Predictors of suboptimal adherence to isoniazid preventive therapy among adolescents and children living with HIV

A systematic review exploring the role of tuberculosis stigma on test and treatment uptake for tuberculosis infection

BACKGROUND

Tuberculosis (TB) stigma may be a barrier to engagement in testing and treatment for TB infection (TBI). We systematically reviewed the available evidence on how TB stigma influences engagement with TBI testing and treatment.

METHODS

Electronic databases (e.g., CINAHL, Central, OVID) were searched from 1963 to 1st August 2024. Quantitative, qualitative, and mixed-method studies reporting the effects of TB stigma on engagement with TBI testing and treatment were included in the review. Descriptive synthesis was applied to the quantitative studies, and thematic analysis was applied to qualitative studies. The risk of bias was assessed by using the mixed methods appraisal tool.

RESULTS

Seventeen studies were included in the review (12 qualitative, four quantitative and one mixed methods). TB stigma was complex and multifactorial with six overlapping domains: public, anticipated, self, experienced, secondary, and structural. Perceptions or experiences of stigma were associated with lower rates of engagement in testing and adherence to treatment in TBI.

CONCLUSIONS

Perceptions of TB stigma among people with TBI were related to the common social representation of TB disease such as its being contagious or disease of the poor. Negative perceptions of active TB appear to carry over to its infection, despite people being informed about the nature of TBI. Our findings could inform more effective communication to support TBI testing and treatment engagement.

Machine learning model to predict the adherence of tuberculosis patients experiencing increased levels of liver enzymes in Indonesia

Indonesia is still the second-highest tuberculosis burden country in the world. The antituberculosis adverse drug reaction and adherence may influence the success of treatment. The objective of this study is to define the model for predicting the adherence in tuberculosis patients, based on the increased level of liver enzymes. The longitudinal study using adult tuberculosis patients treated with the first line of antituberculosis was conducted prospectively. The pregnant women and patients with complications such as gout, diabetes mellitus, liver disorder and HIV were excluded. We measured the total bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) and adherence over the 2nd, 4th, and 6th months of the treatment. We used the ORANGE Data mining as the machine learning to predict the adherence. We recruited 201 patients, whereas the male participants and less than 61 years old as the dominant participants. Around 33%, 35% and 35% tuberculosis patients experienced the increase level of bilirubine, ALT and AST, respectively. There were significant differences in ALT and AST between good and poor adherence groups, especially in the female patients. The Neural Network and Random Forests were the most suitable models to predict tuberculosis patients' adherence with good Area Under The Curve (AUC).

Person-centered and youth-oriented interventions to improve TB Care for adolescents and young adults

INTRODUCTION

Globally adolescents and young adults (AYA) with tuberculosis (TB) face unique challenges. Until recently they have received little attention and few tailored interventions exist. To improve TB outcomes in this population, there is a need to implement tailored interventions. However, limited research has been conducted about how to meet the needs of AYA with tuberculosis. In this paper we present the findings of a qualitative study to explore the needs of AYA with TB in Zimbabwe and to identify interventions to optimize their engagement in TB care.

METHODS

We conducted two participatory workshops with 16 AYA, aged 10-24 years diagnosed with TB to explore their experiences of TB disease and treatment. Through subsequent interviews with 15 of the same AYA and with two other key stakeholder groups (health care providers n = 11 and policy makers n = 9), we sought to identify areas of convergence and divergence about what youth-orientated services and policies would be effective in Zimbabwe. Qualitative data were analyzed iteratively and thematically.

RESULTS

The findings are presented to align with four levels of a socio-ecological framework: individual, community, health system and policy. All three stakeholder groups highlighted the unmet mental health and TB literacy needs of AYA, which are particularly acute early in their TB care journey, as well as the imperative of engendering family support and securing the continuity of educational or employment opportunities during and after receiving TB care. There was a consensus that clinical services needed to become more youth-centered by extending training for health care providers and investing in peer-delivered psychosocial support. More broadly, there was also a strong consensus that adolescent-specific TB policies require further development and implementation, accompanied by community-based TB education and awareness campaigns to emphasize the curability of TB and to reduce TB related stigma.

CONCLUSIONS

There is much to be done to improve TB care for AYA. We found that there is need for alignment on where investment is needed to support the development of context-appropriate and effective interventions. There is an opportunity to benefit from translational learning from other successful approaches, such as HIV, within the region. Implementation of evidence-based interventions and youth-friendly policies and programs are much needed to improve outcomes for AYA with TB.

Completion of isoniazid preventive therapy for latent tuberculosis infection among children and adolescents compared to adults living with HIV in Kinshasa, Democratic Republic of the Congo

BACKGROUND

Little is known about isoniazid preventive therapy (IPT) completion rates among children or adolescents compared to adults living with HIV in Kinshasa, Democratic Republic of the Congo (DRC).

METHODS

We conducted a retrospective cohort analysis including children, adolescents, and adults living with HIV who were treated at FHI360 and partners-implemented HIV care programs at six health zones in Kinshasa, DRC, from 2004 to 2020. The primary outcome was the proportion of children, adolescents versus adults who did complete 6 months of daily self-administered IPT. Log-binomial regression assessed independent predictors of IPT non-completion and Kaplan-Meier technique for survival analysis.

RESULTS

Of 11,691 eligible patients on ART who initiated IPT, 429 were children (<11 years), 804 adolescents (11-19 years), and 10,458 adults (≥20 years). The median age was 7 (IQR: 3-9) years for children, 15 (IQR: 13-17) years for adolescents, and 43 (35-51) years for adults. Among those who were initiated on IPT, 5625 out of 11,691 people living with HIV (PLHIV) had IPT completion outcome results, and an overall 3457/5625 (61.5%) completion rate was documented. Compared to adults, children and adolescents were less likely to complete IPT [104/199 (52.3%) and 268/525 (51.0%), respectively, vs. 3085/4901 (62.9%)]. After adjustment, the only independent predictors for IPT non-completion were health zone of residence and type of ART regimen. Kaplan-Meier analysis showed comparable poor survival among patients who completed IPT versus those who did not (p-value for log-rank test, 0.15).

CONCLUSIONS

The overall sub-optimal IPT completion rate in adults as well as children/adolescents in this setting is of great concern. Prospective studies are needed to elucidate the specific barriers to IPT completion among children, adolescents, and adults in DRC as well as the scale-up of evidence-informed interventions to improve IPT completion, such as adoption of shorter TB preventive regimens.

Community-based tuberculosis contact management: Caregiver experience and factors promoting adherence to preventive therapy

Delivery of tuberculosis preventive therapy (TPT) for children with household exposure to tuberculosis is a globally supported intervention to reduce the impact of tuberculosis disease (TB) in vulnerable children; however, it is sub-optimally implemented in most high-burden settings. As part of a community-based household contact management program, we evaluated predictors of adherence to community based TPT in children and performed qualitative assessments of caregiver experiences. The Vikela Ekhaya (Protect the Home) project was a community-based household contact management program implemented between 2019 and 2020 in the Hhohho Region of Eswatini. At home visits, contact management teams screened children for TB, initiated TPT when indicated and performed follow-up assessments reviewing TPT adherence. TPT non-adherence was defined as either two self-reported missed doses or a pill count indicating at least two missed doses, and risk factors were evaluated using multivariate clustered Cox regression models. Semi-structured interviews were performed with caregivers to assess acceptability of home visits for TPT administration. In total, 278 children under 15 years initiated TPT and 96% completed TPT through the Vikela Ekhaya project. Risk factors for TPT non-adherence among children initiating 3HR included low family income (adjusted hazard ratio (aHR) 2.3, 95%CI 1.2-4.4), female gender of the child (aHR 2.5, 95% CI 1.4-5.0) and an urban living environment (aHR 3.1, 95%CI 1.6-6.0). Children with non-adherence at the first follow-up visit were 9.1 fold more likely not to complete therapy. Caregivers indicated an appreciation for community services, citing increased comfort, reduced cost, and support from community members. Our results are supportive of recent World Health Organization (WHO) recommendations for decentralization of TB preventive services. Here, we identify populations that may benefit from additional support to promote TPT adherence, but overall demonstrate a clear preference for and excellent outcomes with community based TPT delivery.

Tuberculosis in Children Living With HIV: Ongoing Progress and Challenges

There has been much recent progress on control of the tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics globally. However, advances in children have lagged behind, and TB-HIV coinfection continues to be a major driver of pediatric mortality in many settings. This review highlights recent research findings in the areas of prevention, diagnosis, and treatment of HIV-associated childhood TB. Key areas for future research are defined. Current prevention efforts such as vaccination, TB symptom screening, and TB preventive treatment are demonstrated as beneficial but need to be optimized for children living with HIV (CLHIV). Diagnosis of HIV-associated TB in children remains a major challenge, depending heavily on clinicians' ability to judge an array of signs, symptoms, and imaging findings, but there are a growing number of promising diagnostic tools with improved accuracy and feasibility. Treatment of TB-HIV coinfection has also seen recent progress with more evidence demonstrating the safety and effectiveness of shorter regimens for treatment of TB infection and disease and improved understanding of interactions between antiretrovirals and TB medications. However, several evidence gaps on drug-drug interactions persist, especially for young children and those with drug-resistant TB. Accelerated efforts are needed in these areas to build upon current progress and reduce the burden of TB on CLHIV.

Social Determinants of Adherence to Treatment for Tuberculosis Infection and Disease Among Children, Adolescents, and Young Adults: A Narrative Review

Global efforts to eliminate tuberculosis (TB) must address the unique barriers that children (ages 0 through 9 years) and adolescents/young adults (AYA; ages 10 through 24 years) face in adhering to treatment for TB infection and disease. We conducted a narrative review to summarize current knowledge on the social determinants of treatment adherence among these age groups to guide efforts and policy to address their unique needs. Our findings revealed that research on TB treatment adherence among children and AYA is still in its nascent stage. The current literature revealed structural/community-, health system-, household-, and individual-level factors that influence treatment adherence and varied with developmental stage. There is a need to develop multilevel interventions to address the unique challenges that children and AYA face in adhering to TB treatment.

Long-Term Real-World Effectiveness of Aripiprazole Once-Monthly. Treatment Persistence and Its Correlates in the Italian and Spanish Clinical Practice: A Pooled Analysis

BACKGROUND

One of the most significant risk factors for relapse and hospitalization in schizophrenia is non-adherence to antipsychotic medications, very common in patients with schizophrenia. The aim of this analysis was to evaluate the treatment persistence to aripiprazole once-monthly (AOM) and the factors affecting it in the pooled population of two similar studies performed previously in two different European countries.

METHODS

Pooled analysis of two non-interventional, retrospective, patient record-based studies: DOMINO and PROSIGO. Both analyzed treatment persistence after starting AOM treatment in the real-world setting. The primary variable was persistence with AOM treatment during the first 6 months after treatment initiation. A multivariate Cox regression model was used to evaluate the influence of several baseline characteristics on the persistence.

RESULTS

The study population comprised 352 patients included in the two studies, DOMINO (n = 261) and PROSIGO (n = 91). The overall persistence with AOM treatment at the end of the 6-month observation period was 82.4%. The multivariate analysis showed that patients with "secondary school" level of education present a 67.4% lower risk of discontinuation within 6 months after AOM initiation when compared with "no/compulsory education patients" (p = 0.024). In addition, patients with an occupation present a 62.7% lower risk of discontinuation when compared with unemployed patients (p = 0.023). Regarding clinical history, patients with a Clinical Global Impression-Severity scale (CGI-S) score ≤3 present a 78.1% lower risk of discontinuation when compared with patients with a CGI-S score ≥6 (p = 0.044), while patients with a time since schizophrenia diagnosis ≤8.4 years present a 52.9% lower risk of discontinuation when compared with the rest of patients (p = 0.039).

CONCLUSION

The AOM persistence rate observed in this study was 82.4%, which was higher than that reported in clinical trials, aligned with other real-life studies and higher than reported for other long-acting injectable antipsychotics. The persistence rate was high in complex patients, although patients with higher level of education, active occupation, lower initial CGI-S score and shorter time since the diagnosis of schizophrenia appear to be more likely to remain persistent with AOM during the 6 months after initiation.

HIV-Associated Tuberculosis in Children and Adolescents: Evolving Epidemiology, Screening, Prevention and Management Strategies

Children and adolescents living with HIV continue to be impacted disproportionately by tuberculosis as compared to peers without HIV. HIV can impact TB screening and diagnosis by altering screening and diagnostic test performance and can complicate prevention and treatment strategies due to drug-drug interactions. Post-tuberculosis lung disease is an underappreciated phenomenon in children and adolescents, but is more commonly observed in children and adolescents with HIV-associated tuberculosis. This review presents new data related to HIV-associated TB in children and adolescents. Data on the epidemiology of HIV-associated TB suggests that an elevated risk of TB in children and adolescents with HIV persists even with broad implementation of ART. Recent guidance also indicates the need for new screening strategies for HIV-associated TB. There have been major advances in the availability of new antiretroviral medications and also TB prevention options for children, but these advances have come with additional questions surrounding drug-drug interactions and dosing in younger age groups. Finally, we review new approaches to manage post-TB lung disease in children living with HIV. Collectively, we present data on the rapidly evolving field of HIV-associated child tuberculosis. This evolution offers new management opportunities for children and adolescents living with HIV while also generating new questions for additional research.

The Impact of Tuberculosis on the Well-Being of Adolescents and Young Adults

The health needs of adolescents and young adults (AYAs) have been neglected in tuberculosis (TB) care, control, and research. AYAs, who are distinct from younger children and older adults, undergo dynamic physical, psychological, emotional, cognitive, and social development. Five domains of adolescent well-being are crucial to a successful transition between childhood and adulthood: (1) Good health; (2) connectedness and contribution to society; (3) safety and a supportive environment; (4) learning, competence, education, skills, and employability; and (5) agency and resilience. This review summarizes the evidence of the impact of TB disease and treatment on these five domains of AYA well-being.

Tuberculosis in Adolescents and Young Adults: Emerging Data on TB Transmission and Prevention among Vulnerable Young People

Adolescents and young adults (AYA, ages 10-24 years) comprise a uniquely important but understudied population in global efforts to end tuberculosis (TB), the leading infectious cause of death by a single agent worldwide prior to the COVID-19 pandemic. While TB prevention and care strategies often overlook AYA by grouping them with either children or adults, AYA have particular physiologic, developmental, and social characteristics that require dedicated approaches. This review describes current evidence on the prevention and control of TB among AYA, including approaches to TB screening, dynamics of TB transmission among AYA, and management challenges within the context of unique developmental needs. Challenges are considered for vulnerable groups of AYA such as migrants and refugees; AYA experiencing homelessness, incarceration, or substance use; and AYA living with HIV. We outline areas for needed research and implementation strategies to address TB among AYA globally.