Perceptions of multidisciplinary healthcare workers on barriers to isoniazid preventive therapy implementation for persons living with HIV in rural South Africa

Background: South Africa’s initial rollout of isoniazid preventive therapy (IPT) has been successful in reducing tuberculosis (TB) mortality among people living with HIV (PWH) in part due to a multidisciplinary team approach. However, recent data suggests IPT initiation and completion rates have decreased. In this study, we identified barriers to IPT implementation among multidisciplinary healthcare workers (HCWs) in rural South Africa. Methods: A cross-sectional survey was administered to HCWs from a government district hospital and 14 primary healthcare clinics (PHCs) in the Msinga sub-district of KwaZulu-Natal from November 2019 to January 2020. Self-reported data on knowledge, attitudes, beliefs, and practices (KABP) were obtained regarding IPT. HCWs involved in identifying eligible PWH and prescribing IPT were defined as “direct” IPT providers. All other HCWs involved in the IPT care cascade were defined as “indirect” IPT providers. Factor analysis was used to reduce variables, and chi-square analysis was used to compare KABP between indirect and direct IPT providers. Results: Among 160 HCWs, the median (IQR) age was 39 (33-46) years, 76% were women, and 44% were direct IPT providers. Overall, HCWs had positive attitudes towards IPT, believing it to be effective. However, indirect IPT providers reported significantly less knowledge (69% v. 90%) and training (65% v. 82%) regarding IPT, were less likely to perceive patients as having good IPT knowledge (74% v. 89%), and were less likely to believe there was sufficient time to address IPT during clinical encounters (86% v. 96%). They were also less likely to report sufficient isoniazid supplies (63% v. 93%) compared to direct IPT providers. Conclusion: Strengthening IPT implementation will require substantial HCW training targeting indirect IPT providers, who are essential members of the multidisciplinary teams delivering preventive TB care to PWH in rural South Africa, as well as systems-level improvement of isoniazid supply chains.

背景：南非异烟肼预防性治疗（isoniazid preventive therapy, IPT）的初始推广在降低艾滋病病毒感染者（people living with HIV, PWH）的结核病（tuberculosis, TB）死亡率方面取得了成功，这在一定程度上得益于多学科团队协作模式。但近期数据显示，IPT的启动率与完成率均有所下降。本研究旨在明确南非农村地区多学科医护团队中阻碍IPT落地的相关因素。方法：本研究于2019年11月至2020年1月期间，针对夸祖鲁-纳塔尔省姆辛加分区的一所政府区级医院及14家基层医疗诊所（primary healthcare clinics, PHCs）的医护人员（healthcare workers, HCWs）开展横断面调查。我们收集了受试者关于IPT的知识、态度、信念与行为（knowledge, attitudes, beliefs, and practices, KABP）的自我报告数据。将参与甄别符合指征的PWH并开具IPT处方的HCWs定义为"直接"IPT执行者，其余参与IPT照护级联流程的HCWs则定义为"间接"IPT执行者。本研究采用因子分析对变量进行降维，使用卡方检验对比直接与间接IPT执行者的KABP差异。结果：本次研究共纳入160名HCWs，其年龄中位数（四分位间距，interquartile range, IQR）为39（33~46）岁，其中76%为女性，44%为直接IPT执行者。总体而言，HCWs对IPT持有积极态度，认为其具有防治有效性。但间接IPT执行者在IPT相关知识掌握度（69% vs 90%）与培训覆盖情况（65% vs 82%）上显著低于直接执行者；他们更倾向于认为患者对IPT的知晓度不佳（74% vs 89%），且更少有信心认为临床接诊时有足够时间讲解IPT相关内容（86% vs 96%）。相较于直接IPT执行者，间接执行者报告异烟肼药物供应充足的比例也更低（63% vs 93%）。结论：强化南非农村地区IPT的落地实施，需针对间接IPT执行者开展充分的医护人员培训——这类人员是为PWH提供结核病预防性照护的多学科团队中的核心成员，同时还需从系统层面优化异烟肼的供应链管理。