# Prevent TB: Application of choice architecture to implement TB preventive therapy in South Africa

> **NIH NIH R01** · JOHNS HOPKINS UNIVERSITY · 2020 · $578,215

## Abstract

PROJECT SUMMARY
The availability of antiretroviral therapy (ART) has markedly reduced leading causes of HIV-related mortality
and morbidity in Africa, including tuberculosis (TB). Yet TB remains the leading cause of death among people
with HIV. Use of TB preventive therapy (TPT) reduces TB incidence and death, even among people receiving
ART. Although the benefits of TPT among people with HIV have been known for 30 years and international
and national guidelines provide clear prescribing recommendations, TPT is poorly prescribed. Overall in low
and middle income countries 10-30% of people with HIV eligible for TPT receive it. For those who do receive
TPT along with ART, adherence is generally good. Multiple system and provider level barriers appear to be
driving anemic TPT prescribing. Several of these barriers have caused TPT prescribing to be the exception
rather that the routine – barriers based on complex procedures implemented for inaccurate concerns. Primary
among are efforts to completely “rule-out” active TB and concerns for potential liver problems with TPT.
Notably, a study focused on more complex (and more sensitive) TB diagnosis resulted in increased mortality in
the arm with greater TB diagnosis. That arm also had delayed and lower TPT prescribing. This study seeks to
use choice architecture to make TPT prescribing the usual or “default” with not-prescribing occurring only when
the clinician has a real concern (e.g. high concern for TB disease). The effectiveness of the choice
architecture-based implementation strategy will be compared to the usual implementation in a cluster-
randomized trial. Clinics will be the unit of randomization with all patients receiving services at a study clinic
receiving uniform TPT implementation. The primary outcome will be the proportion of patients initiating ART
who also receive TPT. The underlying concept of choice architecture is that optimizing decision making can
lead to reduced cognitive load. Thus we propose to compare cognitive load regarding TPT prescribing between
study arms. We will also assess congruence of the prescribing approach with clinic work flow, acceptability to
providers, implementation measures, and patient-level implementation (e.g. receipt of TPT, adherence, patient
reported problems). This study has the potential to lead the way in reshaping the delivery of TPT and other
routine services in clinics in South Africa and similar settings. Should this implementation strategy prove
effective it will contribute to national and global goals to reduce HIV-associated mortality and TB incidence.

## Key facts

- **NIH application ID:** 9927031
- **Project number:** 1R01AI150432-01
- **Recipient organization:** JOHNS HOPKINS UNIVERSITY
- **Principal Investigator:** CHRISTOPHER J HOFFMANN
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $578,215
- **Award type:** 1
- **Project period:** 2020-02-28 → 2025-01-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9927031

## Citation

> US National Institutes of Health, RePORTER application 9927031, Prevent TB: Application of choice architecture to implement TB preventive therapy in South Africa (1R01AI150432-01). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9927031. Licensed CC0.

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