A central challenge in the fight against tuberculosis (TB) is overcoming the barriers presented by TB therapy, itself. Side-effects are common and treatment courses are long, extending well beyond a year in some cases of drug-resistant disease.1,2 Poor treatment adherence has been linked to microbiologic failure, disease relapse and the emergence of drug resistance.3,4
In response, and in an effort to promote treatment completion, the Centers for Disease Control (CDC) and the World Health Organization (WHO) have advocated for directly observed therapy (DOT), wherein the ingestion of each dose is directly monitored.1,5,6 In many areas, DOT is the current standard of care, though employing DOT in a patient-centered and efficient fashion can be challenging. Scheduling in-person DOT visits is logistically complicated, resource intensive (for patients and TB programs), and can increase both patient and program-level costs. In some individuals, logistical barriers and perceived stigma related to DOT have led to feelings of humiliation, loss of control and stress.7,8
To overcome these barriers, video-based DOT (vDOT) has been proposed as an alternative to in-person observation.1,9,10 Herein, pill ingestion is monitored remotely via digital video capture. vDOT has been implemented using synchronous technologies, such as Skype and FaceTime,11-14 as well as asynchronous ones, wherein recorded videos are uploaded and digitally stored for future review.15 While both the CDC and WHO support the use of vDOT, data on the real-world implementation of vDOT remains limited. To this end, we present two studies which broaden our understanding of vDOT by exploring its potential role in two distinct clinical settings, among two very different patient populations.
In Chapter 1, we present the results of a pragmatic, prospective, pilot implementation of vDOT at three TB clinics in Maryland, US. A mixed-methods approach is employed to assess (1) effectiveness, (2) acceptability and (3) cost. In Chapter 2, we extend the use of vDOT into a high TB burden, low resource setting, though a prospective, pilot implementation of vDOT in Pune, India.
Our work shows that vDOT may be a feasible and acceptable approach to TB treatment monitoring, both within the US and India. Further, vDOT may be associated with cost-savings within the US when compared to traditional in person DOT
