Improving Tuberculosis Prevention Programs Aimed at HIV Patients

Structured leadership and management training for isoniazid preventive therapy (IPT) programs overseen by mid-level health managers boosted inter-district communication and collaboration, even if it did not substantially increase IPT initiation, according to a paper published in The Lancet HIV.

Investigators from Uganda and the U.S. aimed to determine whether structured leadership and management training for program leaders would increase IPT uptake among people with HIV. The study authors said that IPT can reduce the risk of active tuberculosis among people with HIV by between 40 to 60 percent. And while the World Health Organization has recommended IPT for people with HIV since 2008, the study authors noted that uptake is low across sub-Saharan Africa. Barriers to initiation can include ruling out tuberculosis before starting IPT, isoniazid resistance in tuberculosis disease post-IPT, and insufficient healthcare worker knowledge, they said.

For this study, the investigators randomly assigned clusters of 4 to 7 managers in a 1:1 ratio to the intervention or a control group. The intervention lasted 2 years included meeting with Ugandan experts in tuberculosis and HIV in small groups, business leadership and management training, texting services to facilitate communication among managers and frontline workers, and data feedback, the study authors explained. The control group followed standard practice.

Across the 2-year measurement period, the study authors reported the incidence of IPT initiation among adults with HIV was 0.74 starts per person-year for the intervention group compared to 0.65 starts per person-year in the control group. The cumulative incidence of IPT initiation among adults in HIV care was 68 percent in the intervention group and 65 percent in the control group, the study authors learned.

The incidence of tuberculosis among people with HIV was 1.61 cases per 100 person-years in the intervention group compared to 1.57 cases per 100 person-years in the control group, the study authors determined.

The study authors also followed up with the IPT managers, finding that between baseline and Year 1, there was significantly greater average increases in familiarity with IPT and in knowledge of IPT efficacy among the intervention group compared to the control group, they wrote.

In focus group discussions, the managers from the intervention group reported improved communications. The study authors said this improvement led to identifying gaps in training and places where mentorship of junior colleagues was needed, identifying gaps in the supply chain, and increased organization and focused efforts based on the data collection and review. They also said the regional cooperation increased contact tracing and treatment for tuberculosis. The study authors noted that the control group managers noted challenges in managing personnel, a need for feedback on progress for tuberculosis prevention and learnings from other districts.

The study authors also noted the estimated cost of the intervention was $83,508 during year 1 and $62,384 in each subsequent year (the majority of subsequent year costs included $33,045 for meetings with the IPT managers and international consultants). Start-up cost over 6 months was $27,122, which included stakeholder engagement, protocol development, and training of study staff, the first focus group meeting, and developing, installing, and training for the text messaging platform.

“An intervention that provided structured leadership and management training and facilitated subregional collaboration and routine data feedback resulted in increased IPT knowledge, and improved within-district communication and inter-district collaboration,” the study authors wrote. “The higher rates were sustained during the COVID-19 pandemic, suggesting benefits of leadership and management training and collaboration for mid-level health managers who operate at the nexus of guidelines and implementation.”