Implementation of isoniazid preventive therapy among hiv infected children in three health facilities in Nairobi county
Abstract
Background: Approximately 9 million new cases of tuberculosis (TB) occur in the world
every year, 15% of these occur in children less than 15years. In Kenya, children comprise
11% of all tuberculosis cases. Kenya is position 15 of the 22 high tuberculosis burden
countries. 1, 2 Human immunodeficiency virus (HIV) infection increases the risk of
progression from latent tuberculosis to active disease by 20 to 37 fold.1 HIV infected
children have a much higher risk of active disease. Isoniazid preventive therapy has been
shown to reduce tuberculosis related morbidity by 72% and mortality by 54%.24 In 2013,
only 21% of countries globally and 14 out of the 41 high TB/HIV burden countries reported
provision of isoniazid preventive therapy (IPT) to people living with HIV.1 Following the
2011 Kenyan policy, data is needed to inform IPT implementation and scale up in our local
context.
Objectives: To determine the level of uptake of isoniazid preventive therapy among HIV
infected children in care at Kenyatta National Hospital. To evaluate knowledge and
practice of health workers at Kenyatta National Hospital, Mbagathi District Hospital and
Langata Health Centre regarding isoniazid preventive therapy in HIV infected children.
Study Design: This was a mixed method research combining a cross-sectional survey with
structured, in-depth, key informant interviews.
Methods
The study was carried out in paediatric wards, paediatric outpatient clinicsand paediatric
comprehensive HIV care clinic (CCC) at Kenyatta National Hospital and Mbagathi District
Hospital together with the paediatric outpatient clinics at Langata Health Centre.
We enrolled children aged 1 to 15 years with documented HIV infection receiving care in
Kenyatta National Hospital and consenting health care workers (HCW) in the pediatric
units at the three study facilities. We excluded children with active tuberculosis (TB)
together with those found to have contraindications to isoniazid.
We carried out consecutive recruitment of all HIV infected children aged 1 to 15 years
receiving care in the comprehensive care clinic and those admitted in the wards. A
questionnaire was administered to eligible child-caregiver pairs to assess knowledge and
prior or current use of isoniazid for TB prevention. Each child was screened for TB using
the WHO algorithm for TB screening followed by a complete physical examination and
review of available relevant investigations. We approached all HCW in the paediatric units
during the study period. A self-administered questionnaire was given to consenting HCW.
We also conducted key informant interviews of HCW in the KNH CCC.
Data collected was entered into preformed Access database and analyzed using SPSS
version 17.0.
Results: We enrolled 111 children with a median age of 8 (IQR 6.7- 9.6) years. Among
the children in the study 58.6% were male and 106 (96%) were on ART. Baseline CD4was
available for 104 children, 65% of these had a count of <500cells/µL. Majority (79%) had
a current absolute count of>500cells/µL. We observed that IPT uptake was53.2% (95% CI
43.9% - 62.4%) among eligible children. The study demonstrates good completion (88%)
of IPT once initiated. Caregiver education was found to be associated with better uptake of
IPT. Additionally, children whose caregivers had a history of being on IPT had an
increased likelihood of having received IPT (p<0.001, OR 27.50).Increase in baseline CD4
count of the child was associated with an increase in the probability of a child receiving
IPT (p = 0.007).
Of the 66 HCW interviewed 77% were working at KNH, 16% at Mbagathi DH and 6% at
Langata HC. The majority (47%) were postgraduate doctors working in the inpatient
department. The median duration in the paediatric unit was 15 (IQR 3 – 30) months.
Relatively few health workers expressed concern that isoniazid (INH) was not effective
enough (2%) or that the side effects were too dangerous (28.8%). Half of the health workers
had not prescribed INH within the previous year. Moreover, 19.7% indicate a preference
to wait to see whether a patient develops active TB, which can then be treated.
Conclusion: This study demonstrated poor implementation of existing IPT guidelines and
good completion (88%) of IPT once initiated. Half of the health workers had not prescribed
INH within the previous year. There is a need to scale up and strengthen IPT services.
Publisher
University of Nairobi