Tuberculosis (HIV-negative people): improving adherence

Overview

General background | Focus of the review | Comments on evidence | Search and appraisal summary | Substantive changes at this update | Abstract | Cite as

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General background

To improve adherence to anti-tuberculous treatment, in 1995 the World Health Organization (WHO) introduced directly observed treatment, short course (DOTS). In 2005, implementation of DOTS had been undertaken by 187 countries, with 4.9 million patients with tuberculosis managed by this strategy. This overview looks at directly observed treatment (DOT) and the effects of support mechanisms for DOT in people with tuberculosis without HIV infection.

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Focus of the review

This overview provides a representation of the evidence base regarding effectiveness of DOT compared to self-administered treatment, as well as of the support mechanisms that have been investigated to enhance the effectiveness of DOT. Treatment success in tuberculosis relies on adherence. New support mechanisms to DOT (such as mobile phone reminders) emerge and require systematic evaluation of effects.

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Comments on evidence

Five RCTs investigated the effectiveness of DOT versus self-administered treatment and provided moderate-quality evidence. Eight RCTs provided low-quality evidence regarding measures to support DOT, including choice of site, financial incentives, use of healthcare workers, complex interventions, mobile phone reminders, and food incentives.

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Search and appraisal summary

The update literature search for this review was carried out from the date of the last search, June 2010, to June 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 189 studies. After deduplication and removal of conference abstracts, 104 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 86 studies and the further review of 18 full publications. Of the 18 full articles evaluated, three systematic reviews and one RCT were added at this update.

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Additional information

We did not reveal trials (except for one[1]) or subgroup analyses in people at a very high risk or with a proven record of non-adherence, such as homeless people, those with drug addictions, or prisoners. Effects of DOT and support mechanisms in these groups are not known.

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Substantive changes at this update

Directly observed treatment versus self-administered treatment Option restructured. One systematic review added.[8] Categorisation changed from 'unlikely to be beneficial' to 'unknown effectiveness'.

Participant-chosen site versus designated site Option restructured. No new evidence; existing evidence reviewed. Categorised as 'unknown effectiveness'.

Participant-chosen site plus financial incentive versus participant-chosen site alone Option restructured. New evidence added.[12] Categorised as 'likely to be beneficial'.

Clinic-based support versus home-based support Option restructured. No new evidence; existing evidence reviewed. Categorised as 'unknown effectiveness'.

Community-based health worker support versus family member support Option restructured. No new evidence; existing evidence reviewed. Categorised as 'unknown effectiveness'.

Complex support interventions versus usual treatment Option restructured. New evidence added.[14] Categorised as 'likely to be beneficial'.

Mobile phone reminders versus usual treatment Option restructured. New evidence added.[17] Categorised as 'likely to be beneficial'.

Food incentives versus usual treatment Option restructured. New evidence added.[12] Categorised as 'unknown effectiveness'.

Abstract

INTRODUCTION: About one third of the world's population has immunological evidence of previous exposure to Mycobacterium tuberculosis. In 2013, an estimated 9.0 million people developed tuberculosis (TB) and 1.5 million died from the disease. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of directly observed treatment (DOT) versus self-administered treatment (SAT) in people with tuberculosis without HIV infection? What are the effects of support mechanisms for DOT in people with tuberculosis without HIV infection? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2014 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 189 studies. After deduplication and removal of conference abstracts, 104 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 86 studies and the further review of 18 full publications. Of the 18 full articles evaluated, three systematic reviews and one RCT were added at this update. We performed a GRADE evaluation for 12 PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for 13 interventions based on information relating to the effectiveness and safety of directly observed treatment and support mechanisms for directly observed treatment.

Cite as

Ziganshina LE, Eisenhut M. Tuberculosis (HIV-negative people): improving adherence. Systematic review 904. BMJ Clinical Evidence. . 2015 August. Accessed [date].

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