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Motivation higher earlier in treatment
For HIV-infected patients with TB in Port-au-Prince, Haiti, motivation to be cured of their TB was high — but the cost of transportation was even higher, making it very difficult for some patients to get to the clinic every day. So researchers at the Cornell University Infectious Disease Research Unit in Port-au-Prince began delaying directly observed therapy (DOT) until after patients had begun to feel better. As long as the patients felt sick, researchers reasoned, patients would keep taking their pills.
The gambit paid off well, according to Moise Desvarieux, MD, PhD, an assistant professor of epidemiology in the School of Public Health at the University of Minnesota in Minneapolis (who worked with Cornell at the time). By trimming clinic visits during the initial phase of treatment to just once a week and then increasing them to twice weekly later on, researchers cut costs by 40%.1 The money saved was used to help patients pay the cost of transportation later on in therapy.
Compliance was high, with 87% of patients adherent to their treatment. Over 85% of the 194 cases in the study were cured, even taking into account patients who died, had drug-resistant strains, or were lost to follow-up, Desvarieux says.
"If you have the means for giving DOT the whole time, that’s clearly ideal," he says. "But
in many developing countries, the cost of transportation often surpasses the cost of drugs. I think that under such circumstances, flexibility is key." With an unemployment rate of 70%, patients in Port-au-Prince were frequently without the means to afford a daily round-trip bus fare. Many also lacked a stable address, which made it impractical to send an outreach worker into the community.
Window for noncompliance opens later
"Our hypothesis was that people come to the clinic because they are feeling sick," Desvarieux says. "We thought the danger for noncompliance would come later, when they were feeling better." During the initial phase of treatment, patients still received some monitoring, he adds, because they had to come to the clinic once a week to pick up their pills. At that time, clinicians assessed their response to treatment, another useful index of compliance. Patients too sick to come to the clinic received home visits, he adds.
The success of the protocol shows DOT works best when it’s flexible enough to consider local circumstances, Desvarieux says. "I suppose some people might see such an approach as an invitation to chaos," he says. "They might argue that the message should be DOT only and DOT always. But instead of being dogmatic, I think DOT should be flexible; I think this is a call to sensitivity and flexibility." The point is not necessarily that every program should delay DOT until later in therapy, he adds, but that every program should evaluate patients’ situations.
1. Desvarieux M, Hyppolite PR, Johnson WD, Pape JW. A novel approach to DOT for TB in an HIV-endemic area. Am J Public Health 2001; 91:138-141.