Moving Beyond Directly Observed Therapy for Tuberculosis.

Mycobacterium tuberculosis often develops resistance in the setting of monotherapy, either de facto (when an organism is susceptible to only one drug of an intended multidrug regimen) or actual (historically, or in the setting of extensively drug resistant tuberculosis (XDR-TB) salvage regimens) [1][2][3][4].With current regimens, sterilization of drug-susceptible organisms requires at least six months of treatment to prevent disease relapse.Unfortunately, pill burden, drug toxicity, stigma, and poor provider practice often complicate these prolonged treatment courses, and nonadherence is widely blamed for the global epidemic of drug-resistant TB.Directly observed therapy (DOT) has for decades been considered crucial to ensuring anti-TB medication adherence worldwide, but carries important individual and health policy concerns.This week in PLOS Medicine, Fielding and colleagues present a cluster randomized trial of an alternative strategy-managing adherence with reminders delivered by an electronic pillbox or text messaging.DOT is variously defined as 5-7 daily doses per week observed by facility-, workplace-, or community-based healthcare workers or confidants.Although DOT is employed selectively for other communicable and noncommunicable diseases for which incomplete adherence threatens treatment success, DOT in TB treatment has become enshrined as "canon in a field long characterized by fervor in principle and practice" as in no other disease [5].First implemented in Madras and Hong Kong in the 1950s [6], DOT became globally endorsed (as one of five key components of the World Health Organization directly observed therapy short-course [DOTS] strategy) [7] in 1994 in the aftermath of public health alarm created by an outbreak of multidrug-resistant (MDR)-TB in New York City [8].Operationalization of DOT varies according to resource availability, cultural factors, and individual provider perception, and is often incomplete, even among populations for which strict adherence is considered essential [9].Although in its best form DOT can be a platform for patient social support and guidance, it has long been debated whether the requirement for witnessed dosing represents the least restrictive alternative in pursuit of public health goals [10].Conceived of as a principal standard of care to protect individuals from drug resistance amplification and communities from a potentially devastating airborne disease, DOT in some cases adversely impacts the dignity, autonomy, and livelihoods of patients who are often already poor and disenfranchised [11].For example, among patients receiving treatment for both HIV and drug-resistant TB, loss of a sense of agency due to provider supervision of TB treatment contributes to preferential adherence to antiretrovirals over drug-resistant TB therapy, complicating combined treatment regimens

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