequently found to be a barrier to treatment. We sought to understand community members’ perceptions of TB and HIV stigma in order to inform future IPT implementation efforts. Methods The study was conducted in the rural KwaZulu Natal province of South Africa. Community members were interviewed anonymously and answers to interview questions were scored to represent stigma. Three different domains of TB knowledge were evaluated: causes, transmission, and treatment and prevention of TB. All three knowledge scores were added to create a total knowledge of TB score. A 7-item scale was used to assess stigma; presence of stigma was defined as 1 or more positive responses on the scale. Descriptive statistics, chi-square tests, linear regression, and Kruskal–Wallis tests were performed. Results Among 104 participants, the mean age was 35 ± 9.3 years, 65% were female, and 26% completed secondary school. Overall, respondents had poor knowledge about the causes (mean = 61, SD = 27) and transmission (mean = 46, SD = 21), and good knowledge of the treatment and prevention (mean = 88, SD = 18) of TB. The vast majority of participants identified the presence of stigma (72%), with a mean score of 1.7, SD = 1.4. Participants were less likely to report stigma with excellent TB knowledge, characterized by accurate responses to at least 95% of the knowledge items (P = 0.025). Factors associated with higher levels of stigma included marital status (P = 0.01), being previously screened for TB (P = 0.008), considering mosquitos as a vector for TB transmission (P = 0.005), worrying about being infected with TB (P = 0.0117), and reporting travel to the clinic to be expensive (P = 0.03). Interest in taking IPT exhibited a trend toward significance with lower levels of stigma (P = 0.057). On multivariable linear regression of stigma, marital status (P = 0.0304) and prior TB screening (P = 0.0149) were significant. Conclusion HIV-related stigma was prevalent among rural South African community members considering IPT. Stigma decreased with higher knowledge levels. Global expansion and implementation of IPT will require interventions to reduce stigma. Disclosures All Authors: No reported Disclosures.

Isoniazid Preventative Therapy uptake for child household contacts of tuberculosis index cases, Kisumu County, Kenya, 2014-2015

Isoniazid Preventative Therapy (IPT) is recommended for children aged less than 5 years that have been in contact with an open case of TB, and screen negative for TB, to prevent the risk of TB progression. We examined IPT uptake among child household contacts of TB index cases, within a TB case detection study, in a high TB burden region. A cross-sectional study involving all IPT-eligible children drawn from a TB case detection study was done in Kisumu County, Kenya between 2014 and 2015. By linking a subset of the study database to the TB program IPT register, we described Child contacts as initiated on IPT and TB index cases as having child contacts initiated on IPT based on whether their names or their child contacts names respectively, were found in the IPT register. Logistic regression analysis was used to describe index and contact characteristics associated with IPT initiation. Of 555 TB index cases recruited into the study, 243 (44%) had a total of 337 IPT-eligible child contacts. Forty-seven (19%) index cases that had child contacts initiated on IPT; they were more likely to have been diagnosed with smear positive TB compared to those who were diagnosed with smear negative TB (OR 5.1, 95% CI 1.1-23.2; P=0.03) and to reside in rural Kisumu compared to those in urban Kisumu (OR 3.3, 95% CI 1.6-6.8; P<0.01). The 51 (15%) child contacts that were initiated on IPT were more likely to be were first degree relatives of the index case compared to those who were not (OR 2.6, 95% CI 1.2-5.5; P=0.02) and to reside in rural Kisumu compared to those in urban Kisumu (OR 2.6, 95% CI 1.2-5.1; P<0.01). IPT initiation, which is influenced by index and contact characteristics, is suboptimal. The TB program should provide health worker training, avail appropriate pediatric TB diagnostic tools, job aids and monitoring tools, and ensure continuous supply of medication, and to facilitate IPT implementation. Additionally, targeted health education interventions should be formulated to reach those who are unlikely to accept IPT.

Isoniazid preventative therapy uptake for child household contacts of TB index cases, Kisumu County, Kenya, 2014-2015

Background Isoniazid Preventative Therapy (IPT) is recommended for children aged less than 5 years that have been in contact with an open case of TB and screen negative for TB to prevent the risk of TB progression. We examined IPT uptake among child household contacts of TB index cases within a TB case detection study in a high TB burden region. Methods A cross-sectional study involving all IPT eligible children drawn from a TB case detection study was done in Kisumu County, Kenya between 2014 and 2015. By linking a subset study database to the TB program IPT register, we described Child contacts as ‘initiated on IPT’ and TB index cases as ‘having child contacts initiated on IPT’ based on whether their names or their child contacts names respectively, were found in the IPT register. Logistic regression analysis was used to describe index and contact characteristics associated with IPT initiation Results Of 555 TB index cases into the study, 243 (44%) had a total of 337 IPT-eligible child household contacts. Forty-seven (19%) index cases that had child contacts initiated on IPT; they were more likely to have been diagnosed with smear positive TB compared to those who were diagnosed with smear negative TB (OR 5.1, 95% CI 1.1-23.2; p=0.03) and to reside in rural Kisumu compared to those in urban Kisumu (OR 3.3, 05% CI 1.6-6.8; p<0.01). The 51 (15%) child contacts that were initiated on IPT were more likely to be were first degree relatives of the index case compared to those who were not (OR 2.6, 95% CI 1.2-5.5; p=0.02) and to reside in rural Kisumu compared to those in urban Kisumu (OR 2.6, 95% CI 1.2-5.1; p<0.01). Conclusion IPT initiation, which is influenced by index and contact characteristics, is suboptimal. The TB program should provide health worker training, avail appropriate pediatric TB diagnostic tools and continuous supply of medication, and job aids and monitoring tools to facilitate IPT implementation. Additionally, targeted health education interventions should be formulated to reach those who are unlikely to accept IPT.