"It's about my life": facilitators of and barriers to isoniazid preventive therapy completion among people living with HIV in rural South Africa

Abstract

Despite the recent rollout of Isoniazid Preventive Therapy (IPT) to prevent TB in people living with HIV in South Africa, adherence and completion rates are low. To explore barriers to IPT completion in rural KwaZulu-Natal, South Africa, we conducted individual semi-structured interviews among 30 HIV patients who had completed or defaulted IPT. Interview transcripts were analyzed according to the framework method of qualitative analysis. Facilitators of IPT completion included knowledge of TB and IPT, accepting one's HIV diagnosis, viewing IPT as similar to antiretroviral therapy, having social support in the community and the clinic, trust in the healthcare system, and desire for health preservation. Barriers included misunderstanding of IPT's preventive role in the absence of symptoms, inefficient health service delivery, ineffective communication with healthcare workers, financial burden of transport to clinic and lost wages, and competing priorities. HIV-related stigma was not identified as a significant barrier to IPT completion, and participants felt confident in their ability to manage stigma, for example by pretending their medications were for unrelated conditions. Completers were more comfortable communicating with health care workers than were defaulters. Efforts to facilitate successful IPT completion must include appropriate counseling and education for individual patients and addressing inefficiencies within the health care system in order to minimize patients' financial and logistical burden. These patient-level and structural changes are necessary for IPT to successfully reduce TB incidence in this resource-limited setting.

Keywords: HIV/AIDS; Isoniazid preventive therapy; adherence; qualitative methods; tuberculosis.

Figure 1

Facilitators and barriers to IPT adherence among HIV patients accessing HIV care in rural KZN, South Africa. IPT = Isoniazid preventive therapy, KAP = Knowledge, attitudes, practices, TB = Tuberculosis. In order to adhere to IPT, patients must have accepted their HIV diagnosis and be in a social situation in which they either feel comfortable disclosing their status or feel that they can manage their social situation to keep their status hidden. Patients must trust that the health care system will not only provide effective medical care but also will empower them to communicate effectively with providers so that any questions or problems such as side effects can be addressed. They must have the ability and resources (transport fare, a job that allows time off) to physically access care including getting to clinic appointments and taking pills consistently. They must believe that TB is a risk even if they are asymptomatic and that IPT will reduce that risk without adverse effects, and they must make health a priority. These concepts influence each other; for example, trust in health system is also necessary for HIV testing and diagnosis; presence of social support can mitigate economic burdens; knowledge and beliefs about IPT come from both social networks and within the health system; sometimes the desire for health preservation is outweighed by immediate lack of resources to survive.