Underutilization of Isoniazid Drug Therapy to Prevent TB Disease Progression in Swaziland Ministry of Health
Ministry of Health
Brendan J. Cronin1, Marianne Calnan2, Lisa V. Adams1, Samson Haumba2 1Geisel School of Medicine at Dartmouth, Hanover, NH, USA; 2University Research Co. LLC, Washington DC, USA and Mbabane, Swaziland RESULTS - Tables
BACKGROUND
•  Swaziland has the highest TB incidence in the world and TB causes
an estimated 50% of the nation’s HIV patient deaths
•  75-80% of HIV patients in Swaziland have latent TB infection
•  TB infection can reactivate to TB disease, especially in those
immunosuppresed by HIV
•  A 6-month course of Isoniazid Preventive Therapy (IPT) prevents
progression of latent TB infection to TB disease for up to 18 months
•  In 2011 the Swaziland government recommended IPT for all HIV
patients at all national health facilities
•  We sought to determine if this policy was being implemented
Table 1: IPT Treatment Outcomes
Outcome
Completed 6 months of IPT treatment
Died
Transferred Out
Still on Treatment
Lost to Follow Up
Stopped IPT but continued ARTs
Other
Number of Patients (n=400)
189 (47%)
0 (0%)
8 (2%)
6 (1%)
19 (5%)
159 (40%)
19 (5%)
Table 2: Patients Eligible for and Initiated on IPT
DESIGN/METHODS
Clinic •  We reviewed TB/HIV annual reports from 2012 & 2013 for number
of HIV-infected patients screened for TB to determine those eligible
for, initiated on, and maintained until completion of a full course of
IPT at 4 health facilities in Swaziland
1
2
•  A retrospective review of patients initiated on IPT was performed to
assess IPT adherence
3
•  We extracted data on IPT/ART prescription refills, dates of IPT
therapy and IPT outcomes from 400 individual patient records at
facility data rooms and pharmacies
4 Year
Pa,ents Screened for TB
2012
2013
2012
2013
2012
2013
2012
2013
6758
13261
8912
10158
7814
3521
10831
7629
Pa,ents Eligible Pa,ents Ini,ated for IPT
on IPT
6565 (97%)
13051 (98%)
8761 (98%)
9969 (98%)
7705 (98%)
3482 (99%)
10771 (99%)
7566 (99%)
211 (3%)
28 (0.2%)
41 (0.5%)
18 (0.2%)
148 (2%)
79 (2.3%)
7 (0.06%)
0 (0%)
CONCLUSIONS
RESULTS
•  During 2012-2013, 68,884 HIV patients were screened for TB at
the 4 facilities
•  67,870 (98.5%) of all documented HIV patients had TB disease
ruled out by symptom screen and were considered eligible for IPT
•  only 532(<1%) of eligible patients were initiated on IPT
•  Less than half (47%, 189/400) of patients examined in the
individual record review had documentation of completing IPT
•  40% (159/400) of reviewed patients were prescribed at least one
month of IPT and returned for consistent antiretroviral therapy
(ART) refills despite discontinuing IPT
•  These patients adhered to their HIV therapy for an average of 18
months after stopping IPT
•  Of the patients who had traceable discontinuation dates, 29%
(42/144) stopped IPT after one month and 91% (131/144) stopped
within 4 months
•  Completeness of IPT data varied by site and ranged from 75% to
less than 50%
•  Our study documents massive underutilization (> 98%) of IPT
among eligible HIV-infected patients and low treatment completion
rates among those initiating IPT in Swaziland
•  Many other countries have shown poor completion results
•  Given the large proportion of IPT-noncompleters who remained
adherent to ART, poor IPT adherence may be due to lack of
documentation and/or increased pill burden
•  Further efforts to increase IPT uptake and adherence among this
high-risk population are necessary to decrease the burden of future
TB disease in Swaziland
•  Factors for IPT adherence need to be investigated and addressed
Acknowledgements:
Support for this work was provided by TB CARE II, which is funded by the United States
Agency for International Development (USAID) under Cooperative Agreement Number AIDOAA-A-10-00021. The project team includes prime recipient, University Research Co., LLC
(URC), and sub-recipient organizations Jhpiego, Partners in Health, Project HOPE along
with the Canadian Lung Association; Clinical and Laboratory Standards Institute; Geisel
School of Medicine at Dartmouth: The Section of Infectious Disease and International
Health; Euro Health Group; and the Rutgers University School of Medicine Global
Tuberculosis Institute. The findings of this study are the sole responsibility of Dartmouth
College, and do not necessarily reflect the views of USAID or the United States
Government.