VI. PROPOSED SUPERVISION OF TREATMENT BASED ON MONITORED SAT AND DOT GIVEN SELECTIVELY

Monitored SAT appears to be a promising tool to help caregivers and treatment supporters identify those patients who can be successfully treated with SAT. The resources saved not giving DOT to reliable patients could be directed to the less reliable patients using appropriate supportive and remedial measures such as
1) Focused counseling of the patient and family,
2) DOT when necessary (selective DOT),
3)  Enlisting a new supporter if the original supporter is ineffective,
4) Retrieval of defaulters, and
5) Extending the duration of therapy to compensate for poor adherence when it occurs.

The early monitor record which appears to identify patients at increased risk of defaulting would alert caregivers and supporters to make sure they knew the address(s) of potential defaulters, increase the counseling of these patients and their families, and make prompt home visits whenever they miss a refill appointment. Furthermore, monitored SAT should reduce the motivation for defaulting by minimizing the number of time consuming and potentially stigmatizing visits to clinics or community workers for DOT.

WHO recommends extending the duration of treatment when poor adherence occurs. (WHO 2006;WHO 2003A)  A poor record of picking up medication refills is the usual indication of poor adherence when SAT is given. The monitor record should provide much more detailed adherence data for judging how much additional therapy is needed and for convincing patients, their families, and if necessary community leaders that therapy must be taken for a longer time.

For additional compensatory therapy to be effective, drug resistance must not have developed during the period of interrupted treatment.  The use of fixed dose combinations (FDCs) of anti TB drugs, which prevents monotherapy, removes one cause of drug resistance. A WHO publication that quoted indirect evidence from South Africa and Brazil (Blomberg et al. 2001) plus subsequent data from Los Angeles (Moulding et al. 2004) suggest that drug resistance occurs infrequently, despite interrupted treatment, when FDCs containing INH and RMP are given. WHO treatment guidelines recommend FDCs. (WHO 2006; WHO 2003A) While the issue needs further study, especially for HIV positive patients, extending the duration of therapy when poor adherence occurs should result in treatment success in most cases as long as FDCs are used.
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SUMMARY

I. INTRODUCTION

II. THE SUCCESS AND PROBLEMS WITH DOT

III. RELIABLE PATIENTS - A POTENTIAL RESOURCE FOR REDUCING THE ADHERENCE PROBLEM

IV. DETERMINING THE ADHERENCE OF PATIENTS

V. EXPERIENCE WITH SELF ADMINISTERED TREATMENT GIVEN IN MEDICATION MONITORS (MONITORED SAT)

VI. PROPOSED SUPERVISION OF TREATMENT BASED ON MONITORED SAT AND DOT GIVEN SELECTIVELY

VII. USE OF MONITORED SAT TO IMPROVE TREATMENT OUTCOMES AND EXPAND SERVICES IN VARIOUS SETTINGS

VIII. CAN MEDICATION MONITORS HELP PREVENT DRUG RESISTANT DISEASE

IX) USE OF MEDICATION MONITORS WHEN MANAGING HIV/AIDS and HIV/AIDS/TB

X) EXPENSE AND PRACTICALITY OF USING MEDICATION MONITORS

XI. EVALUATION

XII. IN SUM

REFERENCES:

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