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.