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Doubts about DOT: antiretroviral therapy for resource-poor countries

Liechty, Cheryl A; Bangsberg, David R

Epidemiology & Social: Concise Communication

Introduction: Directly observed therapy programs developed for tuberculosis (TB) have been suggested as a model for the provision of HIV medications in resource-poor countries in order to ensure adherence and prevent drug resistance.

Methods: Opinions were formed based on a review of scientific literature regarding the effectiveness of witnessed dosing in directly observed TB therapy programs, adherence to HIV antiretroviral therapy in resource-rich and resource-poor settings, relationship between adherence and HIV antiretroviral drug resistance, HIV viral load and risk of HIV transmission, and stigmatization concerns related to HIV and TB in resource-poor settings.

Results/conclusions: We suggest that the enthusiasm for HIV directly observed therapy programs is premature based on: equivocal evidence that witnessed dosing is superior to self administered therapy; mistaken assumptions that resource-poor countries are a ‘special case’ with respect to adherence; possible paradoxical impact of good adherence on HIV drug resistance; unproven efficacy of antiretroviral therapy in preventing HIV transmission; and potential stigmatization of daily antiretroviral dosing.

From the the Epidemiology and Prevention Interventions Center, Division of Infectious Diseases, and the San Francisco General Hospital AIDS Program, San Francisco General Hospital, UCSF, and The Academic Alliance, Kampala, Uganda.

Correspondence to D. Bangsberg, EPI Center, RM 301, Building 100, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, California 94110, USA.

Received: 8 July 2002; revised: 11 October 2002; accepted: 22 January 2003.

© 2003 Lippincott Williams & Wilkins, Inc.