It's hard work, but it's worth it: the task of keeping children adherent to isoniazid preventive therapy.

Children carry approximately 15% of the global tuberculosis (TB) disease burden, leading to an estimated 1 million cases of childhood TB annually.1 Following infection with Mycobacterium tuberculosis, young children are at high risk of primary disease progression and disseminated disease in the absence of appropriate preventive therapy.2 Accurate identification of M. tuberculosis-infected children is possible using contact tracing and characterisation of epidemiological risk factors3 without tests for M. tuberculosis infection.4 Nevertheless, delivery of isoniazid preventive therapy (IPT) is sub-optimal in high-burden TB settings, with as few as 5–66% of eligible child contacts receiving therapy.5–10 Following the World Health Organization’s recommendation to intensify case finding and IPT use in persons living with the human immunodeficiency virus (HIV),11 there has been growing interest in the delivery of both pre- and post-exposure IPT in children with and without HIV infection. As countries begin to roll out pre-exposure IPT programmes targeting HIV-infected children, previously paralysed post-exposure IPT programmes have been enhanced through the introduction of IPT registers and the increased availability of single-drug dispersible paediatric isoniazid (INH) formulations. South Africa, an upper middle-income country, has a medium human development index, but it figures among the 22 countries with the highest burden of TB disease.12 Although the South African National TB Programme (SANTP) has been recommending post-exposure IPT for many years for child contacts aged <5 years, IPT uptake ranges from <5%10 to 21% in routine health care settings,9 to 73% in clinical research settings,5,13 while adherence is approximately 24%.5,13 Among South African children hospitalised for TB, opportunities for IPT are missed in up to 70% of young children.14,15 A growing body of literature shows that obstacles to the effective delivery of post-exposure IPT are many and inter-related.9,10 Many of the major barriers identified in a recent review of problems in IPT implementation have been resolved in South Africa using a standardised screening protocol for children. However, the issues of maintaining adherence to extended prophylactic treatment programmes and the negotiation of care giver acceptability needs further consideration.16 A recent survey of parents currently administering IPT in Cape Town found very positive responses to IPT once these barriers had been overcome.17 We completed a qualitative assessment to understand factors influencing parents’ decisions to allow IPT to be administered to their children and completion of the 6-month course of treatment.