13.2 Treatment delivery model

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    13.2.1 Self-administered treatment

    Self-administered treatment (SAT) is taken autonomously by the patient without daily supervision. The patient is seen at a health facility at regular intervals (e.g. monthly) to receive drugs, support and treatment education. SMS telephone reminders may be considered to reinforce adherence.

    13.2.2 Directly observed therapy 

    Drugs are sometimes provided daily to the patient and the treatment is taken under direct observation (DOT) by a third party.

     

    DOT may be provided:

    • In health facilities (facility-based DOT): in this model, DOT is implemented in a centralised setting and treatment is administered by healthcare workers.
    • Outside of health facilities (community or home-based DOT): in this model, DOT is implemented in a decentralised setting and is usually provided by supervised, trained and remunerated treatment supporters.
      For the roles and responsibilities of treatment supporters see Appendix 20.
    • Remotely (video-observed therapy or VOT): VOT uses secure Internet connections via a smart phone or computer application to remotely supervise patients taking their treatment.

     

    DOT is labour-intensive to implement and can be inconvenient for patients. Community and home-based DOT and VOT require fewer resources (personnel and transport) than facility-based DOT and may be more convenient for patients.

     

    Box 13.1 – Recommended treatment delivery models

     

     Drug-susceptible TB (DS-TB)

    • DOT has not been proven to improve treatment outcomes for DS-TB when compared to SAT in controlled trials [1] Citation 1. Karumbi, J. and P. Garner. Directly observed therapy for treating tuberculosis. Cochrane Database Syst Rev, 2015(5): p. CD003343. 
      https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003343.pub4/full
      .
    • When there is no factor to complicate adherence, and provided the patient receives appropriate support, treatment should be self-administered.
    • There are some situations in which DOT may be preferred:
      • Patients with mental health issues or serious socioeconomic problems (e.g. the homeless) and all patients incapable of taking drugs on their own.
      • Prisoners (risk of drugs being sold or stolen).

     

    Drug-resistant TB (DR-TB)

    • Due to the lack of fixed-dose combinations (FDC), length of treatment, adverse effects of TB drugs and lack of therapeutic alternatives if treatment fails, patients usually require reinforced support.
    • If DOT is considered useful, home-based DOT [2] Citation 2. Williams et al. Community-based management versus traditional hospitalization in treatment of drug-resistant tuberculosis: a systematic review and meta-analysis. Global Health Research and Policy (2016) 1:10
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5693550/pdf/41256_2016_Article_10.pdf
       or VOT are preferred to facility-based DOT. A combination of approaches may be required for some patients.

     

    Latent TB infection (LTBI)

    • LTBI treatments can be self-administered.
    • DOT may be preferred with the 3HP regimen, as it may cause serious hypersensitivity reactions. However, SAT can be considered if the patient well informed and is able to seek rapid medical attention if adverse effects develop.

     

     

    References