2. Abbreviations: FGD = Focus Group Discussion INH = Isoniazid IPT = Isoniazid Preventive Therapy for TB PWH = People with HIV-infection DOT = Directly observed treatment Background: HIV is the most powerful risk factor for reactivating latent TB infection into TB disease IPT is effective in reducing the risk of developing TB disease among PWH Adherence to the 9-months IPT is challenging due to social complexity of HIV Chiang Rai is one of the provinces with some of the highest rate of TB and HIV. AIDS is the leading cause of death in the province (164.4/100,000). TB has re-emerged as a public health problem in the province due to the HIV/AIDS epidemic since 1992.

3. Cambodia Myanmar China Laos Vietnam Bangkok Chiang Rai Population 1.2 millions (hill tribe 13 %) 93% completed compulsory education 1 regional hospital, 16 district hospitals, 212 health centers, 3 private hospitals Chiang Rai, Thailand

4. New TB rate by HIV status per 100,000 persons Chiang Rai Province (1987-2000) Year TB/HIV Research Project, RIT-JATA Study setting and population Chiang Rai Regional Hospital Of the 412 PWH (enrolled in IPT program), 42 PWH who achieved 95-100% adherence rate were invited to participate in FGD

5. Objective To investigate the reasons for a high level of adherence to the nine-month IPT and to propose strategies for promoting adherence to IPT Definition 95-100 % adherence rate = Through pill-counting during the 9-month therapy, the clients take 95-100% of total number of INH pills Method Forty-two PWH were identified and invited to participate in the FGD; only 28 PWH could participate. Five sessions of FGD were conducted by the same moderator (without the presence of health service providers)one group of single males; two groups of married males; one group of married females and one group of widowed females. Each discussion was composed with 5-8 participants. The session lasted for 2 - 2.30 hours. All discussions were tape recorded and transcribed verbatim. Qualitative content analysis was applied.

6.  Free of charge  Monday-Friday 8:00 a.m.- 4:00 p.m.  One nurse one clerk (take turn)  Use of follow up letter if miss-appointment > 1 week  No home visit due to confidentiality issue TB/HIV Research Project(RIT-JATA) Regimen Daily 300 mg. of INH and vitamin B complex for 9 months (one month supply) Characteristic of IPT service

7. Result Reasons for achieving 95-100% adherence rate Concern about young children and aging parents. Needs to prolong life in order to take care of family. Trust in doctor/nurse. Everything recommended by doctors should be good things and should follow Accepted HIV status well Need to discuss with health staff. Participating in IPT service was a good opportunity to discuss and to consult about HIV related psycho-social issues.

8. “I donated blood and I was told that my blood is positive. I do not have risk to be infected by AIDS. But the doctor told me my blood is positive. I have to believe doctor. When doctor introduced medicine (INH) to me I believed the medicine is good otherwise doctor will not prescribe. I do not remember what medicine is for” (A 52 years old HIV-positive man) “...I live in dormitory. Nobody knows about my HIV positive. Every morning I have to make up my face. I can not put the medicine (INH) on my cosmetic desk because my friends will suspect why I have to take medicine. So I put a reminding message on the cosmetic desk to be read as “Have you brushed your teeth this morning?”. When I see this message, I will take the medicine.” (An HIV-positive homosexual young man)

9. Is DOT needed? Several participants in the married male group reported that their wives reminded them to take INH. The other groups mostly took pills by themselves. Very occasionally, some participants forgot taking pills for 1-2 days because of stay overnight outside house, too busy with the funeral service or taking care of sick spouses. Without staff instruction, these participants developed their own medicine reminder systems, including: -marking a calendar after taking pills -putting reminder message in visible locations -putting INH package in the locations which were linked to their daily activities such the place where they eat, drink, sleep, change clothes, watch television, cosmetic desk

12. Acknowledgement Japanese Foundation for AIDS Prevention (JFAP) and Ministry of Health, Welfare and Labor, Japan supported the study Dr.Renu Srismith, Dr.Wat Uthaivoravit and staff nurses of Social Preventive Medicine Department, Chiang Rai Hospital for approval the study and their kind collaboration. All participants kindly participated in the focus group discussion Conclusion A high level of adherence to IPT are due to concern about young children and aging parents; good relationship between health staff and clients; well acceptance of HIV status. Without DOT, high adherence could be achieved through the medicine reminder systems developed by clients.