Infectious Disease · Medical Literature
Comparing adherence strategies and facility DOT in TB care: a systematic review with meta-analysis.
Abstract
BACKGROUND Adherence to TB treatment is crucial for successful outcomes. While facility-based directly observed therapy (FB-DOT) is a common strategy, recognition of its limitations has spurred the development of flexible approaches. We have compared the effectiveness of alternative adherence-enhancing strategies with FB-DOT. METHODS We searched three databases and four registries from June 2013 to May 2025. We included comparative studies evaluating interventions designed to improve adherence to TB treatment in people aged 15 years or older, excluding adherence to multiple therapies. Meta-analyses were conducted for treatment success, treatment completion, cure rate, and loss to follow-up. RESULTS Twenty-five studies involving 19,103 participants were included. Self-administered treatment and reminder-based interventions achieved treatment success comparable to FB-DOT. Community-based DOT showed similar cure and completion rates but was effective at reducing loss to follow-up (71% reduction). Video-supported treatment and digital adherence technologies demonstrated neutral effects across treatment outcomes. Multicomponent strategies showed heterogeneous results. CONCLUSION Alternative adherence strategies can offer improvements over FB-DOT in specific contexts. However, their variable effectiveness limits universal implementation. Adherence support, community engagement, and social determinants should guide programmatic design and implementation. .
Clinical relevance
Adherence to TB treatment remains a critical determinant of cure, prevention of resistance, and interruption of transmission, yet facility-based directly observed therapy (FB-DOT) imposes significant logistical and patient-centered burdens that may paradoxically worsen outcomes in certain populations. This systematic review with meta-analysis addresses the evidence gap regarding whether alternative adherence-enhancing strategies can match or surpass FB-DOT across key treatment outcomes. With 19,103 participants across 25 comparative studies spanning over a decade of evidence (2013–2025), these findings are directly relevant to national TB program design, resource allocation, and patient-centered care models globally.
Key findings
1. Self-administered treatment (SAT) achieved treatment success rates comparable to FB-DOT, suggesting non-inferiority in appropriately selected patients without requiring daily clinic attendance. 2. Reminder-based interventions (e.g., SMS, phone call reminders) also demonstrated treatment success equivalent to FB-DOT, supporting their role as low-cost adjuncts or alternatives. 3. Community-based DOT (CB-DOT) showed similar cure and treatment completion rates compared to FB-DOT, while achieving a 71% reduction in loss to follow-up — the most clinically impactful quantitative finding in the review. 4. Video-supported treatment (VST) and digital adherence technologies (DAT) demonstrated neutral effects across all evaluated treatment outcomes (treatment success, completion, cure, and loss to follow-up), neither superior nor inferior to FB-DOT. 5. Multicomponent strategies yielded heterogeneous results across studies, precluding a definitive directional conclusion and suggesting that bundled intervention effectiveness is highly context-dependent. 6. The review included only participants aged 15 years or older and excluded adherence to multiple concurrent therapies, which limits direct generalizability to pediatric populations and complex co-treatment scenarios (e.g., TB-HIV with ART).
Practice implications
TB programs should prioritize community-based DOT over facility-based DOT for patients at high risk of loss to follow-up — particularly those with geographic, occupational, or socioeconomic barriers to clinic attendance — given the 71% reduction in loss to follow-up demonstrated in this meta-analysis. Self-administered treatment combined with reminder-based strategies represents a viable, patient-centered alternative to FB-DOT for adherent, motivated patients with drug-susceptible TB, and should be considered in settings where CB-DOT infrastructure is limited. Programmatic design should move away from a one-size-fits-all DOT model and instead integrate individualized adherence support informed by social determinants of health, community engagement capacity, and local health system resources, as no single alternative strategy demonstrated universal superiority.