{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,7,18]],"date-time":"2026-07-18T09:06:15Z","timestamp":1784365575384,"version":"3.55.0"},"posted":{"date-parts":[[2026,7,15]]},"group-title":"Public and Global Health","reference-count":39,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T00:00:00Z","timestamp":1784073600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,7,15]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Tuberculosis preventive therapy (TPT) is a cornerstone intervention for reducing TB incidence among people living with HIV, yet its integration into routine care remains inconsistent in high-burden settings. While policy frameworks are well established, less is known about how frontline healthcare workers (HCWs) operationalize TPT within constraint health systems. Thisstudy explores healthcare workers\u2019 (HCWs) perspectives on TPT implementation in Indonesia and the Philippines using normalization process theory (NPT), to understand how TPT is (or fails to be) embedded in everyday clinical practice.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Weconducted ten focus group discussions and four in-depth interviews with HCWs across major TB\/HIV treatment centers in Manila, Philippines and Jakarta, Indonesiabetween June to December 2023. Data were analyzed using reflexive thematic analysis, followed by interpretative mappingontofour NPT constructs: coherence, cognitive participation, collective action and reflexive monitoring.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>\n                    TPT implementation was characterized by a persistent gap between policy intent and routine practice. Under\n                    <jats:italic>coherence<\/jats:italic>\n                    , HCWsdescribed fragmented knowledge and limited exposure to standardized protocols, undermining confidence in TPT delivery.\n                    <jats:italic>Cognitive participation<\/jats:italic>\n                    was constrained by a doctor-centric model and high staff turnover, weakening shared ownership of TPT. In\n                    <jats:italic>collective action<\/jats:italic>\n                    , operational fragilities, including weak documentation systems, supply interruptions, and poor inter-level coordination, resulted in inconsistent delivery. Through\n                    <jats:italic>reflexive monitoring<\/jats:italic>\n                    , HCWs identified patient concerns around side effects and pill burden, alongside provider concerns regarding diagnostic uncertainty and fears of missing active TB. Across settings, HCWs actively proposed system-oriented solutions, including SOP standardization, team-based training, digital reminders, and strengthened care continuity mechanisms.\n                  <\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>TPT implementation is not limited by awareness alone but by the absence of routinized systems that support consistent practice. Strengthening implementation requires shifting from individual-dependent delivery toward system-enabled integration, through standardized protocols, distributed workforce engagement, embedded monitoring mechanisms, and uninterrupted drug supply systems. Interventions that align with everyday clinical workflows and reinforce collective responsibility across cadres are critical to closing policy and practice gap.<\/jats:p>\n                <\/jats:sec>","DOI":"10.64898\/2026.07.13.26357999","type":"posted-content","created":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T23:45:13Z","timestamp":1784159113000},"source":"Crossref","is-referenced-by-count":0,"title":["Concerns, Priorities, and Pathways: Healthcare Provider Perspectives on Implementing Tuberculosis Preventive Treatment for People with HIV in Indonesia and the Philippines"],"prefix":"10.64898","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6066-586X","authenticated-orcid":false,"given":"Prashant","family":"Kulkarni","sequence":"first","affiliation":[{"name":"Johns Hopkins Centre for Infectious Diseases in India (CIDI), Pune, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Steiner","sequence":"additional","affiliation":[{"name":"Johns Hopkins University, School of Medicine, Baltimore, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-3769-4747","authenticated-orcid":false,"given":"Alieen","family":"Gianan-Gascon","sequence":"additional","affiliation":[{"name":"Research Institute for Tropical Medicine \u2013 Department of Health, Muntinlupa City, Philippines"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Candice Eula","family":"Lamigo","sequence":"additional","affiliation":[{"name":"Research Institute for Tropical Medicine \u2013 Department of Health, Muntinlupa City, Philippines"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-0023-139X","authenticated-orcid":false,"given":"Bianca Joyce","family":"Sornillo","sequence":"additional","affiliation":[{"name":"Research Institute for Tropical Medicine \u2013 Department of Health, Muntinlupa City, Philippines"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-3140-8862","authenticated-orcid":false,"given":"Ruth Anne","family":"Hechanova-Cruz","sequence":"additional","affiliation":[{"name":"Research Institute for Tropical Medicine \u2013 Department of Health, Muntinlupa City, Philippines"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna Maureen","family":"Dungca-Lorilla","sequence":"additional","affiliation":[{"name":"Research Institute for Tropical Medicine \u2013 Department of Health, Muntinlupa City, Philippines"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aljira Fitya","family":"Hapsari","sequence":"additional","affiliation":[{"name":"Universitas Indonesia, Jakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Retnosari","family":"Hardaningsih","sequence":"additional","affiliation":[{"name":"CiptoMangunkusumo General Hospital, Jakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mira","family":"Yulianti","sequence":"additional","affiliation":[{"name":"CiptoMangunkusumo General Hospital, Jakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4331-2381","authenticated-orcid":false,"given":"Anshari Saifuddin","family":"Hasibuan","sequence":"additional","affiliation":[{"name":"CiptoMangunkusumo General Hospital, Jakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evy","family":"Yunihastuti","sequence":"additional","affiliation":[{"name":"CiptoMangunkusumo General Hospital, Jakarta, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Priyanka","family":"Raichur","sequence":"additional","affiliation":[{"name":"Johns Hopkins Centre for Infectious Diseases in India (CIDI), Pune, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rossana","family":"Ditangco","sequence":"additional","affiliation":[{"name":"Research Institute for Tropical Medicine \u2013 Department of Health, Muntinlupa City, Philippines"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan E","family":"Golub","sequence":"additional","affiliation":[{"name":"Johns Hopkins University, School of Medicine, Baltimore, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher J","family":"Hoffmann","sequence":"additional","affiliation":[{"name":"Johns Hopkins University, School of Medicine, Baltimore, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark Donald 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