According to a report by the World Health Organization, more than 80% of tuberculosis (TB) cases and deaths were associated with low and middle-income countries in 2022. Common poverty conditions, such as crowding and inadequate ventilation, were found to contribute greatly to its spread. 

To treat tuberculosis, patients are required to undergo months of antibiotic therapy. Directly observed therapy (DOT), is a widely employed strategy that relies on confirming patient adherence to treatment protocol, where health care workers observe patients taking anti-TB medication. However, DOT requires significant time and resources for health care providers and patients. Digital Adherence Technologies (DATs), on the other hand, are digital tools (internet, phones, computers, or detectors) that allow patients to take their medication at their convenience while adherence is relayed to healthcare providers without direct observation. As a modern strategy to combat TB, DATs can help affected individuals and families from a wide range of income levels by reducing implementation costs over time.

Types of Digital Adherence Technologies

Several types of DATs can be implemented to improve TB treatment outcomes:

1. Medication sleeves/labels are a form of custom packaging on fixed-dose anti-TB medication that contains a unique code the patient can use to report adherence. After removing a pill, the patient is required to call a toll-free phone number or send a free SMS message to submit the code and prove daily consumption. This DAT was first implemented in India and is now used throughout Bangladesh, the Democratic Republic of Congo, Ethiopia, Myanmar, Nigeria, the Philippines, Tanzania and Uganda. 
2. Equipped with a sensor and mobile data connection, Smart Pill Boxes alert healthcare providers to patient medication adherence whenever they are opened. This DAT includes features such as a rechargeable battery and a LED and/or speaker to enable reminders and has been implemented in 20 countries with varying income levels, including Brazil, Mozambique, and China.
3. Video Supported Treatment (VAT) requires patients to use a secure remote application to record then upload videos of themselves ingesting medication that the provider can later access. This DAT has been implemented in 17 countries, spanning across Asia and Africa.

DATs have varying costs, levels of accessibility and ease of implementation. Poverty, resource limitations and insufficient infrastructure can pose challenges to implementing these technologies. Medication sleeves require phone access and communication infrastructure to support phone calls or text messages. Smart pillboxes require adherence platform access but are user-friendly and work with various pill types. VATs require phone access, mobile data or Wi-Fi and an in-country server to store video files yet are considered suitable for use with different drug types.  These requirements help determine the logistics of implementing a DAT for a specific country.

Implementing Digital Adherence Technologies

The Stop TB Partnership and the ASCENT Project are two organizations among many that continually research and implement digital adherence technologies for tuberculosis treatment. The Stop TB Partnership funded the implementation of medication sleeves and video-observed treatment in Nigeria, where tuberculosis rates are high, from October 2021 to August 2022. According to a December 2023 report, more than 7,600 patients received digital adherence technologies through this project. Patients achieved success with a medication sleeve called 99DOTS, but limited access to smartphones and network difficulties hindered the success of video observed treatment. The project highlighted the importance of digital adherence technologies with low technology requirements, especially in remote locations. 

In 2021, the ASCENT project, organized and funded by Unitaid, began implementing smart pill boxes and medication sleeves in Ethiopia, a low-income country with a high tuberculosis burden. The project provided more than 4,000 people with DATs. In November 2023, the ASCENT team reported broad acceptance of the technologies among patients with tuberculosis, high national support, and concerns regarding costs. The project also revealed ways leaders could improve and increase the use of digital adherence technologies in Ethiopia in the future. 

Conclusion

Digital adherence technologies offer several strategies to support tuberculosis patients through months of medications. Implementing these tools in areas of poverty presents challenges to overcome, including limited resources and frail infrastructure. To this end, organizations will continue to implement, research, and improve the use of DATs for tuberculosis treatment around the world.

– Kelly Carroll
Photo: Flickr