Between patients and prevention

New research suggests that the poor knowledge and attitudes of doctors and healthcare workers in South Africa are limiting access to preventative tuberculosis (TB) therapy.



The qualitative study by the health research non-profit, the Aurum Institute, found that many doctors and health workers shied away from prescribing isoniazid preventative therapy (IPT), in which daily doses of the antibiotic isoniazid are administered for at least six months to reduce TB risk in HIV-positive people.



The reasons most often cited by health professionals for not prescribing IPT included an inability to rule out active TB, little knowledge about IPT's benefits, and little confidence that patients would continue taking the medicine, said Dr Salome Charalambous, HIV/AIDS Programme Director at Aurum, who presented the research at the institute's annual symposium for health workers in Johannesburg.

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IPT can reduce the risk of active TB in people living with HIV by about a third, according to the World Health Organization (WHO). South Africa has had national guidelines for administering IPT since 2002, but coverage has been estimated at below 1 percent. Health workers interviewed for the study also said they felt the Department of Health had not done enough to communicate the current IPT guidelines to them.



The WHO lists TB as the leading killer of people living with HIV, and South Africa has an HIV prevalence rate of about 18 percent. The country also shoulders one of the world's highest TB burdens, according to the WHO.



"It's not to say everyone must be started on IPT, but there are a whole lot of people who could benefit from IPT but are not," Charalambous told IRIN/PlusNews.



More about the professionals, less about the patients



International and national guidelines caution doctors to avoid issuing preventative TB therapy in people who have active TB. Charalambous said the difficulty in diagnosing active TB, which can hide in tissue outside of the lungs, deterred many health professionals from using IPT.



"Standard pulmonary TB is not [present in] more than 30 percent of our patients, so sputum, abscess, lymph nodes, x-rays are very often negative. I would never use [isoniazid] on my patients for this reason alone,"  said a doctor quoted in the study.



Other doctors were not convinced of the value of giving IPT to patients already on antiretroviral (ARV) medication. Little research has been done on the effects of IPT on patients taking ARVs, but new findings presented by Aurum at the recent 2010 Conference on Retroviruses and Opportunistic Infections showed that IPT drastically decreased mortality in newly initiated ARV patients.



Aurum's qualitative study showed that health workers' attitudes to patients influenced their willingness to prescribe IPT. "It was interesting that staff felt that patients would not understand the concept of taking medication while feeling well, but when we asked patients they didn't say taking a preventative tablet would be a problem," Charalambous commented.



The researchers recommended that the Health Department clarify the screening process and initiation requirements for IPT, and that patients be educated about treatment options for preventing TB.



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