Exploring Perspectives on Tuberculosis Preventive Treatment Completion among contacts and people with HIV in Khayelitsha, South Africa using the Health Belief Model

Background: Tuberculosis (TB) preventive treatment (TPT) is recommended to prevent the development of active disease among high-risk groups, including close TB contacts and people living with HIV. However, TPT uptake and completion are suboptimal in high-incidence settings like South Africa. This study explored perspectives on TPT completion in Khayelitsha, a township in Cape Town. Methods: We conducted in-depth interviews with 20 participants at six primary healthcare facilities in Khayelitsha, purposively sampled to capture diverse perspectives on TPT completion. The sample included 12 caregivers of children who completed (n=7) or stopped TPT (n=5), and 8 adults who completed (n=5) or stopped (n=3) TPT. Thematic analysis used inductive coding to identify initial themes, which were organised deductively according to the Health Belief Model (HBM) constructs of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Results: While participants mostly recognised they were at risk of TB, perceived susceptibility was impaired by gaps in knowledge about transmission, including understanding that child contacts could develop TB. Perceived severity of TB was high and was also associated with TB-related stigma, which was driven by fears of infectiousness. Participants did not all perceive the benefits of TPT due to gaps in knowledge of TB and specifically TPT. Barriers included unpleasant medication taste, lack of child-friendly formulations, missed appointments due to work commitments, and negative experiences with healthcare providers, which affected TPT uptake and completion. Most participants received 6H; however, those receiving 3HP praised the shorter regimen. Cues to action are prompts to start or continue health behaviour, including support from health workers, such as CHWs. Participants who completed TPT reported high self-efficacy afterwards, whereas those who stopped TPT experienced low self-efficacy and identified opportunities for enhanced support. Conclusions: Strategies to address barriers to TPT uptake and completion include providing child-friendly formulations, improving healthcare experiences more broadly, and implementing practical support strategies. Greater involvement of CHWs with community TPT delivery and support could reduce barriers. Interventions should incorporate family-centred counselling and training for healthcare providers on approaches to strengthen TPT uptake and completion and reduce TB incidence in high-burden settings.