Abstract ID: 470

Author Name:Jintana Ngamvithayapong-Yanai

Email: jip@loxinfo.co.th

Presenter Name: Jintana Ngamvithayapong-YanaiAuthors: Ngamvithayapong-Yanai J1,2, Luangjina S1, Yanai H2, Sawanpanyalert P1

Institutions: TB/HIV Research Foundation, Thailand; Research Institute of Tuberculosis,Japanese Anti-Tuberculosis Association; JapanTitle: High Adherence to Isoniazid for TB Preventive Therapy among HIV-InfectedPersons in Chiang Rai, Thailand

Problem Statement: HIV is the most powerful risk factor for reactivating latent tuberculosis(TB) infection into TB disease. Isoniazid preventive therapy (IPT) is effective in reducing therisk of developing TB disease among asymptomatic people with HIV (PWH). Poor adherence toIPT challenges the efforts of TB control and HIV/AIDS care due to the social complexity ofHIV/AIDS.Objectives: To investigate the reasons for a high level of adherence to the nine-month IPT andto propose strategies for promoting adherence to IPT.Design: Qualitative study.Setting and Study Population: The study was conducted in a provincial hospital, where 412PWH were enrolled in the IPT program. We identified and invited 42 PWH who achieved a 95–100% adherence rate (measured by pill count) to participate in focus group discussions; only 28PWH could participate. Five focus groups were organized according to homogeneous attributes,including sex, marital status, education, and occupation. There was one group of single males,two groups of married males, one group of married females, and one group of widowed females.Results: The majority of participants completed primary school and were daily income earners.It took some of them 1.5–2 hours to travel from their homes to the hospital. All participantsaccepted their HIV status well, although most single males and some widowed females kept theirHIV status secret. The monthly visits to the IPT program was the only chance for theseparticipants to talk with providers about HIV. These participants were satisfied with the serviceand with the providers. Despite being good adherents, about one-quarter of the participants stilldid not know about the effect of isoniazid in preventing clinical tuberculosis. The most importantmotivation for good adherence was concern about their young children and aging parents. Thisconcern motivated them to prolong their lives by every method learned from the providers,including IPT. Without staff instruction, these participants developed their own medicinereminder systems, including marking a calendar after taking medication and keeping an isoniazidpackage or reminder message in visible locations linked to their daily activities, such as theplaces where they eat, drink, sleep, and change their clothes.Conclusions: A high level of adherence to IPT may be best achieved by building a goodrelationship between health staff and PWH and careful enrollment of PWH. IPT should beprovided only to people who accept their HIV status. The medicine reminder systems developedby adherent PWH can be shared with other PWH in other settings.

Study Funding: Japanese Foundation for AIDS Prevention and Ministry of Health, Welfare, andLabor, Japan

Abbreviations:FGD = Focus Group Discussion

INH = Isoniazid

IPT = Isoniazid Preventive Therapy for TB

PWH = People with HIV-infection

DOT = Directly observed treatment

Background:• HIV is the most powerful risk factor for reactivating latent TB infection into TB disease

• IPT is effective in reducing the risk of developing TB disease among PWH

• Adherence to the 9-months IPT is challenging due to social complexity of HIV

• Chiang Rai is one of the provinces with some of the highest rate of TB and HIV. AIDS is the leading cause of death in the province (164.4/100,000). TB has re-emerged as a public health problem in the province due to the HIV/AIDS epidemic since 1992.

Cambodia

Myanmar

China

Laos

Vietnam

Bangkok

Chiang Rai

Population 1.2 millions (hill tribe 13 %)

93% completed compulsory education

1 regional hospital, 16 district hospitals,

212 health centers, 3 private hospitals

Chiang Rai, Thailand

0

20

40

60

80

100

120

140

160

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

HIV-negative

HIV-unknown

HIV-positive

New TB rate by HIV status per 100,000 persons

Chiang Rai Province (1987-2000)

Year

TB/HIV Research Project, RIT-JATA

Study setting and population• Chiang Rai Regional Hospital• Of the 412 PWH (enrolled in IPT program), 42 PWH who achieved 95-100% adherence rate were invited to participate in FGD

Objective• To investigate the reasons for a high level of adherence to the nine-month IPT and to propose strategies for promoting adherence to IPT

Definition95-100 % adherence rate = Through pill-counting during the 9-month therapy, the clients take 95-100% of total number of INH pills

Method• Forty-two PWH were identified and invited to participate in the FGD; only 28 PWH could participate.

• Five sessions of FGD were conducted by the same moderator (without the presence of health service providers)one group of single males; two groups of married males; one group of married females and one group of widowed females.

• Each discussion was composed with 5-8 participants. The session lasted for 2 - 2.30 hours.

• All discussions were tape recorded and transcribed verbatim. Qualitative content analysis was applied.

Free of charge Monday-Friday 8:00 a.m.- 4:00 p.m. One nurse one clerk (take turn) Use of follow up letter if miss-appointment >

1 week No home visit due to confidentiality issue

TB/HIV Research Project(RIT-JATA)TB/HIV Research Project(RIT-JATA)

Regimen

Daily 300 mg. of INH and vitamin B complex for 9 months (one month supply)

Characteristic of IPT service

Result

Reasons for achieving 95-100%

adherence rate

• Concern about young children and aging parents. Needs to prolong life in order to take care of family.

• Trust in doctor/nurse. Everything recommended by doctors should be good things and should follow

• Accepted HIV status well

• Need to discuss with health staff. Participating in IPT service was a good opportunity to discuss and to consult about HIV related psycho-social issues.

“I donated blood and I was told that my blood is positive. I do not have risk to be infected by AIDS. But the doctor told me my blood is positive. I have to believe doctor. When doctor introduced medicine (INH) to me I believed the medicine is good otherwise doctor will not prescribe. I do not remember what medicine is for” (A 52 years old HIV-positive man)

“ ...I live in dormitory. Nobody knows ab out my HIV positive. Every morning I ha

ve to make up my face. I can not put the medicine (INH) on my cosmetic desk be

cause my friends will suspect why I hav e to take medicine. So I put a reminding

message on the cosmetic desk to be re ad as “Have you brushed your teeth thi

s morning?”. When I see this message, I will take the medicine.”

(An HIV-positive homosexual young man)

Is DOT needed?• Several participants in the married male group reported that their wives reminded them to take INH. The other groups mostly took pills by themselves.

• Very occasionally, some participants forgot taking pills for 1-2 days because of stay overnight outside house, too busy with the funeral service or taking care of sick spouses.

• Without staff instruction, these participants developed their own medicine reminder systems, including:

-marking a calendar after taking pills

-putting reminder message in visible locations

-putting INH package in the locations which were linked to their daily activities such the place where they eat, drink, sleep, change clothes, watch television, cosmetic desk

HIV-positive widow

My husband already died. My motheris 70 years old. My daughter is onlytwo years old. Who will take care themif I die? I must be healthy to f eedmy f amily. I will take any medicine toprolong my lif e.

Only staff in this clinic (I PT clinic) knowabout my HI V. Nobody in my f amily orf riends know about my blood test result.Coming to I PT clinic is the only way that Ican find somebody who I can talk about myHI V…to release my stress and myworrisome. My parents are old. They will behurtf ul if they become to know that I aminf ected with HI V.

Medicine Reminder Systems(developed by adherent

clients)

Medicine Reminder Systems(developed by adherent

clients)

…storing medicine in a visiblelocation...

…storing medicine in a visiblelocation...

TB/HIV Research Project(RI T- J ATA)TB/HIV Research Project(RI T- J ATA)

Acknowledgement

• Japanese Foundation for AIDS Prevention (JFAP) and Ministry of Health, Welfare and Labor, Japan supported the study

• Dr.Renu Srismith, Dr.Wat Uthaivoravit and staff nurses of Social Preventive Medicine Department, Chiang Rai Hospital for approval the study and their kind collaboration.

• All participants kindly participated in the focus group discussion

ConclusionA high level of adherence to IPT are due to concern about young children and aging parents; good relationship between health staff and clients; well acceptance of HIV status. Without DOT, high adherence could be achieved through the medicine reminder systems developed by clients.