Infecting a third of the global population, M tuberculosis has a large pool of individuals from whom millions of active tuberculosis(TB) cases emerge annually. HIV infection is associated with a tenfold life-time risk of TB. Isoniazid preventive therapy(IPT) decreases TB risk by 65% and up to 80% when combined with antiretroviral therapy. Despite this benefit, countries have been slow in implementing this intervention. This study describes processes, outcomes and lessons learnt in IPT scale up in Kenya
We conducted a desk-review of guidelines, standard operating procedures(SOPs), Ministry of Health (MOH) and PEPFAR work plans, meeting notes, reports, and analyzed MOH IPT uptake and treatment outcome data from January 2014 to December 2016 in MS Excel®. Treatment outcomes were defined as: Treatment completed- completion of 6 month IPT; Dead- died while on IPT; Default- lost to followup; not evaluated- no outcome and; discontinued- stopped IPT. Results were presented as counts, percentages, and graph.
From 2009 to 2013, revision of national guidelines allowed wider IPT implementation, TB screening was institutionalized and Xpert MTB/RIF testing rolled out. Pilot projects were implemented, documented and used to inform scale-up. IPT was included in HIV and TB program performance contracts. A joint MOH, US government and implementing partner technical working group was formed, SOPs and materials for training of counties and site level staff developed and IPT launched nationally in 2015. Joint procurement planning was done, drugs purchased by the TB program and distributed by the HIV program. IPT was integrated into the standard package of HIV care and prioritized in HIV treatment acceleration initiatives. PEPFAR implementing partners (IP) were assigned targets and engaged in quarterly progress review meetings. IPT uptake among 1050000 PLHIVs increased almost 50-fold from 9,981 at end-2014 to 493436 in December 2016 and to 80% national coverage by August 2017. Among 28,483 patients initiating IPT in 2015 in 14 Nairobi sites, 90% completed treatment, 0.4% died, 4.9% defaulted, 2.0% were not evaluated and 3.0% were discontinued. Among those discontinued, 0.2% had TB while 0.5% had adverse drug reactions. Challenges included occasional stock out of drugs and reporting tools.
IPT can be scaled up with high completion rates. Strong MOH leadership, integration of IPT in routine HIV care, IP involvement, and accountability are critical to program success.