Can digital tech improve TB treatment?

A number of digital technologies have been introduced to the market over the years to improve patients’ adherence to tuberculosis treatment. One of them is a smart pill box that reminds patients to take their medication and also notifies health care workers whether patients have taken their drugs.

But with sparse data showing how feasible it is to implement such technologies as part of national TB programs across different settings, KNCV Tuberculosis Foundation — in partnership with The Aurum Institute, the London School of Hygiene & Tropical Medicine, and PATH — has launched a global study called the ASCENT project to find out.

Funded by Unitaid, the study was launched in mid-2019, and the preparatory phase involving 3,000 TB patients was conducted from January to June 2021. The research phase of the study started soon after in July and expects to enroll more than 10,000 drug-sensitive TB patients across five countries with high TB burdens or high multidrug/rifampicin-resistance, such as Ethiopia, the Philippines, South Africa, Tanzania, and Ukraine.

The project includes three particular digital adherence technologies: A smart pillbox, a mobile phone app that allows health workers to observe TB patients’ drug intake through video, and a medication label called 99DOTS that allows patients to notify their health care providers that they’ve taken their medication by calling or texting a toll-free number.

These types of digital adherence technologies are already being used in a number of countries in varying scales. A few studies show they are effective in reducing poor medication adherence, but it’s unclear whether those findings can be generalized to other settings, Kristian van Kalmthout, project director at ASCENT, told Devex.

“What could work in the Philippines might not work in [other countries] and vice versa. But what are the enablers for these technologies to work? And how can you best implement them to not only evaluate, but also to provide guidance to other countries and other partners that would like to implement [these technologies]?” he asked.

ASCENT’s aim is to evaluate all three digital adherence technologies in different settings where treatment, disease epidemiology, and technology literacy vary to understand how beneficial the technologies are in different contexts, he said. For example, the use of video to observe TB treatment may be more feasible in locations where people have more access to smartphones.

The 99DOTS medication label, meanwhile, is not part of the study in Ukraine because the country uses a different TB pill pack than other countries, van Kalmthout said.

“We hope that our research and our evaluations will contribute to the World Health Organization policy improvements to [TB] treatment, but also in the countries. So it has policy development, but also training and capacity building [components],” he added.

The study also aims to understand whether their usage actually improves patient outcomes, and how acceptable these technologies are to both patients and health care workers.

TB requires a lengthy treatment regimen comprising multiple drugs, which is burdensome to patients and poses challenges for their continued, regular intake. To ensure patients take their medications, national health TB programs recommend that they come to clinics or health care facilities so a health care worker can ensure they are taking their prescribed drugs.

This is crucial to ensure success in their TB treatment but also to prevent the development of drug-resistant TB.

However, it can be challenging for patients to follow, particularly for those living in remote areas and needing to commute long distances. The daily commute to facilities also constitutes additional financial burden to the patients.

Van Kalmthout said the study will also look at the products’ affordability for national TB programs to ensure sustainability and scalability.

The smart pillbox is now part of the Stop TB Partnership’s Global Drug Facility, a procurement platform offering quality-assured TB drugs at a lower cost to governments and nongovernmental organizations. At $53.75, the kits include a plastic container, batteries, a chip and wireless data good for at least three years — meaning it could be used by multiple patients over that period. The plastic container can be cleaned or replaced for each patient, but the chip inside, which is the expensive component, can be transferred to a new container — saving government costs.

Van Kalmthout said that while they expect to finalize the study by the end of 2022 or early 2023, they plan to disseminate early findings from their evaluations throughout the duration of the project.

This coverage, presented by the Bay Area Global Health Alliance, explores the intersection between technology, innovation, and health. How are tech, innovation, and cross-sector partnerships being leveraged to accelerate equitable access to health care?