Managing adherence for Latent TB Infection (LTBI) regimens through Tuberculosis Preventive Therapy
Updated: Apr 13, 2022
It is known that not everyone who is infected with Tuberculosis (TB) bacteria becomes sick. The TB bacteria can live inside the body without showing any symptoms and this is known as latent TB infection (LTBI). In cases where there is a compromised immune system, the bacteria becomes active, multiplies, and causes TB disease. While not everyone with LTBI will develop TB, about 5–10% of infected people will develop TB over their lifetimes, if not treated for LTBI. In order to prevent individuals from developing the disease, presumptive TB individuals receive preventive medicine on a daily or weekly regimen but it has been observed that non-adherence to medical regimes (either due to forgetfulness, lack of information about the side effects, or infrequent follow-ups) can be a leading challenge for the implementation of large scale LTBI programs. Tuberculosis Preventive Therapy (TPT) reduces TB incidence by 30–50% and the risk of severe illness or death by 35%*
Everwell has been designing and implementing solutions to address these adherence-related challenges supporting national TB programs to contain symptoms in individuals with LTBI. The Everwell Hub supports multiple DATs (Medication Sleeves also known as 99DOTS, Video Observed Therapy, Smart Pill Boxes, and Self-Adherence) to assist individuals on treatment and their caregivers in optimizing treatment adherence.
Everwell has been the technical partner with the University of California San Francisco Committee on Human Research, the Makerere University School of Public Health Research Ethics Committee, and the Uganda National Council for Science and Technology to support the implementation of the 3HP regimen in Uganda at the Mulago HIV/AIDS clinic. Under this regimen, individuals consume their medication once every week for 12 weeks. For this intervention, individuals take their first dose of medication under direct observation and are provided with a 4-week supply of 3HP to take weekly via self-administration. Individuals take medication at home and report medication adherence using the 99DOTS technology, with an in-person refill visit at their week 6 dose and week 12 dose.
Individuals make toll-free calls to confirm medication dosing. Clinic staff can remotely access patient adherence data through a web dashboard and mobile phone application. Interactive voice response (IVR) reminders, check-in phone calls, and two-way messaging are also core features of the platform that enable real-time identification of people who miss doses for further follow-up and monitoring of potential side effects. Thus, digital adherence technologies address well-known barriers to treatment adherence including lack of time and transportation difficulties to regularly attend clinics.
Several adaptations were made to the adherence dashboard to reflect the requirements of the weekly dosing regimen:
Choice of Dosing Day: Individuals can choose which day of the week they would like to consume their medication - this helps prevent toxicity to doses taken too close to each other, enables easier person management for staff, establishes regularization of dosing behavior and dosing reminders.
Buffer Doses: Doses taken on a day other than the expected dosing day are flagged using a different color in the adherence calendar, enabling staff to prioritize follow-up as necessary.
IVR Based Tasklists: Based on individual check-in, task lists are populated for health care workers which help prioritize follow-up among individuals in need (especially in resource constrained environments). To enable adverse event reporting, we designed IVR-based task lists. IVR based task lists populate follow-up for individuals based on their response to the IVR check-in.
If an individual checked in negatively to the IVR call, a health care worker immediately triages follow-up for such patients to address any adverse drug effects which they might be facing. If individuals miss their weekly check-in call, they appear on the missed check-in tasklist thereby nudging health care workers to retrain those individuals on IVR call engagement.
Our efforts cater to 1700 patients in Uganda who maintained an average adherence of ~93%. Please refer to the sources section for more details*.
The TB Preventive Therapy module was launched in India (Nikshay) on World TB Day this year. This module enables users to register and track the management of TPT beneficiaries. Users can now add contacts of individuals with TB and high-risk populations eligible for TPT across the public and private sectors. In addition to this, users would be able to add medication dispensation, treatment adherence, and comorbidity details for TPT beneficiaries.