9. Patient support to enable adherence to treatment

Treatment support of patients using a patient-centred approach is needed to maximize treatment adherence and enable early detection of patients who are not responding to treatment. Communitybased or home-based DOT is conditionally recommended over health facility-based DOT or unsupervised treatment. DOT administered by trained lay providers or health care workers is conditionally recommended over DOT administered by family members or unsupervised treatment. Video (virtual) observed treatment (VOT) can replace DOT when the technology is available, and can be appropriately organized and operated by health care providers and patients (1, 2, 122).

Apart from DOT, several other interventions are considered important to promote treatment adherence and a patient-centred approach. NTPs need to improve patient access to a package of treatment adherence interventions, in conjunction with the selection of a suitable treatment administration option, which is defined as material support (e.g. food, financial incentives and reimbursement of transport fees), psychological support, home visits, use of information technology, medication monitors and staff education. Moreover, counselling and patient education on the disease and on treatment adherence are strongly recommended (1, 2, 122). The following recommendations from the WHO Guidelines for treatment of drug-susceptible tuberculosis and patient care 2017 update (2) continue to apply to patients with drug-susceptible and drug-resistant TB:

Recommendation 8.1 Health education and counselling on the disease and treatment adherence should be provided to patients on TB treatment

(Strong recommendation, moderate certainty in the evidence)

Recommendation 8.2 A package of treatment adherence intervention²¹ may be offered for patients on TB treatment in conjunction with the selection of a suitable treatment administration option²²

(Conditional recommendation, low certainty in the evidence)

Recommendation 8.3 One or more of the following treatment adherence interventions (complementary and not mutually exclusive) may be offered to patients on TB treatment or to health care providers:

a) tracers²³ or digital medication monitor²⁴ (conditional recommendation, very low certainty in the evidence);

b) material support to patient²⁵ (conditional recommendation, moderate certainty in the evidence);

c) psychological support²⁶ to patient (conditional recommendation, low certainty in the evidence)

d) staff education²⁷ (conditional recommendation, low certainty in the evidence)

Recommendation 8.4 The following treatment administration options may be offered to patients on TB treatment:

a) Community- or home-based directly observed treatment (DOT) is recommended over health facility-based DOT or unsupervised treatment (conditional recommendation, moderate certainty in the evidence)

b) DOT administered by trained lay providers or health care workers is recommended over DOT administered by family members or unsupervised treatment (conditional recommendation, very low certainty in the evidence)

c) Video observed treatment (VOT) can replace DOT when the video communication technology is available and can be appropriately organized and operated by health care providers and patients (conditional recommendation, very low certainty in the evidence)

Recommendation 8.5 Patients with MDR-TB should be treated using mainly ambulatory care rather than models of care based principally on hospitalization (1)

(Conditional recommendation, very low certainty in the estimates of effect)

Recommendation 8.6 A decentralized model of care is recommended over a centralized model for patients on MDR-TB treatment (1, 2, 123)

(Conditional recommendation, very low certainty in the estimates of effect)

The implementation of the recommended patient-centred care interventions is particularly important in improving treatment outcomes of patients on MDR-TB treatment (124). Various models and toolkits for patient-centred supportive care have been developed and piloted for implementation in different settings (125).

²¹ Treatment adherence interventions include social support such as material support (e.g. food, financial incentives, and transport fees); psychological support; tracers such as home visits or digital health communication (e.g. SMS, telephone call); medication monitoring; and staff education. The interventions should be selected on the basis of the assessment of individual patient’s needs, provider’s resources and conditions for implementation.

²² Treatment administration options include DOT, VOT, non-daily DOT (e.g. not every dose supervised treatment, weekly or a few times per week supervision), or unsupervised treatment.

²³ Tracers refer to communication with the patient, including via SMS, telephone (voice) calls, or home visit.

²⁴ A digital medication monitor is a device that can measure the time between openings of the pill box. The medication monitor may have audio reminders or send an SMS to remind the patient to take medications, along with recording when the pill box is opened.

²⁵ Material support can be food or financial support such as: meals, food baskets, food supplements, food vouchers, transport subsidies, living allowance, housing incentives, or financial bonus. This support addresses indirect costs incurred by patients or their attendants in order to access health services and, possibly, tries to mitigate the consequences of income loss related to the disease.

²⁶ Psychological support can be counselling sessions or peer-group support.

²⁷ Staff education can be adherence education, charts or visual reminders, educational tools and desktop aids for decision-making and reminders.

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