Improving coverage and completion rate of isoniazid preventive therapy among eligible HIV patients using quality improvement approaches: a case study of State Hospital, Ijebu Ode, Ogun State, Nigeria

Introduction Tuberculosis (TB) is a major killer of people living with HIV. One key strategy to reduce the incidence of tuberculosis in HIV patients is the use of Isoniazid Preventive Therapy (IPT). However, coverage of IPT among eligible HIV clients is poor. This study aims to improve IPT coverage using quality improvement approaches that help identify the root cause and improve coverage of isoniazid preventive therapy. Methods The quality improvement (QI) project spanned over six months corresponding to three PDSA cycles. Root causes for low IPT initiation and completion in State Hospital Ijebu Ode were identified using fishbone analysis. The root causes were subjected to prioritization matrix and implementation plan was developed for the first two root causes with the highest composite matrix scores. Longitudinal data were collected over the six months period with learning session at the end of every two-month PDSA cycle. Data was analyzed using Microsoft Excel 2010 and presented in charts and tables. Results The two most contributory factors to low IPT initiation and completion in the facility with prioritization matrix scores of 30 and 25 respectively were poor tracking system for IPT eligible clients and poor documentation of IPT commencement in the patients care cards and IPT registers. Findings showed improvement in both IPT initiation and completion with increase in initiation rate from 11% to above 50%, and increase in completion rate from 53% to 95.4%. Conclusion The use of quality improvement approaches can improve coverage and completion rate of IPT among eligible HIV patients. Government and health programmers should support facilities to apply QI approaches to solving health service delivery.


Introduction
TB is a leading preventive cause of death among People Living with HIV (PLHIV). According to the Global tuberculosis report (2017), an estimated 300,000 death among PLHIV were due to tuberculosis in 2017 [1]. Africa accounts for 72% of PLHIV who had tuberculosis in 2017 [1]. Antiretroviral Therapy (ART) reduces, but does not eliminate the risk of TB disease among PLHIV [2,3]. The World Health Organization recommends Isoniazid Preventive Therapy (IPT) for PLHIV as part of the TB prevention package that includes infection control and intensified TB case finding-the 3 I's [4]. Despite the WHO recommendation and the adoption of the IPT recommendation in the Nigeria national guidelines for HIV prevention, treatment and care, the TB preventive treatment coverage among PLHIV newly enrolled in care in Nigeria was 39% [1,5]. Despite the evidence-based benefits of IPT initiation among eligible PLHIV, a number of poor resource countries like Nigeria have documented low IPT coverage, citing reasons such as stock-outs of isoniazid, adherence issues, fear of developing resistance to isoniazid, pill burden and fear of side effects [6,7]. This study therefore aims to show that using quality improvement methodology can help to identify the priority root causes of poor coverage and improve TB preventive treatment coverage in poor resource setting.

Results
The two most contributory factors to low IPT initiation in the facility with prioritization matrix scores of 30 and 25 respectively were poor

Discussion
In developing countries, isoniazid preventive therapy for PLHIV has shown not to have received much emphasis [10]. The 2013 WHO TB control report estimated that less than 0.5% of HIV infected persons worldwide received IPT [11]. The overview of this study is to show that the use of quality improvement methods can help to prioritize the root causes of poor coverage of IPT and also improve TB preventive treatment coverage in poor resource setting. A preventive therapy service requires supervision of clients for a long period of time which may not be effective if there is a large work load of clients by the health personnel. In this study, it was discovered that poor tracking system of patients eligible for IPT was a contributory factor to a low uptake of this medication which was similar to result found in a study with 0.4% coverage rate of IPT among eligible PLHIV [12]. This is less than the ideal coverage of a preventive service proven to reduce morbidity and to a lesser extent mortality related TB among PLHIV. However, the other matrix score with high contributory factor to poor coverage of IPT in this study was poor documentation of IPT commencement in the care cards and IPT registers. One can really deduce that there is a need to enforce role of ART treatment programs as they bring in more organization and resources through effective trainings to build capacity of the health care workers. The matrix ranking method used is a versatile tool to help the professionals facilitate decision making and determine the sequence in which to attack the problem or work towards the objective. Other factor with lower matrix scores in the study is missed appointments which was in relation to what was found in a study by Mesele Mindachew et al. [13].
In organizational context, the heavy workload on health care providers from initiating IPT, considering the fear of adherence and associated side effects which may occur among the patients is a key issue that must be focused on. Heavy workload among health providers can often result in compromised quality and should be addressed as part of organization context reforms to support IPT [14] which gave a clearer picture of the findings in our study. Furthermore in our findings, the main barrier hindering implementation of IPT uptake were predominantly related to Isoniazid supply problems of (stock out) concerns and the development side effects which was similar to what was found in another study in Ethiopia on PLHIV [15].
The non-availability of INH was also reported by Getahun et al. [11] in their study. Differences in access to Isoniazid could have contributed to the lower coverage observed in the Northern part of Teklay [15]. The side effects from a study by Durovni et al. [16] reported that 1.2% of persons initiating IPT discontinued therapy due to adverse reactions which is similar to factors identified as a low contributory factor of side effects in this study. The uptake rate of IPT was above the current national coverage but fell below the national set target of 90% [17] in a study in Kenya as a contrast to what was observed as low uptake of IPT in this study.

What this study adds
 Use of quality improvement approach to identify root causes of poor IPT coverage;  Documentation, coverage and completion of isoniazid preventive therapy can be improved using quality improvement approaches.      -Immediate documentation of IPT initiation by the clinician.

Table and figures
-IPT initiation will be available in the clients' care card and IPT register.
-Number of clients initiated on IPT was documented by the clinician. -Immediate documentation by the pharmacist into IPT register.
-Timely documentation of IPT commencement into IPT register and pharmacy database.
-Number of clients initiated on and documented in IPT register.