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CORRESPONDENCE

`DOTS’ and ‘DOT’ for delivering antiretroviral therapy in resource-poor countries

Harries, Anthony D

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Liechty and Bangsberg [1] made the case that the enthusiasm for HIV directly observed treatment (DOT) programmes is premature, and they show that there is little evidence as yet that DOT for antiretroviral drugs improves virological, immunological or clinical outcomes. The enthusiasm for HIV DOT stems from the experience of tuberculosis control programmes, in which the direct observation of treatment is promoted as one part of an overall strategy for tuberculosis control. Criticism of HIV DOT may be valid, but it misses the point and detracts from the overall message that the strategy for tuberculosis control might be a useful model on which to base a strategy for delivering antiretroviral therapy.

The overall aim of tuberculosis control is to reduce mortality, morbidity, and transmission of the disease, while preventing the development of drug resistance. The main intervention is standardized combination chemotherapy provided under direct observation, at least during the initial phase of treatment, to all identified sputum smear-positive tuberculosis patients, the main sources of infection. The framework for effective tuberculosis control incorporates a global strategy called ‘directly observed treatment, short course’ (DOTS) (Table 1) [2]. DOT is just one component of this policy package. Other components, such as a quality assured diagnostic service, uninterrupted supply of drugs and a standardized monitoring and evaluation system are also essential to the strategy of achieving the global targets for tuberculosis control: an 85% cure rate and a 70% case detection rate for new cases of smear-positive pulmonary tuberculosis [2]. A similar strategy for delivering antiretroviral drugs has been successfully tested in small projects in resource-poor countries [3], and this may provide a simple, structured, safe and effective way of providing a high technology intervention to places where it is most needed, such as in sub-Saharan Africa [4].

Table 1
Table 1:
Five components of the DOTS strategy.

DOT versus self-administered treatment in the context of tuberculosis control has also been the subject of extensive debate, particularly about what approach improves treatment adherence. The randomized controlled trials in South Africa and Pakistan [5,6], which showed that DOT was no more effective than self-administered treatment, have been widely used to throw doubt on the effectiveness of this observed therapy approach. However, in the trials it is important to note that all alternative options for treatment care processes were associated with high default rates and poor treatment outcomes. This suggests that the debate around DOT should be broadened, and there is in fact a growing appreciation that DOT is not just about watching patients take their medication [7]. It is more about making life acceptable for tuberculosis patients during their treatment, and finding creative ways of helping patients complete their treatment successfully. DOT should be conceptualized as a broad package of support to the patient, within the framework of a chronic care model [7]. DOT, therefore, may vary in terms of what the package contains and the context in which the package is being implemented. A similar concept of HIV DOT would seem reasonable when considering the provision of life-long antiretroviral drugs to patients with HIV/AIDS. Nevertheless, as Liechty and Bangsberg [1] pointed out, a broader concept of DOT still needs to be evaluated, so that practice and policy is based on sound evidence.

References

1. Liechty CA, Bangsberg DR. Doubts about DOT: antiretroviral therapy for resource-poor countries.AIDS 2003; 17:1383–1387.
2. World Health Organization. Treatment of tuberculosis. Guidelines for national programmes, 3rd ed. WHO/CDS/TB/2003.31.313. Geneva: World Health Organization; 2003.
3. Farmer P, Learndre F, Mukherjee J, Gupta R, Tarter L, Kim J. Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy).World Health Bull 2001; 79:1145–1151.
4. Harries AD, Ny Nyangulu DS, Hargreaves NJ, Kaluwa O, Salaniponi FM. Preventing antiretroviral anarchy in sub-Saharan Africa.Lancet 2001; 358:410– 414.
5. Zwarenstein M, Schoemann JH, Vundule C, Lombard CJ, Tatley M. Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis.Lancet 1998; 352: 1340–1343.
6. Walley JD, Khan MA, Newell JN, Khan MH. Effectiveness of the direct observation component of DOTS for tuberculosis: a randomised controlled trial in Pakistan.Lancet 2001; 357: 664–669.
7. Macq JCM, Theobald S, Dick J, Dembele M. An exploration of the concept of directly observed treatment (DOT) for tuberculosis patients: from a uniform to a customised approach.Int J Tubercl Lung Dis 2003; 7:103–109.
© 2004 Lippincott Williams & Wilkins, Inc.