3.3 Considerations for implementation

The 6-month rifampicin-based regimen is the standard regimen for the treatment of DS-TB in many countries and has been for many years; thus, there is a great deal of experience in using this regimen.

Rapid diagnostic testing and universal DST is a recommended target for all NTPs (4). In settings where DST results are not yet routinely available to guide the management of individual patients, patient history and clinical judgement are used to make decisions on the empirical use of this regimen.

Diagnostic challenges include being a long distance from the facilities where quality TB diagnostics are available, technical difficulties in implementing these tests and difficultly in accessing health services. The coronavirus disease (COVID-19) pandemic has further complicated rapid and universal access to quality TB diagnosis. Also, diagnosis of TB in children is particularly challenging.

NTPs should obtain and use their country-specific drug-resistance surveillance to estimate the level of MDR/RR-TB. Periodic drug-resistance surveys or ongoing surveillance in each country are essential for monitoring the impact of the regimen and the overall treatment programme (1).

To improve treatment adherence and minimize the acquisition of MDR/RR-TB, it is critical for NTPs to ensure adequate treatment support in the context of patient-centred care. Implementing treatment support and care requires resources to ensure optimal adherence and provide patient education and counselling (1).. It is important to educate and support patients, to ensure that they complete treatment with all the prescribed doses within the planned period of time (1).

Daily dosing is considered optimal because it reduces the probability of selecting resistant mutants. However, such dosing may be challenging for NTPs in terms of providing daily treatment support.

The use of FDCs may provide programmatic benefits by making it easier to order medicines, simplifying supply chain management, reducing the occurrence of stock-outs, and facilitating drug delivery and prescription. FDCs with proven bioavailability may also provide additional benefits, especially in settings with many TB patients and a limited number of health care workers, because FDCs reduce the need for additional health care staff and for training in dosing and dispensing of medications, while contributing to a lower pill burden for patients. However, because use of FDCs lacks the flexibility that is available when using loose tablet formulations, FDCs do not always provide optimal dosing in all individuals (1).

NTPs need to procure a quantity of loose or single drug formulations for certain treatment conditions. Having single drug formulations available would also be beneficial to programmes in cases of adverse reactions to TB medications, when drugs must be reintroduced one at a time (see Section 8 for details) (1).

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