Community Health Workers Can Strengthen Isoniazid Preventive Therapy Implementation in Rural KwaZulu-Natal, South Africa

Abstract

Background Tuberculosis (TB) remains one of the top 10 causes of death globally, disproportionately affecting HIV-infected individuals. South Africa has the sixth highest TB incidence rate in the world at 834/100,000 and 60% of TB cases are HIV coinfected. The WHO highlights isoniazid preventive therapy (IPT) as a major strategy to combat HIV-associated TB. Community health workers (CHWs) have been utilized in the differentiated care models for HIV treatment programs; pilots have shown their efficacy in screening for TB. No studies have evaluated CHW’s role in implementing IPT. This study explores the potential role of CHWs in expanding IPT in rural KwaZulu-Natal, South Africa.Methods The study was conducted in the Msinga sub-district where CHWs were provided training in multidisease screening including HIV, TB, hypertension, and diabetes mellitus, and educated on the nuances of IPT eligibility. CHWs screened up to 30 individuals a month. The primary outcome was the proportion of patients who were HIV(+) and TB(−) identified by CHWs as eligible for IPT and subsequently referred for care. The secondary outcomes included the percentage of those referred for IPT that were linked to care and the percent initiated on IPT.ResultsAmong 1279 individuals screened for HIV and TB December 2015–September 2016, 213 (16.7%) were HIV positive and had a negative TB symptom screen. Of those, 114 (54.5%) were currently on IPT or had been on IPT in the last 12 months and were thus not eligible for preventive treatment. Of the remaining 99 community members eligible for IPT, CHWs referred 46 (46.5%). For those referred, median age was 39 (IQR 30–48) and 91.3% were female. Of those, 29 (63%) linked to care and 11 (23.9% of all referred and 37.9% of those linked to care) initiated treatment.Conclusion In rural areas of KwaZulu-Natal, South Africa, CHWs have the capacity to not only screen for infectious and chronic disease, but to simultaneously evaluate for prevention opportunities, such as for IPT. Further research exploring barriers to IPT initiation in rural areas and resource limited settings should be prioritized to inform the role that CHWs can play in implementing IPT. Future efforts should focus on closing the gaps in the IPT cascade of care in order to maximize the impact of IPT on the TB epidemic.Disclosures All authors: No reported disclosures.