Patient-reported barriers and facilitators
Almost all PLHIV were aware that their HIV-positive status put them at a higher risk of developing active TB and were willing to take 3HP to lower their risk. They also understood that TB can easily spread from person to person. Almost all were open to taking medicines if it was recommended by their health workers at the clinic in order to reduce their chances of contracting TB (Table 1).
“TB is a terrible disease; what I know about it is it spoils one of the organs and that is the lungs and once the lungs are spoilt then of course next is death……And I have seen very many people suffering from TB you wouldn’t like the same. So, if there is a chance of prevention, I welcome it”. (Middle-aged Male, PLHIV interview)
Most PLHIV preferred self-administration of 3HP as it would be cheaper, would suit their daily lives better and would allow them to take their medicines at their convenience.
“You are not inconvenienced. You can even take the medicine and finish it without anyone knowing that you are on medication. Even at work you will not be disturbed by having to seek permission”. (Middle-aged Female, PLHIV interview)
At the same time, the delivery of 3HP using the DOT strategy was perceived by PLHIV as potentially beneficial given greater contact with the health workers, who would ensure that they took the medication and could address any patient concerns or side effects.
Several of the PLHIV interviewed were: 1) unaware that TB could be prevented, 2) did not perceive the importance of TB preventive therapy or 3) queried the logic of treating someone who is not “sick” with TB:
“My thoughts are why you give me medicine if I am healthy…. You may find that God did not plan for them to die of the disease-causing organism for TB and yet they are taking medicine… No. I do not support that!” (Young Female, PLHIV interview)
PLHIV perceived the weekly 3HP dose, which consists of 11 tablets, as too many and potentially prohibitive. Some doubted their own ability to swallow 11 tablets at once:
“The problem is because for me I have been taking 2 tablets [Septrin and ARVs], now what has shocked me is taking 11 tablets. I don’t know the danger with taking because I have never taken such many tablets”. (Middle-aged Male, PLHIV interview)
PLHIV feared potential side effects, believing that the medicines used to treat TB were “tough” on the body and were concerned that they could arise especially when combined with their current ART regimens. Some of the participants were also concerned about the duration of protection afforded by 3HP:
“My concern might be, leave alone the side effects when you take it aren’t you very vulnerable to contract TB again…. So, I don’t know, will I be vulnerable to such TB or will I be protected”? (Middle-aged Female, PLHIV interview).
The weekly clinic appointments associated with DOT were perceived as costly in terms of transport, time, childcare, and absence from work. Those who resided far away from the clinic expressed additional concern:
“One challenge would be transport costs will be high…. Transport costs, sometimes time, and maybe getting permission from work”. (Young Female, PLHIV interview)
SAT as a delivery strategy was perceived to be convenient but some expressed that the lack of dosing supervision combined with the unusual once-weekly dosing schedule could potentially lead to poor adherence to 3HP:
“Now doctor, some people you can give them medicine and when they come here, and you ask them; did you take your medicine? They will say yes. But truthfully, they got 11 tablets, took three of them and stopped”. (Middle-aged Female, PLHIV interview)
Health worker-reported barriers and facilitators
All health workers interviewed mentioned that TB was the leading cause of severe illness and death among PLHIV in care at the clinic and perceived TB prevention as very important (Table 2).
“In this clinic, of the 16,000 patients, most are stable and if you look at the cause of mortality it is TB related. … So, it deserves much attention”. (Medical Doctor at the clinic)
Almost all the health workers felt that taking 11 tablets at once would be perceived as too high a pill burden, especially for those already struggling to adhere to their daily ART.
“…I have been concentrating on my triple [three daily ARV pills] and now you want to give me more medication. …some of them are not so positive about it.” (Medical Doctor at the clinic).
Yet, health workers believed that the fear of getting TB would motivate PLHIV to take and complete 3HP. They also conceded that the once-weekly dosing schedule of 3HP could convince some PLHIV to take it despite the potential pill burden.
“Taking it once a week rather than taking it daily much as the tablets are many. Maybe one will be like “anyway am taking many but once a week”. (Medical Doctor at the clinic)
Most health workers preferred to treat PLHIV using DOT to ascertain completion of the required doses but acknowledged that most PLHIV in their care would most likely prefer SAT given the implications of costs and convenience. Conflicting work schedules were also perceived as a potential challenge for weekly clinic appointments.
Health workers perceived inadequate knowledge about TB as a potential challenge for PLHIV to accept and complete 3HP. They noted that while most PLHIV knew the common signs and symptoms of TB, they still had misconceptions such as TB being hereditary, or transmitted through cigarette smoking and alcohol drinking. These misconceptions could potentially result in non-acceptance of TPT or poor adherence once initiated on treatment. They also noted that TB is a highly stigmatized disease both at the clinic and within the communities where patients reside. Due to this and drawing from their experiences at the clinic, some health workers believed that PLHIV would be uncomfortable to be seen taking TB medicines. Health workers also observed that PLHIV would be concerned about potential side effects, while others mistrusted any new medications:
“Balese biragala kututta.” (This literally means they have brought medications to kill us) … “And then other people think that the TB prevention medications, are very strong, they are very toxic that they will affect the liver and the kidney”. (Nurse at the clinic)
Finally, most health workers reported that they had never used technology to monitor drug adherence of PLHIV remotely and were uncertain about the reliability of adherence determined electronically:
“Technology no, mostly we depend on self-report, pill count, say I have been taking so what is your balance? Then you negotiate around that. Technology no.” (Nurse at the clinic)
Behavioral diagnosis and intervention options
The behavioral diagnosis obtained from the patient and provider reported barriers to acceptance and completion of 3HP encompassed all the six domains of the COM-B model (i.e., physical and psychological capability, physical and social opportunity as well as reflective and automatic motivation), as summarized in Table 3.
By linking the behavioral diagnosis obtained using the COM-B model to the BCW framework, we identified appropriate intervention functions that could be used to modify the behavior of both PLHIV and health workers to facilitate the acceptance and completion of 3HP (Table 4). These intervention functions included modifying the psychological capability of health workers through training on how to use digital adherence technology to monitor adherence of PLHIV to 3HP and solving the psychological capability barriers of PLHIV through education, which could help to address the misconceptions held by PLHIV about TB and TPT. The other intervention functions identified included use of dosing/appointment reminders to enable PLHIV to remember to take their once-weekly 3HP doses, the use of persuasion to convince PLHIV to accept 3HP and restructuring the clinic environment to reduce waiting time when patients present for TPT visits.