In Rwanda, when a person is diagnosed with active tuberculosis, public health workers trace their household contacts and offer them preventive therapy — typically a daily dose of isoniazid for six months. The logic is straightforward: latent TB infection, if left untreated, can reactivate years later and cause new infections. Yet a 2025 survey by the Rwanda Biomedical Centre found that only 48% of contacts who started preventive therapy completed the full course. The rest dropped out, most often between the second and fourth months. For a country that has invested heavily in TB control, this gap between initiation and completion threatens to undermine decades of progress.

A Promise of Protection, a Course Left Unfinished

Preventive therapy for TB contacts is one of the most cost-effective interventions in global health. A six-month course of isoniazid reduces the risk of progression from latent to active TB by roughly 60–90%, depending on adherence. Rwanda's National TB Programme has scaled up contact investigation over the past decade, and tens of thousands of people start preventive treatment each year. But starting is only half the battle.

The 2025 survey, conducted across 30 districts, showed low completion rates. Among nearly 4,000 contacts enrolled, completion rates varied widely — from 35% in some rural districts to 62% in Kigali. The median time to discontinuation was 3.2 months. Many contacts simply stopped coming to the clinic; others cited side effects, travel costs, or simply forgetting. Health workers reported that patients often felt healthy and saw no reason to continue taking a daily pill for months on end.

The pattern is not unique to Rwanda. A 2024 systematic review in The Lancet Global Health found that completion of TB preventive therapy in sub-Saharan Africa averages 55–70%, with wide variation. Rwanda's figures sit at the lower end of that range, partly because of rigorous reporting that captures losses other countries might miss. Still, each incomplete course represents a missed opportunity: the person remains at risk of developing active TB, which can then spread to others. And because isoniazid is the backbone of both prevention and treatment, inconsistent exposure may select for resistant organisms — a concern the World Health Organization has flagged repeatedly.

Why Starting Is Easier Than Finishing

Several barriers combine to prevent completion. For many rural Rwandans, a daily pill regimen is a logistical burden. A farmer in the Northern Province may need to walk an hour to the nearest health centre, then queue for another hour, all while losing a morning of work. The cost of transport — typically in the range of US$ 1–3 — may not sound large, but for a household living on a few dollars a day, it adds up over six months.

Side effects, though usually mild, are often unreported. Isoniazid can cause nausea, abdominal discomfort, and tingling in the hands and feet. Some patients stop the drug without telling anyone. Health workers, each responsible for dozens of patients across multiple conditions, rarely have time for proactive adherence counselling. A 2023 study in BMC Public Health found that only one in five Rwandan health facilities had a designated adherence counsellor for TB.

Stigma also plays a role. Taking TB drugs — even preventive ones — can mark a household as infected. Neighbours may avoid the family, children may be kept home from school. In a small community, the social cost of being seen collecting pills every morning can outweigh the perceived health benefit. Some patients hide their medication, skip doses, or stop altogether.

Health system factors compound these individual barriers. Stock-outs of isoniazid occur intermittently, forcing patients to travel to another facility or wait days for resupply. Clinic hours often coincide with work hours. And while Rwanda's community health worker network is among the most robust in Africa, its members are responsible for 100–150 households each, leaving little time for TB-specific follow-up.

The Cost of Dropping Out

When a contact stops preventive therapy prematurely, the immediate consequence is that their latent infection remains untreated. The risk of reactivation persists. Rwanda's TB incidence was estimated at 56 per 100,000 population in 2024 (WHO), down from over 100 a decade ago, but still representing roughly 7,000 new cases each year. A substantial proportion — possibly one-third or more — of these arise from untreated latent infections among contacts.

There is also a broader public health cost. Each incomplete course of isoniazid represents a waste of resources — the drugs themselves, the clinic time, the tracing efforts. The cost per person for a full six-month course is modest, around US$ 15–25 in drug procurement and delivery, but multiplied across thousands of dropouts, the sum becomes significant. A 2025 analysis from the Rwanda Biomedical Centre estimated that improving completion by 20 percentage points could prevent roughly 800 active TB cases annually, saving an estimated US$ 1.2 million in treatment costs.

Drug resistance is a direct concern. While isoniazid monoresistance is not yet common in Rwanda — prevalence is around 4% among new cases — incomplete exposure is a known driver. The World Health Organization has warned that subtherapeutic exposure to isoniazid can select for resistant mutants, particularly in the context of high bacillary loads. A 2022 modelling study in PLOS Medicine projected that if completion rates remain below 60%, the proportion of isoniazid-resistant TB could double within a decade.

Every contact who drops out represents not only a personal health risk but a potential source of onward transmission and a contributor to the slow erosion of first-line drug efficacy. Rwanda's TB programme cannot afford to ignore the gap.

Shorter Regimens on the Horizon

One promising solution is to replace the six-month isoniazid course with a shorter regimen. The three-month weekly combination of rifapentine and isoniazid (3HP) has been endorsed by the WHO since 2020 for contacts aged two years and older. In clinical trials, completion rates for 3HP exceed 80%, and side effects are comparable to daily isoniazid.

Rwanda has piloted 3HP in five districts since 2023, with encouraging results. A preliminary analysis presented at the 2025 Union World Conference on Lung Health reported an 82% completion rate among the first 1,200 contacts enrolled. Patients reported preferring the weekly regimen because it required fewer clinic visits and fit more easily into rural livelihoods. The Ministry of Health has since expanded the pilot to ten districts, with plans for national rollout by 2028.

Yet barriers remain. Rifapentine is more expensive than isoniazid — roughly US$ 30–45 per course compared to US$ 15–25 — and its supply chain is less reliable. The drug requires cold chain storage, which adds logistical complexity in remote areas. And while 3HP is shorter, it still requires directly observed therapy (DOT) for each weekly dose, which can be burdensome for both patients and health workers.

Alternatives are also in the pipeline. A one-month regimen of rifapentine plus isoniazid is under investigation, and a four-month regimen of daily rifampicin has shown non-inferiority in trials. The WHO has expressed cautious optimism, but the evidence base for very short courses in high-burden settings remains thin. Rwanda's experience with 3HP will be closely watched.

Community Adherence Workers Fill Gaps

While shorter regimens may improve completion, they are not a silver bullet. Many of the same barriers — distance, cost, stigma — apply regardless of regimen length. This is where Rwanda's network of community health workers (CHWs) comes in. With roughly 60,000 CHWs nationwide, Rwanda has one of the highest densities of community-based health workers in sub-Saharan Africa. They are responsible for directly observing therapy for TB patients and, increasingly, for preventive therapy contacts.

CHWs track defaulters through phone calls and home visits. They provide education, address side effects, and offer encouragement. A 2024 study in BMC Infectious Diseases found that peer support from CHWs raised completion of TB preventive therapy by 20 percentage points in three districts of the Eastern Province. The effect was strongest among women, who often faced additional barriers such as childcare responsibilities and household duties.

But CHWs are overstretched. Each worker covers 100–150 households, and their responsibilities extend beyond TB to maternal health, malaria, nutrition, and non-communicable diseases. Incentives — small monthly stipends, bicycles, and cell phones — help, but turnover is high. A 2025 assessment by the Rwanda Biomedical Centre found that CHW attrition averaged 12% per year, driven by low pay and lack of career progression.

Despite these challenges, CHWs remain the backbone of Rwanda's TB control efforts. Their proximity to communities, cultural knowledge, and trust make them uniquely positioned to address adherence. The question is whether the system can support them adequately to meet the growing demand for preventive therapy.

Digital Tools to Nudge Completion

Alongside community workers, digital health tools are being deployed to close the adherence gap. Rwanda's electronic medical record system (EMR) now covers over 90% of health centres, and the National TB Programme has integrated a module that automatically flags patients who miss a scheduled dose. In a pilot in Musanze district, SMS reminders sent to patients' phones reduced missed doses by a third, according to a 2024 report in the Journal of Public Health in Africa.

Smart pill bottles — containers that record each opening and send a mobile alert when a dose is missed — have been tested in a small study in Kigali. Early results suggest they improve adherence, but the cost (roughly US$ 50 per bottle) limits scalability. The Ministry of Health is exploring a simpler version using low-cost Bluetooth-enabled caps that work with basic phones.

Data use, however, remains limited by training and internet reliability. Many health centres have the EMR but lack the bandwidth to sync data daily. Some clinicians are unaware of the flagging system or too busy to act on it. A 2025 evaluation by the University of Rwanda found that only 40% of flagged patients were contacted within one week of a missed dose.

Still, the potential is clear. Digital tools can supplement human effort, especially in urban areas where phone ownership is high. The challenge is to integrate them into existing workflows without adding to the burden on already overstretched staff. As one programme manager put it, “We have the data. We need the time to use it.”

From Pilot to Policy: What Needs to Shift

Rwanda's National TB Programme has set a target of 90% completion for TB preventive therapy by 2028. Reaching that goal will require a shift from clinic-based to community-dispensed therapy, integration of TB prevention into maternal-child health visits, and funding for short-course regimens as first line for contacts. The 2025–2030 National Strategic Plan includes these elements, but implementation is uneven.

One priority is to reduce the number of clinic visits required. Currently, many districts require monthly refills and DOT at a health facility. Moving to community-based DOT — where CHWs deliver the medication to the patient's home — has been shown to improve completion in pilot programmes. The cost is modest: an additional US$ 5–10 per patient for CHW time and transport.

Another opportunity is to integrate TB preventive therapy into routine health services. For example, women attending antenatal care or child vaccination clinics could be screened for TB contact and offered preventive therapy on the spot. A 2023 pilot in two districts found that this approach increased initiation by 40%, though completion data are still being collected.

Finally, the programme must measure what matters. Currently, many reports focus on initiation rates — how many contacts started therapy — rather than completion. Shifting the metric to completion would incentivise the system to invest in adherence support. Rwanda is not alone in this; most national TB programmes worldwide underreport completion. But with its strong data infrastructure and political commitment, Rwanda has a chance to lead.

None of these changes is easy. They require coordination between the Ministry of Health, district health teams, CHWs, and international partners. They require sustained funding — the Global Fund is the largest donor for TB in Rwanda, but its grants are time-limited. And they require patience: behavioural change, whether in patients or health workers, takes time.

But the alternative — continuing to start therapy for thousands of contacts who will not finish — is a waste of resources and a missed opportunity to bend the curve on TB incidence. The tools exist. The question is whether the system can deploy them at scale.

This article is for informational purposes only and does not constitute medical advice. Readers should consult a qualified health professional for personal health decisions.