Patient-informed policy change: A qualitative study of barriers to free treatment for latent tuberculosis infection in Peruvian shantytowns

Background: Close contacts of patients with active tuberculosis in Peru are eligible for free latent tuberculosis infection treatment (LTBIT), which is safe and effective. However, only approximately 35% commence and 12% adequately complete LTBIT.

Objective: The reasons for this poor LTBIT uptake are poorly characterized so we addressed this knowledge gap with a qualitative study.

Methods: Semi-structured, qualitative interviews were conducted with members of households of patients with active tuberculosis disease to explore opportunities to improve uptake and adherence and help inform policy. Themes emerged through methodology modeled on Grounded Theory and were analyzed with the Dedoose program to find similarities in knowledge, beliefs and attitudes in the caretakers of tuberculosis patient contacts. The data were coded to reflect themes including time adhered to LTBIT, reasons for discontinuing use, barriers to LTBIT uptake, experience of the healthcare system, and tuberculosis knowledge.

Findings: Stigma and fear of tuberculosis and inaccurate tuberculosis knowledge were frequent. The most significant barriers to LTBIT uptake were a lack of awareness of LTBIT confounded by high indirect costs of accessing LTBIT. Families with no LTBIT uptake often expressed that they knew nothing about LTBIT and were unaware that it was recommended for them. Many also believed that giving healthy children pills would weaken them. Family members usually believed that tuberculosis was transmitted via cutlery, so believed that separate eating utensils were needed to protect children rather than LTBIT.

Conclusions: These patient-identified barriers to care are critical in developing tuberculosis preventive therapy policy changes in resource-limited settings.