Tuberculosis Preventive Treatment Update — U.S. President’s Emergency Plan for AIDS Relief, 36 Countries, 2016–2023

Discussion

PEPFAR has supported the widespread integration of TPT as part of the HIV standard of care. As a result, approximately 13 million persons with HIV have completed TPT. These TPT completions meaningfully contributed to the 2018 UNHLM target for TPT among persons with HIV, the only UNHLM target achieved (1).

TPT initiation rates among ART-naive clients help monitor adoption of TPT into routine practice and are expected to be higher than initiation rates among ART-experienced clients, who might have already completed a course of TPT. Trends in overall initiations provide insight into TPT scale-up over time because climbing initiation rates would be expected when programs are rolling out TPT to the existing patient population. Declining overall TPT initiation rates over time might suggest programmatic saturation, in which all eligible ART clients have already received TPT. Importantly, PEPFAR program data cannot be used to directly measure saturation because these data are not person-level, and TPT completion was not collected before FY17.

Although overall TPT initiation rates trended downward, the percentage of ART-naive clients who received TPT increased. These trends might be indicative of a prioritization of TPT provision for those newly initiated on ART. At the country level, TPT coverage might vary by clinical guidance, eligibility, or supply chain mechanisms. Initiation rates were similar by age and sex, suggesting these factors did not play a major role in TPT initiation overall. However, lower initiation rates were noted among younger ART-naive clients compared with those aged ≥15 years.

Findings from this analysis were consistent with other reports that found lower TPT completion rates among ART-naive clients (3). Lower TPT completion rates have been found to be associated with perceived stigma (4), which might be higher among those recently diagnosed with HIV (5). High levels of stigma related specifically to TPT have also been documented (6), and other barriers to TPT completion such as pill burden (7), lack of health education, and distance to health facilities (8) can affect ART-naive clients differently.

Limitations

The findings in this report are subject to at least four limitations. First, PEPFAR-wide results represent a diverse range of settings and populations, and the number of countries reporting TPT data varied over time.*** As a result, aggregated values might not reflect trends in individual countries or subnational units, and trends over time are not representative of a true cohort. Second, because TPT completion is often measured on the basis of pill dispensation and self-report rather than direct observation or biomarker monitoring, completion rates might be overestimated. Third, the data used for this analysis were collected in a programmatic setting for monitoring purposes. Data quality might fall short of the accuracy and precision of data collected for clinical studies or in other research settings. Finally, no person-level data were available, and data were reported in broad age bands (<15 and ≥15 years), precluding more specific analyses.

Implications for Public Health Practice

The steady increase in TPT completion rates suggests substantial improvements in HIV and TB service delivery, monitoring, and reporting practices. However, opportunities remain to ensure full TPT coverage and maximize the impact of TPT in reducing TB morbidity and mortality. An ongoing need exists to ensure all ART-naive clients receive the requisite support to access and complete a full course of TPT. Patient-level electronic medical record systems could be developed and expanded to better identify underserved geographic areas and subpopulations and to monitor outcomes over time. Offering patient-centered approaches to treatment delivery can help make health care access a positive and convenient experience for clients by aligning service delivery with their preferences and needs (9). Increasing access to short-course regimens for all could improve completion rates (2), and ensuring availability of pediatric TPT formulations might increase coverage among persons with HIV aged <15 years. Promoting the use of digital adherence tools, such as mobile telephone applications and electronic sensor-enabled pill boxes (10), could help support clients throughout the course of treatment. Finally, further population-level analyses could help determine whether TPT implementation has been associated with reductions in TB incidence and TB-attributable deaths in settings where broad TPT coverage was achieved. Importantly, lessons learned from TPT implementation in PEPFAR-supported programs might prove useful for TPT provision among other populations at risk, including household contacts of persons with TB.