Early-phase scale-up of isoniazid preventive therapy for people living with HIV in two districts in Malawi (2017)

PLoS One. 2021 Apr 1;16(4):e0248115. doi: 10.1371/journal.pone.0248115. eCollection 2021.

Abstract

Background: Isoniazid preventive therapy (IPT) against tuberculosis (TB) is a life-saving intervention for people living with HIV (PLHIV). In September 2017, Malawi began programmatic scale-up of IPT to eligible PLHIV in five districts with high HIV and TB burden. We measured the frequency and timeliness of early-phase IPT implementation to inform quality-improvement processes.

Methods and findings: We applied a two-stage cluster design with systematic, probability-proportional-to-size sampling of six U.S. Centers for Disease Control and Prevention (CDC)-affiliated antiretroviral therapy (ART) centers operating in the urban areas of Lilongwe and Blantyre, Malawi (November 2017). ART clinic patient volume determined cluster size. Within each cluster, we sequentially sampled approximately 50 PLHIV newly enrolled in ART care. We described a quality-of-care cascade for intensive TB case finding (ICF) and IPT in PLHIV. PLHIV newly enrolled in ART care were eligibility-screened for hepatitis and peripheral neuropathy, as well as for TB disease using a standardized four-symptom screening tool. Among eligible PLHIV, the overall weighted IPT initiation rate was 70% (95% CI: 46%-86%). Weighted IPT initiation among persons aged <15 years (30% [95% CI: 12%-55%]) was significantly lower than among persons aged ≥15 years (72% [95% CI: 47%-89%]; Rao-Scott chi-square P = 0.03). HIV-positive children aged <5 years had a weighted initiation rate of only 13% (95% CI: 1%-79%). For pregnant women, the weighted initiation rate was 67% (95% CI: 32%-90%), similar to non-pregnant women aged ≥15 years (72% [95% CI: 49%-87%]). Lastly, 95% (95% CI: 92%-97%) of eligible PLHIV started ART within one week of HIV diagnosis, and 92% (95% CI: 73%-98%) of patients receiving IPT began on the same day as ART.

Conclusions: Early-phase IPT uptake among adults at ART centers in Malawi was high. Child uptake needed improvement. National programs could adapt this framework to evaluate their ICF-IPT care cascades.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Ambulatory Care Facilities / organization & administration*
  • Antitubercular Agents / therapeutic use
  • Child
  • Child, Preschool
  • Female
  • HIV / isolation & purification
  • HIV Infections / drug therapy
  • HIV Infections / epidemiology
  • HIV Infections / microbiology*
  • HIV Infections / virology
  • Humans
  • Isoniazid / therapeutic use*
  • Malawi / epidemiology
  • Male
  • Mass Screening / statistics & numerical data*
  • Middle Aged
  • Pregnancy
  • Tuberculosis / diagnosis
  • Tuberculosis / epidemiology
  • Tuberculosis / prevention & control*
  • Tuberculosis / virology*
  • Young Adult

Substances

  • Antitubercular Agents
  • Isoniazid

Grants and funding

This project was supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of a non-research determination. CDC developed the study protocol; collection, management, analysis, and interpretation of data; writing of the report; and the decision to submit the report for publication. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the funding agencies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.