Browsing by Author "Sauvé, Reg S."

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    The Effectiveness and Acceptability of Six-Month Isoniazid Preventive Therapy amongst People Living with HIV in KwaZulu-Natal, South Africa
    (2018-06-20) Boffa, Jody; Williamson, Tyler S.; Mayan, Maria J.; Fisher, Dina A.; Sauvé, Reg S.
    Tuberculosis (TB) preventive therapy is an integral part of global strategies to end TB. Isoniazid preventive therapy (IPT) is currently the only regimen recommended globally for low-resource settings with high burdens of TB and TB-HIV. In South Africa, where the incidence of TB and TB-HIV are among the highest in the world, health districts were quick to facilitate access to six-month IPT in the absence of active TB symptoms for all people living with HIV, amid numerous unknowns. My doctoral thesis responds to some of these unknowns; specifically, the effectiveness of IPT to reduce TB incidence and its acceptability in communities where latent TB infection was previously unfamiliar. The research occurred within a community-based participatory research framework including regular meetings with grassroots community advisory teams in three communities of uMgungundlovu District, KwaZulu-Natal. IPT effectiveness was evaluated utilising a retrospective cohort design, comparing TB incidence across two years among people receiving IPT alone, antiretroviral therapy (ART) alone, or IPT+ART to those without intervention. Acceptability was evaluated utilising the ethnographic method, including extensive field work, eight group interviews to learn about perspectives of TB infection, disease and IPT, and nine individual interviews with people accepting, discontinuing or declining IPT to learn about IPT experiences and decision making. Among those who completed the regimen, IPT significantly reduced the two-year TB incidence by 100% among women (97.5%CI=78-100%), with a less certain effect among men: IR=0.46, 95%CI=0-85%. IPT also appeared to provide additional prevention for people on ART. Nevertheless, IPT was interpreted by some as dangerous when the costs related to pill collection or consumption exacerbated poverty, the stigma associated with HIV and ART were conflated with its use, or it was seen as toxic. Clinical expectations of IPT initiation and adherence may also conflict with expectations of women in Zulu culture. Some women may initiate IPT to please the healthcare provider, rather than from a belief in preventive benefits. Taken together, findings suggest that IPT can reduce the risk of TB among people living with HIV, but may not be a high priority when economic and social needs compete.