1644 - “And the stick to fight TB is IPT”: Perspectives on TPT Implementation Among Senior Nurses in Rural South Africa

Background: Tuberculosis (TB) disproportionately affects people living with HIV (PLH). The World Health Organization (WHO) has endorsed tuberculosis preventative therapy (TPT) in resource-limited settings with high HIV and TB burdens. South Africa has led global TPT efforts, yet implementation remains sub-optimal.

Methods: In a rural, impoverished region of South Africa with high TB and HIV prevalence, primary care clinic-based senior nurses were asked to participate in anonymous, semi-structured interviews assessing TPT knowledge, beliefs, and attitudes. The currently available regimen is isoniazid preventive therapy (IPT) for 12 months. Through an iterative process, a code list was generated and applied to each transcript. The data were analyzed using thematic analysis and Nvivo 12 software to identify facilitators and barriers to IPT prescribing.

Results: Among 22 nurses at 14 primary health clinics, 86% were female, median age 39 (IQR 31-54.8) years, with median 10.5 (IQR3-18) years of health care experience. Nurses felt that TPT was effective at preventing TB. Barriers to implementation included limited time to counsel patients due to understaffing in high-volume clinics and lack of documentation of IPT prescription in patients’ charts, which limited effective follow-up.  Nurses certified in Nurse-Initiated Management of Antiretroviral Therapy (NIMART) expressed confidence in their IPT knowledge, but those not certified wanted additional training. Nurses identified patient-level factors impeding TPT implementation, including transportation, HIV-related stigma, mobility, particularly among men, and pill burden associated with length of IPT (12 months) with concurrent daily chronic medications. Facilitators included availability of IPT in both hospitals and primary care clinics, and capacity for task-shifting to other healthcare professionals (counselors, staff nurses). The impending rollout of 3HP (12 weeks of isoniazid-rifapentine) was viewed favorably.

Conclusion: Nurses identified limited time to counsel PLH and lack of standardized training programs as the main barriers to implementation of TB preventative therapy. Addressing these barriers will be critical to successful implementation of new TPT regimens.