Clinic and Provider Innovations to Improve Tuberculosis Infection Screening and Preventive Therapy Uptake in Brazil: Qualitative Findings From the PREVINE-TB Study

Abstract

Introduction

Diagnosing and treating tuberculosis (TB) infection are critical to reducing TB mortality among people with HIV (PLHIV). Blood-based screening using QuantiFERON-TB Gold Plus (QFT+) and shorter-course TB preventive therapy (TPT) regimens such as 3-month weekly isoniazid and rifapentine (3HP) hold promise to improve TB outcomes.

Methods

We conducted 38 qualitative interviews to explore implementation challenges and solutions related to QFT+ use and TPT uptake among PLHIV participating in the PREVINE-TB study in Brazil and utilized thematic analysis.

Results

Clinic and provider implementation innovations and examples of positive deviance helped explain quantitative differences in QFT+ use and TPT uptake between cities including predetermination of eligible patients for QFT+ screening based on nurse review of electronic medical records, specialized TB clinics, the use of TPT Champions, and digital communication.

Conclusions

Clinic and provider innovations can support QFT+ use and TPT uptake to improve TB outcomes, including in the context of health systems challenges.

Plain Language Summary

Introduction

Diagnosing and treating tuberculosis is critical to reducing TB mortality among people with HIV. Easier screening approaches and shorter-course TB preventive therapy regimens hold promise to improve TB outcomes.

Methods

We conducted 38 qualitative interviews to explore implementation challenges and solutions for these newer innovative screening and prevention of TB among people living with HIV participating in a clinical trial in Brazil. We used thematic analysis of the interviews.

Results

Clinic and provider implementation innovations helped explain quantitative differences in newer screening and preventive therapy approaches that were observed between cities. These included: predetermination of eligible patients for screening based on nurse review of electronic medical records, specialized TB clinics, the use of TPT Champions, and digital communication strategies.

Conclusions

Clinic and provider innovations can support the use and uptake of innovative screening methods and prevention of TB regimens to improve TB outcomes.

Introduction

Tuberculosis (TB), which is a highly preventable and treatable disease, is the leading cause of infectious disease deaths worldwide, contributing to more than double the number of deaths compared to HIV/AIDS.^1,2 Tuberculosis is the leading cause of death among people living with HIV (PLHIV) globally, and PLHIV have approximately 16-fold higher odds of becoming ill from TB compared to their HIV-negative counterparts. ³ Brazil is among the highest TB burden countries, and recent research has shown that there are significant differences in progress toward eliminating TB across geographic regions within the country, ⁴ inhibiting the achievement of global targets to reduce TB-related morbidity and mortality. ⁵ The COVID-19 pandemic further exacerbated the burden on many low- and middle-income countries (LMICs) health systems, including Brazil. In Brazil, the COVID-19 pandemic led to increased TB incidence and mortality between 2020 and 2022 after several years of decline, whereas the TB incidence rate was 44.6 per 100,000 people and the number of TB deaths were 6746 in 2020 compared to a TB incidence rate of 49.0 per 100,000 people and 9900 deaths in 2022. ⁶

Over the past decade, several important biomedical advances have made TB infection (TBI) easier to screen for and treat. These include blood-based interferon-gamma release assays (IGRA) like QuantiFERON-TB Gold+ (QTF+), which can be integrated into routine blood draws, such as viral load and CD4 testing for PLHIV. In addition, shorter course TB preventive therapies (TPT) such as 3HP (3-month of weekly isoniazid and rifapentine) and 1HP (1-month of daily isoniazid and rifapentine) have promise to improve TPT adherence and completion compared to 6 to 9 months of isoniazid monotherapy. ⁷ Yet, the systematic roll-out and uptake of these advances has been slow, including in Brazil, where IGRA-based TBI screening and 3HP were first recommended in 2020. This has led to inequities in TB care and outcomes in resource-constrained settings. ⁸

Prior qualitative research across diverse settings has identified barriers to LTBI screening and treatment implementation, including limited adherence due to gaps in knowledge about the asymptomatic nature of LTBI, side effects, and insufficient provider follow-up. ⁹ From the provider side, knowledge gaps around LTBI treatment are significant barriers to LTBI management in primary care settings: qualitative research in the United States identified barriers limiting primary care teams from following United States Preventive Services Task Force recommendations. ⁹ A study in Malaysia found that healthcare providers’ (HCPs) comprehensive knowledge plays a central facilitating role in TPT uptake, while barriers included misinterpretation of TB skin testing (TST) results and patient apprehensions about medication side effects. ¹⁰ In the United Kingdom, qualitative interviews with healthcare professionals found that low prioritization of LTBI, lack of resources, and complexity of clinical decision-making were key service-level barriers explaining the gap between national policy and actual screening practice. ¹¹

PREVINE-TB was a multicenter implementation study that sought to improve TBI screening and TPT uptake among PLHIV through the use of QFT+ paired with routine CD4 and viral load testing at 4 clinical care sites across 3 major cities in Brazil: Rio de Janeiro, Manaus, and São Paulo. Adherence to national TB screening and preventive therapy guidelines has historically been a challenge globally and in Brazil, as documented by prior trials and analysis, including compared to adherence to Brazilian national HIV guidelines. ¹² Cost and logistical constraints, including high patient loads and overburdened public health clinics, which influence provider motivation, were previously identified as barriers to the roll-out of novel LTBI screening and treatment methods such as QFT+ and 3HP in Brazil. ¹³ The purpose, in turn, of the parent PREVINE-TB trial was to assess the cost-effectiveness of these newer approaches in identifying and treating LTBI. Quantitative findings from the PREVINE-TB study found that the integration of IGRA in routine HIV care was feasible and could lead to improved TBI screening for PLHIV compared to TST. Yet, uptake of LTBI screening as well as TPT uptake was suboptimal within the trial among participating PLHIV and varied significantly across sites. ¹⁴

In this article, we explore this site-level variation in PREVINE-TB's impact using a positive deviance approach. Positive deviance is an assets-based theoretical framework that emerged several decades ago in the context of global health, specifically nutritional epidemiology, in relation to how individuals and families within a community in Vietnam were able to prevent malnutrition in their children. ¹⁵ This seminal work shed light on how individual and family-level differences in behaviors and deviation from social norms that might be harmful to health could be harnessed within public health interventions to support broader social and behavior change within a given setting. This orientation has also been extended to institutional-level dynamics such as clinic-related practices influencing patient care, ¹⁶ including disease-specific screening, clinical management, and medication prescribing practices. Recent work has extended the positive deviance lens to document innovative solutions to both HIV and TB-related screening, prevention, treatment, and care across a variety of settings, including several LMIC.^17,18

Building on our baseline qualitative work within the PREVINE trial where we characterized the clinic context, ¹³ in the current analysis, we sought to explore PREVINE-TB's key implementation challenges and solutions, including low QFT+ use and TPT uptake, among HCPs as part of an implementation science process evaluation. Specifically, we focused on the ways in which the clinic context and provider dynamics facilitate or inhibit screening of PLHIV for TBI and the use of QFT+ results to inform TPT initiation. Using a positive deviance framework, we identified examples of how clinics in distinct settings were able to successfully identify and overcome shared and unique challenges to optimize implementation.

Methods

We conducted the qualitative research presented here from February 2021 to April 2022 during the implementation of the PREVINE-TB study intervention activities. Semistructured in-depth interviews (IDIs) were conducted with HCPs from the 4 participating clinics involved in the PREVINE-TB study from 3 large and diverse cities in Brazil. PREVINE-TB was implemented in 4 public clinics, including 2 clinics in Rio de Janeiro, 1 in São Paulo, Brazil, and one in Manaus, cities where, at the time of protocol development, there were approximately 50,000, 100,000, and 29,000 PLHIV, respectively. Clinics were chosen in Rio de Janeiro, São Paulo, and Manaus to represent the different levels of the HIV epidemic in the country, and the clinics chosen were identified as representative of clinics in these settings and throughout Brazil in terms of size, current antiretroviral therapy (ART) regimens, and provision of LTBI screening and treatment. In São Paulo, the participating clinic was an HIV reference center with over 6000 patients being followed for HIV care at the time of the study's development. In Rio, HIV clinics are generally smaller, and hence the 2 participating clinics had between 800 and 1200 patients each. In Manaus, the participating clinic was the primary HIV and TB/HIV coinfection reference center in the city and had a total of 1500 patients.

Participants for the qualitative study presented here were purposively sampled ¹⁹ to capture HCPs involved in all 4 PREVINE-TB trial sites. Within that frame, we sought diversity of HCPs in terms of training (eg, physicians and nurses), role in the clinic (eg, role in terms of ordering LTBI testing or treatment), and experience with TB/HIV care (eg, length of time). Study investigators from each clinical care facility helped to identify and recruit potential participants for interviews. All HCPs approached agreed to participate in the one-time interview. Interviews lasted approximately 60 min each. A total of 38 IDIs were conducted including 18 HCPs from the 2 participating clinics in Rio de Janeiro, 13 HCPs from the participating clinic in São Paulo, and 7 HCPs from the participating clinic in Manaus. This distribution is reflective of the number of providers across sites and allowed us to explore potential differences and commonalities across the 3 cities. Ten to 15 individuals are generally understood as a sufficient sample to begin to describe a phenomenon of interest, ¹⁹ in this case experience with LTBI screening and TPT within the PREVINE-TB trial, from the view of a given population group within the field of qualitative research.

A semistructured guide using open-ended questions related to the process, challenges, and facilitators of implementation of the PREVINE-TB intervention activities was used to facilitate and support discussion in the interviews conducted in Portuguese [guide available in supplementary files in Portuguese and English translation]. Two female Brazilian interviewers with [BC and DPF] with an MPH who had both qualitative training and prior experience in qualitative research in the context of TB/HIV conducted the IDIs with HCPs in a private clinic room. Throughout data collection, we developed interview summaries based on field notes after each interview. These summaries provided an overview of the context, dynamics, and themes emerging from each interview. We reviewed these summaries as a team to determine when saturation was reached and when to complete data collection based on consistency and redundancy of themes. This allowed us to determine our final sample of 38 participants in total. ¹⁹

In-depth interviews were audio-recorded and transcribed in Portuguese. Thematic content analysis, including coding, ²⁰ was conducted by 2 members of our team [DK and LSDK]. To approach the data, we first read all transcripts in their entirety. We then created an initial codebook based on key a priori domains of interest based on the interview guide, as well as review of interviewer field notes and the reading of transcripts. Key domains focused on intervention implementation related to TBI screening and TPT, barriers to implementation fidelity, including clinic constraints and provider attitudes, and potential facilitators using the positive deviance lens to capture innovations and solutions employed within the clinics. Coding was conducted using the qualitative software NVivo. As coding proceeded, we added emergent codes to the codebook and used memos to document potential themes. After coding of all transcripts was completed, we ran and synthesized the code output and further developed salient themes. We explored themes for convergence and divergence across providers and clinics. Illustrative quotes were selected to represent findings per thematic area. The reporting of this study conforms to the Consolidated Criteria for Reporting Qualitative Studies Checklist ²¹ [available in Supplemental Files associated with this manuscript].

Written informed consent was obtained from each study participant prior to enrolment in the study. All interviews were conducted in a private setting at the respective clinic. The study protocol was approved by the Institutional Review Board (IRB) of the Johns Hopkins School of Medicine (Approval no. 174166) in the United States and Brazilian National Research Ethics Committee (CONEP) (CAAE n° 06015119.6.1001.5279, approval number #3.722.764/2019).

Results

Sample Characteristics

As shown in Table 1, almost half (47.4%) of the 38 HCPs interviewed were nurses, nurse assistants, or nurse technicians (18/38), and all were involved in providing TB care to PLHIV. Another 31.6% of participants were physicians (12/38), while 10.5% (4/38) were pharmacists and 7.9% (3/38) were laboratory technicians. One participant was a health officer who was also a clinician. Participants had an average of 14.6 years of work experience in the field of TB/HIV care, with a range from 2 to 32 years. Additionally, participants had been working at study clinics for an average of 11.4 years, ranging from 1 month to 30 years.

Table 1.

Demographic Characteristics of Participating Healthcare Providers (N = 38).

Variable	Frequency or mean	N or range
City:
Rio de Janeiro	47.4%	18/38
São Paulo	34.2%	13/38
Manaus	18.4%	7/38
Profession:
Nurse	34.2%	13/38
Physician	31.6%	12/38
Pharmacist	10.5%	4/38
Laboratory technician	7.9%	3/38
Nurse technician	7.9%	3/38
Nurse assistant	5.3%	2/38
Health officer	2.6%	1/38
Years in TB/HIV care	14.6	(2.0, 32.0)
Years at the clinic	11.4	(0.10, 30.0)

Structural and Health Systems Constraints

Across clinical care settings, almost all participating HCPs noted the salience of health systems challenges related to TBI screening among PLHIV and subsequent TPT uptake, including having enough time to focus on and prioritize TBI testing and treatment, given high patient loads and persistent understaffing in their clinics. Participants noted individual-level issues, such as perceiving that patients may be concerned about adding TPT to their existing ART regimen and low awareness of the importance of TBI screening and treatment among some providers. However, most HCPs characterized the more formidable challenges as those linked to time, staffing, and resources at the clinic level. Many providers highlighted the impact of these environmental-structural factors at the various clinics where they worked on the initial provider requisition for TBI screening, which in turn impacted the rest of the TB cascade. A nurse from Manaus, where the clinic had over 8000 active patients living with HIV at the time of the interview, relayed:

The obstacle that could exist, as I mentioned, is the doctor soliciting the exam (TB screening) for the patient. Because, in reality, it is this, the obstacle in my view, it is the screening request. If the patient has the solicitation for the exam (TB screening), then they know that in the next CD4 or viral load (blood draw) that they will have, it can all be done together. (Female, Nurse, Manaus)

In the context of ongoing systems-level challenges, HCPs also reported specific implementation innovations and examples of positive deviance documented at the clinic level, which may help to explain quantitative differences in TBI screening and TPT uptake that were observed between cities as described in the sections that follow.

Predetermination of Eligible Patients

At the time of the study, IGRA-based TBI screening was available through the public health system in Brazil, while not widely utilized. In Rio de Janeiro, several nurse participants referred to their experience in prior TB-related studies, including those using the TST to screen for TBI, where nurses helped to facilitate screening by discussing screening with patients and prompting physicians to order testing for patients with HIV when appropriate. Nurse-initiated screening was seen to be crucial given the limited number of physicians and because many resident physicians rotate in and out of clinic. Nurses felt that the same approach could be done in PREVINE-TB and beyond to allow nurses to, at a minimum, cue up eligible patients for TBI screening via QFT+. As a nurse stated:

Don’t restrict TB screening (with QFT+) to physicians. We saw this in prior studies realized a few years back and what did we do? We trained nurses to see the patient first, prior to the physician consult. So the interaction with the patient was not only with the doctor. I think that is the way to amplify the impact of the study (PREVINE). (Female, Nurse, Rio de Janeiro)

Building on this prior experience, the Rio de Janeiro sites began engaging nurses at participating clinics to determine which patients were eligible for TBI screening. They identified eligible patients and referred them for screening which was then conducted at the moment of routine blood draws for CD4 and viral load, rather than introducing screening during a doctor's visit and then having to wait for the next blood draw which could be months away. As one HCP relayed:

At the moment of the blood draw we approach people, sometimes more than 10 a day and then “Flavio,” who is always here at the clinic, approaches them right then. I support him by looking at the charts ahead of time to see who has already been treated for TB or who should be screened. (Female, Nurse, Rio de Janeiro)

Specialized TPT Clinics

Finding innovative ways to both ensure consistent screening for TBI and refer eligible patients for TPT was another key implementation challenge. To respond to this challenge, in Manaus, the participating clinic founded a specialized TBI clinic to improve TPT uptake among eligible PLHIV.

We now have a dedicated doctor in charge, at our own clinic, that is exclusively there to treat patients that are candidates for the use of preventive therapy for latent TB infection. (Male, Physician, Manaus)

Another provider from Manaus described the importance and impact of this type of clinic-level innovation in the context of the COVID-19 pandemic:

Here we now have an LTBI clinic, right? Before I was helping to initiate patients on TPT, but the demand was really great, and with the pandemic (COVID-19) and we have a lot of HIV patients, and it was really chaos to be honest. And then what happened? The LTBI clinic was created. Now I immediately send any positive (QFT+ results) to them, I don’t worry about CD4 level, I just send them. (Male, Physician, Manaus)

Electronic Medical Records

In addition to ensuring optimal TBI screening using QFT+, clinics sought to innovate to ensure that those needing TPT would receive it using strategies such as digital prompts within patient electronic medical records (EMRs), as described below. Here again, nurses were involved to ensure that physicians had QFT+ results in their hands when they saw their patients.

Here, we have a new visual system. I can see the results (QFT+) before the patient sees the doctor, and when I see that the patient, let's suppose, is IGRA positive and they are returning on March 20th, I grab their file and I can put an electronic note for the doctor in the EMR from my computer. And when the patient comes on that day the doctor sees the message to refer them for TPT. They can also print the test results and give it to the patient from their screen. (Female, Nurse, Manaus)

Electronic medical record alerts were also used in São Paulo to facilitate TPT uptake, again leveraging the availability and expertise of nurses.

It is principally the nursing team that is involved. We have an alert system that signals if a patient is QFT+, and if so the idea is to find this patient and determine if they have active TB or if they should begin TPT…one opens the screen and you see: a pop-up window that says: “QuantiFERON positive on a given date.” (Female, Nurse, São Paulo)

Tuberculosis Preventive Therapies Champions

An additional component mentioned several times by providers, particularly those in São Paulo, was the importance of clinic-level leadership and “champions.” One specific physician in São Paulo was noted by multiple participants as someone who rallied clinic coworkers to understand the importance of TBI screening and TPT for PLHIV. The example below also highlights the importance of context-appropriate digital communication, in this case, WhatsApp, a free, cross-platform text and voice messaging service, which is commonly used in Brazil and many other LMIC to facilitate coordination.

Here, the topic of LTBI is in vogue again in our clinic. We have the doctor “Elena” who talks a lot about this. She even started a WhatsApp group and sent us reminders about LTBI screening and TPT. (Female, ID Doctor, São Paulo)

Another São Paulo provider mentioned the importance of having a specific leader at the clinic, following progress and positively motivating coworkers, in an ongoing manner, to do more. By monitoring data and incremental improvements, this TPT Champion was able to motivate her colleagues to join her in reaching the clinic's and PREVINE's study-related goals:

We have been keeping track of the medical charts closely… “Elena” did the calculation of the number of patients each provider was seeing and how many should be eligible for LTBI and how many were screened and how many received TPT….by monitoring the charts…an ongoing quality control. (Male, Doctor, São Paulo)

Discussion

This qualitative study sought to understand the realities and mechanisms of resilience and innovation associated with clinic implementation strategies to improve TBI screening and TPT uptake among PLHIV in 3 large urban centers in Brazil. Consistent with our baseline qualitative work within PREVINE, we documented barriers to the use of QFT+ and TPT uptake, such as overburdened health systems with high patient volume and inadequate staffing across sites. ¹³ However, findings from this qualitative process evaluation within the course of the trial provide key insights that help to interpret and contextualize overall trial findings, including differences in TBI screening and TPT uptake across high-volume and high-patient-load clinics serving PLHIV. Results indicate that strategic innovations by clinics and providers can support IGRA-based TBI screening and TPT uptake among PLHIV, even in the face of ongoing health systems challenges. By engaging differing sizes and types of clinical facilities (eg, volume, specialization), as well as different types of health providers (eg, physicians, nurses), we were able to better understand how distinct intervention approaches and actors can be leveraged to support improvements in TB outcomes among PLHIV in resource-constrained settings.

Task Shifting

One of the key findings from this qualitative study is the importance of task shifting, including the critical role of nurses, given their rapport, patient communication skills, and the limited availability of physicians to conduct TB screening in high-volume clinics in resource-constrained settings. In the case of Rio de Janeiro, nurses were engaged to identify a list of patients for whom physicians could order IGRA screening and identify eligible PLHIV at their routine blood draw visits for viral load or CD4 counts. Task shifting has been important for HIV prevention and treatment, including working with nurses to screen for HIV and initiate pre-exposure prophylaxis and ART. ²² Task shifting has also been utilized in a number of countries to promote TBI and TPT uptake, including work from Ethiopia. ²³ In synch with these trends, since the time of the PREVINE-TB study, the Ministry of Health of Brazil has now updated its TB management guidelines to allow nurses to order IGRA for TBI screening. Additionally, with these updates, nurses are now authorized to prescribe TPT in Brazil, further enhancing their role in TB care and prevention, ²⁴ offering an important potential model for leveraging the critical role of nurses to improve TB outcomes in other similar settings.

Tuberculosis Infection Specialized Clinics

In Manaus, given challenges with staffing, patient load, and workflow logistics within a busy HIV clinic, the strategic decision was made to create a specialized TBI clinic to manage and promote TBI screening and TPT prescription among PLHIV. The use of a TBI-focused clinic was attributed to streamlined implementation processes and reflected in the significant difference in TBI screening using the IGRA in Manaus compared to participating study clinics in Rio de Janeiro and São Paulo. Tuberculosis clinics have frequently been used in the context of directly observed therapy for TB treatment. However, TB-specialized clinics have been less utilized in the case of screening, indicating the importance of this innovation. ²⁵

Advocates of specialized TB clinics argue that they help limit inappropriate treatments, reduce treatment interruption, and improve contact tracking and reporting, as nonspecialist physicians may fail to interact effectively with public health programs. ²⁶ A Swiss TB clinic demonstrated that improvements in treatment outcomes resulted not only from introducing directly observed therapy but from better-trained specialized nurses, improved communication through translators, and reorganized appointment schedule. ²⁶ However, centralized specialized care has limitations. A review that described the framework of the Lancet Global Health Commission on High Quality Health Systems, proposed new and undermeasured indicators of TB care quality, and discussed implications of the Commission's key conclusions for measuring and improving the quality of TB care services. ²⁷ The review found that efforts to integrate TB services within primary care in middle-income countries have been complicated by the perception that specialty care is always superior for TB. ²⁷

Champions

In São Paulo, dynamic leadership from health providers in the clinic setting was key to promoting TBI screening and TPT for those who were IGRA-positive. The use of health providers serving as clinic champions and opinion leaders to diffuse innovations has been a key component of effective social and behavioral interventions related to HIV prevention and care for many years. ²⁸ In the context of TB, both providers and patients are also beginning to be engaged to “champion” increased TBI screening and improved treatment outcomes. ²⁹

Prior studies support the potential for champions to play a vital role in improving uptake and administering LTBI screening and treatment. A systematic review of champion effectiveness in healthcare found that in a subset of 7 studies, 5 reported an association between the use of champions and increased facility-level uptake of innovations, though evidence regarding effects on individual provider and patient-level outcomes was more mixed. ³⁰ Another study found that champion effectiveness depends on their institutional knowledge and capacity to navigate organizational culture so that they are capable of identifying points of potential resistance and leveraging their relationships to overcome them. ³¹

Optimizing technological supports: In São Paulo, the use of technology such as EMR and context-appropriate digital communication tools was reported to facilitate TBI screening and TPT uptake. The use of EMR to identify and default-prescribe TPT among eligible PLHIV has been used in settings such as Malawi. ³² Communication, coordination, and motivation of clinic HCPs through WhatsApp was also described as a key innovation by participants in São Paulo. mHealth is now widely considered a key element of multicomponent social and behavioral interventions related to HIV, as well as TB prevention and care. ³³

Several recent studies reveal the benefits of advanced digital technology in LTBI screening and treatment. At the provider level, EMR-based prompts have shown promise in supporting LTBI. For example, an EMR tool engineered to alert physicians to order QuantiFERON testing when patients met specific LTBI risk criteria increased the proportion of eligible patients tested from 45% to 81%, while also improving the accuracy of screening as reflected by higher rates of positive results. ³⁴ Digital adherence technologies, including SMS reminders and video-observed therapy (VOT), have been tested for active TB treatment, with more limited but growing evidence for LTBI. In Brazil specifically, some states have piloted hybrid models combining directly observed therapy with VOT, yielding promising results, and in November 2023, the Brazilian Ministry of Health began recommending digital technologies for Directly Observed Treatment for people with TB. ³⁵ A recent development effort in Brazil produced a theoretically grounded digital mobile application to support TB treatment adherence. The development effort, titled “Controlling the TB,” is a digital prototype designed to support treatment adherence among patients undergoing TB therapy within the Brazilian Unified Health System. ³⁶

This study has some limitations. First, data were collected at one timepoint during PREVINE-TB; repeated rounds of qualitative interviews may have captured additional innovations, challenges, and nuances. Second, we used one type of qualitative methodology (IDIs). Additional qualitative research, including both IDIs and direct observation of clinical practices within the participating study clinics, would help to illuminate which of these innovations can be sustained over time. Third, results reflect experiences within the PREVINE-TB trial and may not fully capture implementation and roll-out dynamics in real-world settings. Despite these limitations, the study also has a number of strengths. The IDIs conducted reflect the perspectives of a diverse set of HCPs from 3 distinct geographic contexts in one of the largest LMIC as well as with a high TB burden. Findings and lessons learned may be transferrable to other resource-constrained and high TB burden settings, and inform further implementation of LTBI practices in routine care to improve TB outcomes.

Conclusions

Clinic and provider innovations can support equitable access to and uptake of novel TB screening and preventive therapy strategies, such as QFT+ and 3HP, including in the context of health systems challenges in resource-constrained settings. Multicomponent interventions that include dynamic leadership, task shifting, technological supports, and tailored clinic environments may facilitate implementation gains when rolling out innovative TBI screening and TPT strategies, and help improve the TB cascade and reach global TB elimination targets.

Supplemental Material

sj-docx-1-jia-10.1177_23259582261447940 - Supplemental material for Clinic and Provider Innovations to Improve Tuberculosis Infection Screening and Preventive Therapy Uptake in Brazil: Qualitative Findings From the PREVINE-TB Study

Supplemental material, sj-docx-1-jia-10.1177_23259582261447940 for Clinic and Provider Innovations to Improve Tuberculosis Infection Screening and Preventive Therapy Uptake in Brazil: Qualitative Findings From the PREVINE-TB Study by Deanna Kerrigan, PhD, MPH, Lelia H. Chaisson, PhD, MSc, Paula Travassos, RN, MS, Betina Durovni, MD, PhD, Valeria Saraceni, MD, MPH, Solange Cavalcante, MD, Marcelo Cordeiro-Santos, MD, PhD, Renata Spener-Gomes, MD, Alexandra Brito de Souza, PhD, Sumire Sakabe, MD, MSc, Roberta Trefiglio, BA, José Valdez Ramalho Madruga, MD, MSc, Silvia Cohn, MSc, MPH, Lia S. Da Silva Kerrigan, BA, Isadora Salles, MHS, Barbara Castro, PhD, Danielle Portella Ferreira, MPH, Christopher J. Hoffmann, MD, MPH, and Jonathan E. Golub, PhD, MPH in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-2-jia-10.1177_23259582261447940 - Supplemental material for Clinic and Provider Innovations to Improve Tuberculosis Infection Screening and Preventive Therapy Uptake in Brazil: Qualitative Findings From the PREVINE-TB Study

Supplemental material, sj-docx-2-jia-10.1177_23259582261447940 for Clinic and Provider Innovations to Improve Tuberculosis Infection Screening and Preventive Therapy Uptake in Brazil: Qualitative Findings From the PREVINE-TB Study by Deanna Kerrigan, PhD, MPH, Lelia H. Chaisson, PhD, MSc, Paula Travassos, RN, MS, Betina Durovni, MD, PhD, Valeria Saraceni, MD, MPH, Solange Cavalcante, MD, Marcelo Cordeiro-Santos, MD, PhD, Renata Spener-Gomes, MD, Alexandra Brito de Souza, PhD, Sumire Sakabe, MD, MSc, Roberta Trefiglio, BA, José Valdez Ramalho Madruga, MD, MSc, Silvia Cohn, MSc, MPH, Lia S. Da Silva Kerrigan, BA, Isadora Salles, MHS, Barbara Castro, PhD, Danielle Portella Ferreira, MPH, Christopher J. Hoffmann, MD, MPH, and Jonathan E. Golub, PhD, MPH in Journal of the International Association of Providers of AIDS Care (JIAPAC)