|Year : 2019 | Volume
| Issue : 14 | Page : 91-96
Adherence to isoniazid preventive therapy for tuberculosis among HIV patients in Kano, Nigeria
Ibrahim Rabiu Jalo1, Usman Muhammad Ibrahim2
1 Department of Community Medicine, Bayero University, Kano, Nigeria
2 Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||01-Mar-2019|
|Date of Acceptance||01-Jul-2019|
|Date of Web Publication||04-Oct-2019|
Dr. Ibrahim Rabiu Jalo
Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Background: Tuberculosis (TB) is the most common opportunistic infection among human immunodeficiency virus (HIV)-infected individuals. It is a major cause of mortality among patients with HIV and poses a risk throughout the course of HIV disease. Adherence to isoniazid preventive therapy (IPT) is a critical factor that needs to be considered in scaling up services in developing countries. Objectives: The study aimed to assess adherence and associated factors to IPT among HIV patients in Kano. Methods: Using a cross-sectional study design, interviewer-administered questionnaire was used to collect information from 320 HIV patients from two comprehensive health centers (CHCs). Results: Up to two-third, 211 (65.9%) of the participants were aware of the use of isoniazid for the prevention of TB among HIV/AIDS patients, but only about half 172 (53.8%) of the respondents interviewed were currently using IPT for TB prevention. Up to 158 (89.5%) of the 172 respondents interviewed had good level of adherence to IPT and the main reasons to enhance adherence were disclosure of HIV status to partner/relatives (77.9%), adequate counseling about IPT (62.8%), and awareness of IPT for TB prevention (65.9%). Conclusion: Good level of adherence to IPT from this study implies that the need for improve strategies to ensure IPT scale up as adherence to IPT among HIV clients in Kano is optimal, but uptake remains low.
Keywords: Adherence, human immunodeficiency virus, isoniazid preventive therapy, tuberculosis
|How to cite this article:|
Jalo IR, Ibrahim UM. Adherence to isoniazid preventive therapy for tuberculosis among HIV patients in Kano, Nigeria. N Niger J Clin Res 2019;8:91-6
|How to cite this URL:|
Jalo IR, Ibrahim UM. Adherence to isoniazid preventive therapy for tuberculosis among HIV patients in Kano, Nigeria. N Niger J Clin Res [serial online] 2019 [cited 2019 Dec 5];8:91-6. Available from: http://www.mdcan-uath.org/text.asp?2019/8/14/91/268527
| Introduction|| |
In 2014, the global burden of latent TB infection (LTBI) was 23% amounting to approximately 1.7 billion people. The World Health Organization Southeast Asia, Western-Pacific, and Africa regions had the highest prevalence and accounted for around 80% of those with LTBI. Tuberculosis (TB) preventive therapy is the administration of one or more anti-TB drugs to individuals with latent infection with Mycobacterium tuberculosis in order to prevent progression to active TB disease, while isoniazid preventive therapy (IPT) is the administration of isoniazid (INH) to individuals with LTBI in order to prevent progression to active TB disease. INH is one of the most effective bactericidal, anti-TB drugs available at present. While it protects against progression of LTBI to active disease, i.e., reactivation, it also prevents TB reinfection post the exposure to an open case of TB. Carter et al. defined adherence as the extent to which a client's behavior coincides with the prescribed health-care regimen as agreed through a shared decision-making process between the client and the health-care provider.
The recognition of TB as a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected persons has led to renewed interest in TB preventive therapy and its incorporation into the essential package of health care for these individuals. The risk of reactivation of latent infection is low in healthy individuals but is greatly increased in individuals with immunosuppression, most notably that due to HIV infection. In controlled trials conducted by the public health service in ordinary clinical and public health settings, IPT reduced the incidence of TB disease by 54%–88%. The main reason for the variation in efficacy appears to have been the amount of medication actually taken during the period (adherence), in which INH was prescribed. In a trial conducted in Eastern Europe among infected adults with abnormal chest radiographs, a 12-month course of IPT was 75% effective among all persons assigned to the regimen and 93% effective among those who were compliant with therapy. Similarly, IPT was estimated to be 98% effective among children in Houston and in recently infected nursing home patients who were compliant with therapy.,
A study conducted in Ethiopia revealed that poor patient adherence was a major factor for the effective delivery of IPT to HIV patients. The following issues were cited as the reasons for poor adherence; forgetfulness, lack of understanding of condition and patient nondisclosure of HIV serostatus leading to insubstantial social support, underlying mental health issues resulting in missed or irregular patient appointments, weak patient/health-care provider relationship, lack of patient information, patient empowerment and proper counseling on IPT, and the deficient reinforcement by health officials and other stakeholders on the significance of IPT medication adherence as a critical for positive health outcomes. Of those eligible for IPT in Keffi (Nigeria), 103 (95%) kept their clinic appointment and all completed a 6-month course of INH therapy, while a similar survey in Yola revealed that 143 (93%) clients on antiretroviral treatment (ART) completed their IPT., TB preventive therapy among HIV-infected individuals, particularly therapy involving INH reduces TB incidence and is cost-effective and safe. Strategies to overcome barriers to uptake and poor adherence need to be determined.
| Methods|| |
A cross-sectional study design that employed interviewer-administered questionnaire was used to collect information from 320 HIV patients from two primary health-care centers in Kano Metropolis (Unguwa Uku and Kumbotso comprehensive health centers [CHCs]). The study was conducted between July and September 2018.
The study population comprised adult HIV-positive patients (18 years and older) receiving care in the study sites for at least 6 months before the survey.
At the two selected health center, antiretroviral drugs (ARVs), anti-TB drugs, and IPT are provided at no charge (cost) to all patients. However, there is the indirect cost of transportation and loss of man-hour while in the hospital. IPT is offered to all HIV-positive patients who meet a simple screening criterion (clinical Algorithm) based on the absence of the following symptoms: current cough, fever, weight loss, and night sweats based on the recommendation of the 2016 National Guideline for HIV Prevention, Treatment and Care. The recommended regimen for TB preventive therapy in adults is INH (Isonicotinic Acid Hydrazide – INH), 300 mg daily for at least 6 months.
Sample size determination
The sample size for the study was estimated using the formula for single proportion (n = Z2 pq/d2) with proportion of HIV patients on IPT (30%) obtained from a previous similar study and a sample size of 329 was obtained.
A two-stage sampling technique was used. In the first Stage 2, CHCs were selected by balloting from the list of primary health centers providing ART services in Kano metropolis, while in the second stage, a systematic sampling technique was used to select respondents from the selected health facilities.
Data collected were entered and analyzed using IBM SPSS version 20 (Armonk, New York, USA). Age and income of respondents were calculated and presented using mean, standard deviation, median, and range, while frequencies and percentages were used to summarize qualitative variables: sex, religion, marital status, ethnicity, educational status, partner's education, occupation, awareness, willingness, counseling, and disclosure.
Adherence to IPT was the dependent variable, while the independent variables included: age, sex, residence, ethnicity, marital status, ethnicity, religion, educational status, partner's education, occupation, awareness, side effect, willingness, counseling, and disclosure.
Questions used to assess uptake of IPT were dichotomized as “Yes” or “No” responses. Respondents were then categorized as having used IPT or not based on their responses.
Poor adherence is defined as failure to take 80% or missed ≥seven doses of INH pills prescribed in the last 30 days (1 month) prior to the interview, while good adherence is the ability of the respondents to take ≥80% of the prescribed INH pills in the last 30 days (1 month) prior to the interview.
Chi-square test or Fisher's exact test (where appropriate) was used to analyze factors associated with respondent's adherence to IPT. In all tests of significance, P < 0.05 was considered statistically significant. At multivariate level, all variables found to have P < 0.10 and those that were found to be predictors of adherence from the literature review were entered into the binary logistic regression model. Binary logistic regression analysis was used to obtain adjusted odds ratio (AOR) with 95% confidence intervals (CIs) for predictors of adherence to IPT.
| Results|| |
The age of the respondents ranged from 18 to 63 years, with a mean age of 35.07 ± 11.53 years. Majority of the respondents were between the age range of 25–34 years (32.5%) and 35–44 years (25.3%) with 71.9% (230) being females. Almost all the respondents (94.1%) were ever married and up to a third (33.1%) had secondary level of education, while 44.3% had no formal education and up to 15% of the respondents were unemployed. The sociodemographic characteristics of the participants are shown in [Table 1].
About half 172 (53.8%) of the respondents interviewed were currently using IPT for TB [Table 2].
|Table 2: Parameters used to assess adherence to isoniazid preventive therapy|
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Up to 158 (89.5%) of the respondents interviewed had good adherence to IPT [Table 3]. The main reasons reported to enhance adherence were disclosure of HIV status to partner/relatives (77.9%), adequate counseling about IPT (62.8%), and awareness of IPT for TB prevention (65.9%).
|Table 3: Respondent's level of adherence to isoniazid preventive therapy (n=172)|
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Pill burden was the main barrier for uptake (75.6%) and adherence (73.8%) to IPT. Peer support from the support groups (SGs) meetings was reported to inspire respondents through continuous counseling. This was reported to enhance adherence and acceptance of IPT.
At bivariate level of analysis, adherence to IPT was found to be significantly associated (P< 0.05) with respondent's level of education, tribe, IPT uptake, and adequate counseling about IPT [Table 4].
|Table 4: Factors associated with adherence to isoniazid preventive therapy|
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INH uptake, educational level, counseling, tribe, side effects, and willingness to use IPT in the future and three other factors reported to be associated with adherence to IPT from literature review (disclosure, counseling, and INH side effects),, were further subjected to multivariate analysis to adjust for confounding variables as shown on [Table 5].
After adjusting for other covariates, counseling and disclosure were found to remain independent predictors of adherence to IPT. Respondents who received adequate counseling about IPT were two times more likely to adhere to IPT treatment (P = 0.01, AOR = 2.10, 95% CI = 1.19–2.47) and patients who disclosed their HIV status to partner/family were 1.5 times more likely to have good IPT adherence (P = 0.03, AOR = 1.51, 95% CI = 1.38–4.54).
| Discussion|| |
The study found that up to 158 (89.5%) of the respondents interviewed had good level of adherence to IPT and the main reasons reported by respondents for good adherence were disclosure to partner/relatives (81.3%), adequate counseling about IPT (62.8%), and awareness of IPT for TB prevention (55.2%). This, therefore, implies the need for scale up as adherence to IPT among HIV clients is optimal, but IPT uptake remains low.
Studies on IPT delivery have revealed variable rates of acceptance of and adherence to TB preventive therapy among populations at risk for TB, and this level of good adherence was reported by previous studies: IPT adherence rate among HIV-infected patients with a positive tuberculin skin test (TST) who had counseling and transport reimbursement was 87% in a study done in Dar es Salaam, Tanzania, while adherence to IPT in TSTs positive and non-TST-screened HIV-infected patients in Thailand was 84.5% and 79.7% by self-reporting and 81.8% and 73.9% by pill count monitoring., In 2014, a study on IPT adherence rate reported 86.5% adherence in 1 month among HIV-infected patients in Ethiopia. Similarly, a survey conducted in Ethiopia, where a total of 319 individual participated in the study. Within 7 days recall period, the self-reported dose adherence rate was 86.5%, a study on adherence to IPT among HIV patient in Uganda also showed similar finding with an adherence rate of 88% and another study assessed IPT completion and predictors among HIV-infected children and adults in two HIV clinics in Kinshasa, Democratic Republic of Congo. Between September 1, 2012 and June 15, 2013, 546 children (1–15 years) and 1532 adults (>15 years) were initiated on IPT; 86.6% (408/470) of children and 88.2% (1129/1280) of adults with an IPT outcome completed their therapy, while in Nigeria a survey conducted to determine the number of cases of HIV placed on IPT using a cross-sectional study (Enugu, Nigeria), in which HIV patients who were placed on the IPT were identified and followed up showed; of the 65 that started the IPT 63% (41) continued the 2nd month indicating a very poor adherence among the study.,,
Good level of adherence to IPT reported from this study may be due to the fact that majority of the respondent had receive information and adequate counseling about IPT and perceived benefit of the medication, use of strategies to improve adherence such as mobile phone reminders, influence of SG, and single daily dosing of INH. In contrast to results of these survey, a cross-sectional study found overall adherence rate for IPT was only 45%, in a 2010 study among patients attending chest clinics in New York City. Another study from Kinshasa (DR Congo) found that of the 87 patients initiating a 6-month IPT course of INH 300 mg daily, 47.1% (41) completed IPT. Of the 46 interrupters, 16 (34.7%) did not return to the clinic after receiving their first dose of IPT.
Adherence to IPT was found to be significantly associated with the respondent's level of education, IPT uptake, and counseling about IPT. Counseling and disclosure were found to remain independent predictors of adherence to IPT. Similar studies demonstrated and supported our finding. Therefore, health-care worker's should ensure proper counseling and encourage disclosure of HIV status, as this will improve self-esteem and enhanced adherence among all clients eligible for IPT.
| Conclusion|| |
Good level of adherence to IPT reported from this study implies that the need for improve strategies to ensure IPT scale up as adherence to IPT among HIV clients in Kano is optimal, but uptake remains low.
Ethical approval for the study was obtained from the Aminu Kano Teaching Hospital Health Research-Ethics Committee (NHREC/21/08/2008/AKTH/EC/2361). The informed written consent form was given to literate respondents to sign before the questionnaire was administered and for those who cannot read and write, details of the consent form were explained to them, and they subsequently append their thumbprint to the form to indicate consent. The Helsinki Declaration was respected throughout the research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]