Improved delivery of isoniazid preventive therapy with integrated HIV and TB services

Interventions to improve delivery of isoniazid preventive therapy: an overview of systematic reviews

Adams LV, Talbot EA, Odato K, Blunt H, Steingart KR. BMC Infect Dis. 2014 May 21;14(1):281. doi: 10.1186/1471-2334-14-281.

Background: Uptake of isoniazid preventive therapy (IPT) to prevent tuberculosis has been poor, particularly in the highest risk populations. Interventions to improve IPT delivery could promote implementation. The large number of existing systematic reviews on treatment adherence has made drawing conclusions a challenge. To provide decision makers with the evidence they need, we performed an overview of systematic reviews to compare different organizational interventions to improve IPT delivery as measured by treatment completion among those at highest risk for the development of TB disease, namely child contacts or HIV-infected individuals.

Methods: We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE), and MEDLINE up to August 15, 2012. Two authors used a standardized data extraction form and the AMSTAR instrument to independently assess each review.

Results: Six reviews met inclusion criteria. Interventions included changes in the setting/site of IPT delivery, use of quality monitoring mechanisms (e.g., directly observed therapy), IPT delivery integration into other healthcare services, and use of lay health workers. Most reviews reported a combination of outcomes related to IPT adherence and treatment completion rate but without a baseline or comparison rate. Generally, we found limited evidence to demonstrate that the studied interventions improved treatment completion.

Conclusions: While most of the interventions were not shown to improve IPT completion, integration of tuberculosis and HIV services yielded high treatment completion rates in some settings. The lack of data from high burden TB settings limits applicability. Further research to assess different IPT delivery interventions, including those that address barriers to care in at-risk populations, is urgently needed to identify the most effective practices for IPT delivery and TB control in high TB burden settings.

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Editor’s notes: Isoniazid preventive therapy (IPT) is a key component of the “3 Is” strategy to reduce tuberculosis among people living with HIV. Despite evidence of efficacy, initiation of IPT among eligible people in HIV care programmes has been disappointing. When IPT has been delivered as a stand-alone activity, treatment completion has often been poor. This overview of systematic reviews brings together evidence concerning organisational programmes to improve IPT delivery, using treatment completion as the main outcome. Three of the six included reviews, specifically included HIV-positive people.

When IPT delivery was integrated into other services, such as HIV care, good IPT completion rates were reported. A common weakness in the studies reviewed, was the lack of a suitable comparison group. This made it difficult to be sure that the good outcomes were due to the service integration. HIV This Month reported in June 2014 a trial from South Africa, showing that IPT reduces TB incidence among people taking antiretroviral therapy. Viewed together, these studies provide additional evidence supporting IPT delivery as part of the package of care for people in HIV care. More research is needed to guide implementers on how to deliver TB preventive therapy most effectively for people living with HIV.

Avoid TB deaths
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