Many factors were identified to shape delivery and uptake of IPT in the region. The results of this study are presented below based on the five major domains of CFIR namely: characteristics of intervention, characteristics of individuals, process of implementing the intervention, inner settings and outer settings.
Characteristics of the IPT intervention
Although it was adopted from the WHO, observed evidences of IPT in preventing active TB cases among PLHIV and adaptability of the intervention to local contexts led to it being supported by local actors such as healthcare providers, the media, government, civil society organizations and patients.
“We got guideline from WHO that eligible (HIV) clients should be started on IPT. Since we do follow and contextualize WHO directives, we started processes of implementing. Despite being sourced outside, I don’t think this was of any problem because we as government and other stakeholders worked together on this like many other interventions”(Health Administrator)
IPT is provided for free of charge at all the clinics, like other TB and HIV related services, and this facilitated its implementation in the region. However, costs incurred monthly by patients to get to clinics, posed a barrier for some of them. Adverse side effects and complexities associated with the use of Isoniazid such as long duration, pill burden, long queues at the clinics and nausea and numbness discouraged some of the patients to undertake or complete IPT regimen.
“First of all, we take the drugs for long time-six months is longer. So, if possible, the duration perhaps should be reduced. Yes, you take once daily but for six months. It’s so long. There are some people who can’t take for all six months and thus stop taking the drugs” (Expert Client)
Characteristics of Individuals involved in IPT delivery and uptake
Majority of the participants demonstrated good knowledge about IPT in terms of what it is and that it is given to prevent progress from latent TB infection into active TB disease. Such understanding helped them to build trust and get committed towards the intervention and that opting to deliver or undertake IPT was the right thing do in order to reduce burden and deaths related to TB among PLHIV and protect the community.
“IPT is an intervention to protect people living with HIV from getting TB disease. IPT as IPT is provided to all eligible clients regardless of their age for a duration of six month” (Clinician)
However, despite being on IPT, few patients still could not tell exactly what it was and why were they given the drug. The confidence is one’s ability to execute the intervention as guided by guidelines or clinicians, for patients, was critical towards implementation of IPT. When asked of how she understood IPT, one patient replied:
“I don’t know what it means. We are just given drugs for prevention of Tuberculosis but I don’t know what does that mean” (Patient)
Organizational Processes Of Delivering Ipt Intervention
Engagement of stakeholders including those at the lowest level of implementation and the patients in different processing of implementation and decision making such as planning, delivery of IPT and evaluation of implementation of the intervention in the region, not only promoted ownership but also facilitated implementation of IPT.
“Since I joined HIV services, I think one of the good things I have seen is that if there are changes, we clinicians are usually informed and our leaders will go to the meetings to plan how to adopt the changes in our works. I like that because it makes my work easy” (Clinician)
“There are monthly reports that indicate how many patients we have been able to cover and how many patients have completed the regimen within a particular month. So, every month we get a report on IPT completion” (Clinician)
Characteristics within institutions delivering IPT intervention
Close working connectedness among units within the facilities delivering IPT intervention such as laboratory unit, radiology unit and pharmacy and good communication among them helped to ensure uninterrupted and well-coordinated delivery of TB/HIV services including IPT.
“(….) every section does its job: laboratory, radiology unit and counselling. Every people play their roles to help patients. For me, I see a patient, listen to him and prescribe. But when I want blood tests, I send them outside to that room opposite to my office which is our Laboratory” (Clinician)
Implementation readiness characterised by availability of supplies such as drugs, financial and non-financial incentives and learning climate that enable sharing of experience and skills and delegation of tasks had positive influence for delivery of IPT to eligible patients.
“She (District HIV Coordinator), has a lot to do and meetings to attend. She sometimes cannot do all and she will ask some of us to do it. For example, today she is not here, she went to the other CTC for supervision so she asked me to prepare this report. (……) Of course, it feels good when you can also teach others since it makes you confident” (Clinician)
However, inadequate number of clinicians to some of the clinics left the present ones overwhelmed large number of patients to be served and thus prohibited effective delivery of IPT, among other TB/HIV related services.
“…when you go to facilities with enough staff, there is exit desk to ensure a client has received all and correct services and next appointment was provided. But now if I do all those processes, I forget offering IPT to a patient then I start looking for the file so as I can call the patient” (Clinician)
Factors external to the organizations delivering IPT.
Facilities delivering IPT in the region have developed networking among themselves and this enables exchange of supplies such that deficit of supplies in one facility can not interrupt delivery of IPT. This networking has also caused competitive pressure among the facilities towards attaining targets which are set in collaboration between facilities, supporting organizations and authority in the region. All these combined largely influenced implementation of this intervention in the region.
“Cooperation between our facility and others exists and may include sharing of drugs. When they have no drugs, they will borrow from us because here drugs are easily available and one may tell you “Give me three boxes, I will bring it back when I receive my stock” (Clinician)
Although disclosing HIV status to relatives such as spouses and parents was generally accepted as important for getting treatment support, HIV stigma caused some of the patients not to do it which affected their uptake IPT. When asked whether it was important to disclose the HIV status, two patients said:
“Yes, it is very important (disclosing HIV status) because you may get sick or it may be your clinic visit date and someone should take you. You fail to ask someone to collect your drugs. It is very, very important but the question is how to get someone to disclose to. That’s a challenge that gives me headache” (Patient)
To some of the patients, religious teachings were reported to influence their decision to uptake the intervention. Some of the HIV patients, despite being eligible for IPT, may refuse the intervention, believing that for them being religious, there was no chance to contract active TB disease. Describing an incidence that she once faced, one clinician narrated:
“(….) we used to tell her to bring back the empty packages for verification, now since she was a religious person, she could not lie. She used to keep the drugs at home and when she felt like we insisted much to see the used empty packages, she brought all the drugs: “here are your drugs, I am not taking it. I am (mentions her religion), I believe I won’t suffer from TB disease” (Clinician)