Concerns, Priorities, and Pathways: Healthcare Provider Perspectives on Implementing Tuberculosis Preventive Treatment for People with HIV in Indonesia and the Philippines

Background 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. This study explores healthcare workers (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. Methods We conducted ten focus group discussions and four in-depth interviews with HCWs across major TB/HIV treatment centers in Manila, Philippines and Jakarta, Indonesia between June to December 2023. Data were analyzed using reflexive thematic analysis, followed by interpretative mapping onto four NPT constructs: coherence, cognitive participation, collective action and reflexive monitoring. Results TPT implementation was characterized by a persistent gap between policy intent and routine practice. Under coherence, HCWs described fragmented knowledge and limited exposure to standardized protocols, undermining confidence in TPT delivery. Cognitive participation was constrained by a doctor-centric model and high staff turnover, weakening shared ownership of TPT. In collective action, operational fragilities, including weak documentation systems, supply interruptions, and poor inter-level coordination, resulted in inconsistent delivery. Through reflexive monitoring, 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. Conclusions 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.