Can a peer-based intervention impact adherence to the treatment of latent tuberculous infection?

AN ESTIMATED 9–14 million persons in the United States have latent tuberculous infection (LTBI) and are at risk for progression to active TB disease.1 Diagnosis and successful treatment of LTBI is a cornerstone of the US strategy to eliminate TB.2 An estimated 300 000 individuals are treated annually for LTBI in the United States;3 however, LTBI treatment completion rates fall well below established targets, ranging from 30% to 60% for a standard 9-month isoniazid regimen.4 Several US studies have evaluated interventions for improving adherence to LTBI treatment, including use of supervised therapy, financial incentives, counseling, peer education and case management.5 However, few studies have rigorously evaluated LTBI interventions through randomized controlled trials (RCTs),5 and most have focused on specific populations, such as jail/prison inmates,6 drug users,7–9 homeless persons10,11 and immigrants/refugees from TB-endemic countries,12 rather than the mix of populations eligible for LTBI treatment. Peer workers are widely used to promote changes in health behavior and are thought to play a unique role in health care, in part due to shared ethnicity, sex, illness experience, sexual orientation, risk behaviors and/or socio-economic characteristics with the target population.13–15 Peer collaboration is recognized as a potentially powerful tool to influence the complex interaction of factors known to influence adherence.16,17 With TB rates greatly exceeding national averages and the concomitant human immunodeficiency virus epidemic, the Harlem community in New York is vulnerable to TB.18 For many community members, tuberculin skin testing and the determination of LTBI status is frequently required to access homeless shelters, substance use programs and community-based organizations. The objective of this RCT was to assess the effectiveness of a peer-based intervention on adherence and completion of LTBI treatment in a general US clinic population.