VII. USE OF MONITORED SAT TO IMPROVE TREATMENT OUTCOMES AND EXPAND SERVICES IN VARIOUS SETTINGS
A) At Clinics and Health Facilities
Clinics can be overwhelmed by having to provide DOT multiple times each week for all TB patients. DOT often becomes impossible for patients who live too far away or whose work commitments conflict with clinic hours. Providing monitored SAT for reliable patients together with supportive and remedial measures for the less reliable patients would reduce the clinic workload and help solve these problems.
B) By Private Physicians and Pharmacies.
The private sector, which rarely uses DOT, treats a large proportion of the world's TB patients. (Uplekar et al. 2001) Unsupervised pharmacies often provide TB medication. (Lonnroth et al. 2000) Apparently, the burden imposed by DOT plus increased fear of stigma motivates many patients to pay for TB treatment despite the availability of free superior public care.
WHO stresses public private partnerships to address this problem. One of the most successful was in Delhi, India, which achieved 81% success among 168 sputum positive patients. (Lonnroth et al. 2004) However, it took 18 months of active dialog with the community physicians before the program was launched and only a fraction of the physicians participated.
Public private partnerships could probably be more effective, if private patients received their drugs in medication monitors from trained and subsidized pharmacies who reported the adherence record to the private physicians and public health officials. Since physicians could keep their reliable patients without having to provide DOT, they should be more willing to cooperate.
C) By Community Members or Community Workers
WHO recommends an increased community contribution and the use of community workers. (WHO 2003B) Community based lay health workers giving DOT achieved 74% success compared with 57% with clinic based DOT, and 59% with SAT. (Zwarenstein et al. 2000) Unfortunately, attrition of volunteer workers who eventually want to be paid (Kironde and Klaasen 2002) and maintenance of effective supervision (Connolly et al. 1999) can be significant problems. If community workers provided monitored SAT, retrieved the adherence record with the built in LED display, spent minimal time with adherent patients, and focused their attention on the less adherent patients, fewer workers would be needed, modest stipends could probably be given, attrition reduced, and supervision of the workers simplified.
D) By Family Members
The vast majority of patients live in families. Therefore, having a family member give DOT is attractive but controversial. It has been called a slippery slope to sloppy DOTS because of concern that the medication will not be consistently observed. (Frieden and Sbarbaro 2002) However, family member DOT is very attractive because it imposes less of a burden on the patients and the health care system. A cluster randomized controlled trial found family member DOT to be as effective as community member DOT in rural areas in Nepal. (Newell et al. 2006) When patients in Senegal were given a choice, 59.4% had their treatment supervised by a family member, 31.5% by a nurse, and 9.1% by a community health worker. (Thiam et al. 2007) Furthermore, 88% of patients supervised by a family member were cured vs. 77% for all other treatment supervisors. (Thiam et al. 2007) Therefore, despite the controversy it appears that family member DOT with well-trained supporters improves adherence, even though each dose may not be observed. If further supervision were added by providing the drugs in medication monitors, together with adequate supportive and remedial measures when poor adherence was found, even better results would probably be achieved. In fact monitor supervised family member DOT could become the most successful means of delivering DOT.
E) For Patients who Change Their Address
Records are often lost when patients move, despite well-described procedures for preventing this. (Meijnan et al. 2002) For these patients, medication monitors that keep the adherence record from the beginning of treatment and critical clinical data like the sputum status would greatly help subsequent caregivers plan appropriate therapy.
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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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