Digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities

Abstract

Poor medication adherence may increase rates of loss to follow-up, disease relapse and drug resistance for individuals with active tuberculosis (TB). While TB programmes have historically used directly observed therapy (DOT) to address adherence, concerns have been raised about the patient burden, ethical limitations, effectiveness in improving treatment outcomes and long-term feasibility of DOT for health systems. Digital adherence technologies (DATs)-which include feature phone-based and smartphone-based technologies, digital pillboxes and ingestible sensors-may facilitate more patient-centric approaches for monitoring adherence, though available data are limited. Depending on the specific technology, DATs may help to remind patients to take their medications, facilitate digital observation of pill-taking, compile dosing histories and triage patients based on their level of adherence, which can facilitate provision of individualised care by TB programmes to patients with varied levels of risk. Research is needed to understand whether DATs are acceptable to patients and healthcare providers, accurate for measuring adherence, effective in improving treatment outcomes and impactful in improving health system efficiency. In this article, we describe the landscape of DATs that are being used in research or clinical practice by TB programmes and highlight priorities for research.

Keywords: SMS reminders; differentiated care; digital medication monitors; electronic medication packaging devices; medication adherence; mhealth; mobile technologies; tuberculosis.

Figure 1

Examples of different adherence monitoring technologies. (A) 99DOTS, a feature phone-based adherence technology (with permission from Everwell Health Solutions); (B) SureAdherence, a video DOT strategy (with permission from SureAdherence Mobile Technologies); (C) evriMED, a digital pillbox (with permission from the Wisepill Technologies); (D) an ingestible sensor–based adherence monitoring approach (Source: Belknap et al.37). DOT, directly observed therapy; LED, light-emitting diode; SIM, subscriber identification module; TB, tuberculosis.

Figure 2

Functions that digital adherence technologies (DATs) can play to reinforce patient medication adherence and facilitate monitoring and triage of patients by health systems. ‘Differentiated care’ refers to providing different intensities and types of care based on a patient’s level of medication adherence as measured by the DAT.

Figure 3

Example of how digital adherence technologies involving daily reporting of dose-taking could potentially facilitate earlier identification and intervention to address medication non-adherence. The 99DOTS model is used for illustrative purposes. Each box represents a calendar day on the dashboard viewed by healthcare providers. Green boxes represent doses that were ‘called in’ on a given day and red boxes represent doses that were not called in. SMS, short messaging service.

Figure 4

Example of ‘technology fatigue’. Patient response rates to short messaging service (SMS) texts to indicate dose ingestion declined throughout the course of tuberculosis therapy in a study of a two-way SMS intervention in Pakistan, reducing the accuracy of this monitoring approach. Source: Mohammed et al. RR, response rate.