Impact of the 99DOTS digital adherence technology on tuberculosis treatment outcomes in North India: a pre-post study

Abstract

Background 99DOTS is a cellphone-based digital adherence technology. The state of Himachal Pradesh, India, made 99DOTS available to all adults being treated for drug-sensitive tuberculosis (TB) in the public sector in May 2018. While 99DOTS has engaged over 500,000 people across India, few studies have evaluated its effectiveness in improving TB treatment outcomes. Methods We compared treatment outcomes of adults with drug-sensitive TB before and after Himachal Pradesh’s 99DOTS launch using data from India’s national TB database. The pre-intervention group initiated treatment between February and October 2017 (N = 7722), and the post-intervention group between July 2018 and March 2019 (N = 8322). We analyzed engagement with 99DOTS and used multivariable logistic regression to estimate impact on favorable treatment outcomes (those marked as cured or treatment complete). Results In the post-intervention group, 2746 (33.0%) people called 99DOTS at least once. Those who called did so with a wide variation in frequency (< 25% of treatment days: 24.6% of callers; 25–50% of days: 15.1% of callers, 50–75% of days: 15.7% of callers; 75–100% of days: 44.6% of callers). In the pre-intervention group, 7186 (93.1%) had favorable treatment outcomes, compared to 7734 (92.9%) in the post-intervention group. This difference was not statistically significant (OR = 0.981, 95% CI [0.869, 1.108], p = 0.758), including after controlling for individual characteristics (adjusted OR = 0.970, 95% CI [0.854, 1.102]). Conclusions We found no statistically significant difference in treatment outcomes before and after a large-scale implementation of 99DOTS. Additional work could help to elucidate factors mediating site-wise variations in uptake of the intervention.

Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies

“…Across 51 studies reporting adjusted analyses including people with drug-susceptible TB, male sex and older age were associated with unfavorable treatment outcomes in 15 [ 41 , 66 – 79 ] and 15 [ 68 , 69 , 72 , 75 – 86 ] studies, respectively (Fig I in the S6 Appendix and Table D in the S4 Appendix ). Sex and age had nonsignificant associations in 21 [ 67 , 68 , 72 , 77 , 80 , 82 , 84 – 98 ] and 18 [ 41 , 68 , 71 , 72 , 76 – 78 , 83 , 87 , 89 , 91 – 94 , 98 – 101 ] studies, respectively.…”

“…People with more severe symptoms at treatment initiation were less likely to experience loss to follow-up in 2 studies [ 91 , 105 ], but more likely to experience composite unfavorable TB treatment outcomes in 1 study [ 99 ]. There were nonsignificant associations for illness duration in 1 study [ 91 ], smear–positive pulmonary disease in 11 studies [ 66 , 68 – 70 , 72 , 75 , 82 , 88 , 95 – 97 ], and number of symptoms at treatment initiation in 2 studies [ 86 , 91 ].…”

“…Only statistically significant findings are presented. Some studies in the review with adjusted analyses reported nonsignificant findings for health system dissatisfaction [ 93 ], proximity to the nearest clinic [ 41 , 93 , 108 ], treatment costs [ 91 , 93 ], number of providers visited [ 91 ], type of DOT provider [ 41 , 84 ], type of case finding approach [ 127 ], type of adherence monitoring approach [ 75 , 84 , 105 , 109 ], and incorrect and/or inadequate information given by providers [ 73 , 93 , 123 ]. Anganwadi workers are government-supported community health workers.…”

“…Lack of community health worker support [ 73 ] or non-participation in TB support groups [ 126 ] was associated with unfavorable outcomes in 2 studies. Type of DOT or adherence monitoring approach had nonsignificant associations in 4 studies [ 75 , 84 , 105 , 109 ].…”

The Performance of Digital Technologies for Measuring Tuberculosis Medication Adherence: A Systematic Review

“…(9–12) However, people with TB may call the phone number on the medication sleeve without taking their doses (i.e., over-reporting adherence) or take medication doses without calling (i.e., under-reporting adherence), which may hinder the ability to identify people experiencing nonadherence. Other DATs that have been used in routine care by TB programs (13,14) —such as two-way short messaging service (SMS), digital pillboxes, or video-supported therapy—similarly involve an SMS response, pillbox opening, or remote visualization of dosing by video, respectively, serving as a proxy for a treatment dose taken. All may face challenges related to over-reporting or under-reporting of adherence.…”