13.1 Treatment delivery and accompaniment

Good adherence is when the patient follows the treatment as prescribed. Failure to take anti-TB drugs consistently, in an inappropriate way or stopping the treatment too soon, can lead to treatment failure or relapse. Additionally, it may contribute to the development of resistance, which may complicate subsequent treatment, thereby, decreasing the chances of successful outcomes1.

In order to achieve good adherence, treatment is sometimes delivered under direct observation therapy (DOT)2, but DOT can be limiting for patients and is labour intensive to implement. DOT has not been proven to improve results for drug-susceptible TB when compared to self-administered treatment in controlled trials3.

Therefore, when there is no factor that would make it difficult to adhere to therapy, treatment can be self-administrated as long as it is accompanied with adequate patient support (Section 13.3).

Experience with other chronic diseases and with TB therapy has shown that with strong guidance and support, patients can reach high treatment success with self-administrated treatment.

Patient commitment to follow instructions and prescriptions (drug dosages and schedule, length of treatment, diligence in coming in for follow-up visits, etc.) is needed for the entire length of the treatment. It is crucial that the patient understands the treatment, and that the clinic is organized in such a way that the patient can follow the treatment properly all the way to completion.

There are some situations in which DOT is required:
– Second-line treatment: drugs are poorly tolerated and multidrug-resistant TB (MDR-TB) treatment requires a huge pill burden for a long period of time. Missing doses can result in resistance amplification with fatal consequences for the patient. For these reasons, strict DOT is recommended during the entire duration of the treatment.
– First-line treatment:
• Patients in whom adherence is an issue due to mental health problems or serious socioeconomic challenges (e.g. homelessness) and all patients incapable of taking drugs on their own;
• Prisoners: risk of drugs being sold, stolen or not taken.