Globally, South Africa has one of the worst TB epidemics, with approximately one in every 100 persons residing in South Africa developing active TB in 2013, compared to 1 in every 100,000 people residing in Belgium. The failure to reduce the annual number of TB cases in South Africa between 2007 and 2013 (around 320,000 annually) highlights that the national TB control strategy, which is mainly focused on passive case finding and treatment of active TB cases, has failed to control the South African TB epidemic. It has thus become increasingly clear that South Africa will not be able to treat its way out of its TB epidemic.
Because the HIV and TB epidemic are closely linked in the South African setting, implementation of TB preventive strategies among people living with HIV, such as early initiation of antiretroviral therapy and isoniazid preventive therapy (IPT) will be essential to achieve. Treatment of latent TB infection through IPT has been shown to greatly reduce the risk of developing active TB in people living with HIV and children in contact with a TB case. The South African guidelines are however complex. Consequently, implementation may pose great logistical and human resource challenges at primary care clinics. We propose to evaluate the implementation of these guidelines at primary care clinics in order to identify health system approaches to optimize IPT uptake, health care workers fidelity to the guidelines, patient adherence, and cost effectiveness.