Researchers can create the drugs to end disease. What they can’t do is make sure people take them.
Every year, tuberculosis (TB) kills some 1.3 million people across the globe, even though effective treatments are available.
Moldova’s TB rate is around three times higher than the targets set by the Millennium Development Goals. Now, the country’s health department is encouraging those in recovery to video themselves taking their medication. And according to one recent evaluation, it could have the potential to turn the tide on the disease.
Tuberculosis is treatable, but a cocktail of drugs needs to be taken daily for six months after infection is discovered to be safely cleared out of the body.
That means patients have to stick to the program even when their symptoms subside and taking the medication might not feel so necessary. Meanwhile, the drugs’ side effects, can leave those taking them feeling worse than if they abandoned the course of treatment.
The challenge of sticking to the regime isn’t unique to Moldova. The World Health Organisation recommends Directly Observed Treatment (DOT) for recovering tuberculosis patients — namely, mandating patients to take their medication in front of a nominated observer to ensure they don’t forget doses or drop off completely.
In Moldova, medical guidance means going to a clinic every day, for the whole course of treatment.
That’s no small inconvenience, according to Ruth Persian, an advisor at the UK’s Behavioural Insights Team (BIT), who worked with Moldovan NGO Act for Involvement to transform TB treatment in the country’s capital.
“DOT means you don’t only have to adhere to the medication, you have to go to a clinic everyday. That incurs direct and indirect costs: not only are you paying for travel, petrol, or the bus — you can’t be at work while you’re at the clinic.
“Plus, you’re restricted by their opening hours. And then there’s a certain stigma attached: being seen at the clinic every day means neighbours and acquaintances can figure out what’s going on.”
The BIT’s proposed fix was relatively simple: let patients film themselves taking their pills. The BIT/Act for Involvement pilot provided patients with tablet computers loaded with a simple video recording software and linked to a central monitoring service.
A trial with 180 participants took place over three years in the Moldovan capital of Chișinău, and a recent randomised controlled trial suggests it significantly improved adherence rates.
Around 84% of Video Observed Treatment (VOT) patients completed their drug course, compared to only 44% for participants who had to go to a clinic.
It’s cause for optimism, according to Simon Ruda, Director of Home Affairs and International Programmes at the Behavioural Insights Team.
While trials of video observed treatment has taken place in other European settings, the budgets involved have often been significantly higher. The Moldovan project was delivered “on a shoestring,” he said.
“Low- and middle-income countries may look and say, ‘we can’t do that.’ Our response is: ‘yes you can, because we did’.”
The Moldovan Ministry of Health is now keen to expand VOT across the country, but ethical and practical queries remain, not least how to finance the projects’ expansion.
“We’re still thinking about the human interaction component,” said Persian. “If we replace direct interaction with a video, we should think carefully about what that does to behaviour.” Video might be convenient for those in recovery, but it could also weaken the bond between patients and clinicians, for example.
Patients are still required to attend monthly check-ups in person in case of any medical complications, but whether VOT can meaningfully replace face-to-face contact with trained clinicians who could monitor any early warning signs of illness or side-effects remains to be seen.
Another challenge will be targeting those most at need. At the start of the VOT trial, existing data was out-of-date and incomplete. Maintaining clear, easily accessible records will be central to the success of the scale-up.
But in the long-term, the hope is that the project would go some way to encouraging a broader culture of health, in which family members or friends can act as reminders to adhere to treatments and maintain one’s health.
“The overwhelming majority of funding for health research is spent on developing remedies rather than changing the behaviours that can lead to health issues arising in the first place,” said Ruda.
Righting that imbalance could improve outcomes for all. — Edward Siddons
(Picture credit: Flickr/Diarmid)