Directly observed treatment for tuberculosis care and social support: essential lifeline or outdated burden?

In 1993, the World Health Organization (WHO) declared tuberculosis (TB) a global emergency and introduced the Directly Observed Therapy Short Course (DOTS) strategy, built around five key components: government commitment, case detection via sputum smear microscopy, a standardized 6–8 month treatment regimen, a robust recording and reporting system, and an uninterrupted supply of essential TB drugs, with Directly Observed Treatment (DOT) as its cornerstone. DOT, involving healthcare providers or community representatives overseeing patients taking their medications, was designed to ensure adherence, provide social protection,¹ prevent drug resistance, and reduce transmission. While initially lauded for its impact, operational limitations and ethical concerns have since fuelled calls for reform.

Evidence on DOT’s effectiveness has been mixed, with a 2015 Cochrane meta-analysis finding no significant difference in adherence or completion rates between DOT and self-administered therapy.² However, this analysis excluded nationwide studies and overlooked public health impacts and high-risk populations, sparking debate in high-income settings where robust social systems reduce the need for intensive oversight. In low- and middle-income countries (LMICs), nevertheless, poverty, vulnerability, and health system constraints often make DOT indispensable. Nevertheless, over time, global TB strategies have shifted from the DOTS framework to the more patient-centered End TB Strategy, which, while promoting flexibility, has not emphasized DOT. This lack of focus risks undermining its implementation, potentially reducing DOT coverage and weakening TB control efforts. A quick PubMed search indicates declining scientific interest in DOT, particularly since the launch of the End TB Strategy, raising concerns about sustained commitment to this critical intervention.

Brazil’s commitment to DOT offers a compelling case study, by maintaining DOT as a core element of its TB response.³ The Unified Health System requires all TB cases to be reported and treated within the public health network,³ providing a robust framework to evaluate DOT’s impact as both a patient adherence tool and a public health intervention. National data analyses show DOT enhances treatment success across diverse social groups,^4,5 with particularly strong effects among vulnerable populations,⁶ such as people experiencing homelessness, those with HIV, and incarcerated individuals. Cost-effectiveness studies⁶ and scenario simulations⁷ further highlight the potential of expanding DOT coverage to accelerate progress in reducing TB burden.

The implementation of DOT in Brazil continues to face logistical and ethical challenges. Supervised daily medication strains health system budgets, requiring significant resources. Ethical concerns include potential disruptions to patient routines and autonomy. Addressing these issues requires fostering trust among healthcare providers, patients, families, and communities while respecting autonomy and rights. Historically, DOT has followed either a biomedical model, prioritizing professional control, or a comprehensive approach, respecting patients’ values, culture, and social determinants.⁸ The Ministry of Health once incentivized this model with bonuses for each patient cured.

A recently launched and promising solution is the integration of mobile health, such as Video Observed Therapy (VOT), in which patients record their medication intake using mobile devices. VOT enables remote oversight while preserving patient autonomy and reducing the logistical burdens of in-person supervision. Some Brazilian states have piloted hybrid models combining DOT with VOT, yielding promising results.⁹ For populations with vulnerabilities, mobile health solutions have become critical in the post-COVID-19 era, facilitating remote monitoring and supporting adherence to TB treatment in contexts where access to healthcare is limited. Technological innovations aside, DOT targeting must be refined. Evidence from Brazil suggests prioritizing high-risk patients over universal enforcement.^6,7 Risk stratification allows efficient resource allocation, reducing unnecessary supervision for low-risk patients while focusing on those most likely to benefit.

DOT’s adaptability, through hybrid models combining digital tools and community engagement, proves cost-effective and patient-centered, enhancing adherence, especially in high-risk groups. Brazil offers key insights for global TB management. From 2015 to 2022, DOT achieved an 82.1% treatment success rate versus 71.7% without it, with marked benefits for vulnerable populations like people experiencing homelessness and those with HIV.⁶ Additionally, family-supported treatment adds flexibility, empowering patients to choose their approach.¹⁰ Combining traditional DOT, hybrid VOT, and family-supported models can improve adherence while respecting autonomy.

DOT’s selective use remains vital for TB control, particularly in LMICs and among high-risk populations. Hybrid models offer a practical approach to combining patient-centered care with adherence monitoring. With the advance and expansion of new technologies, integrating these innovations into existing systems can enhance treatment outcomes while maintaining a balance between patient autonomy and effective oversight. This adaptive strategy ensures that TB programs remain responsive to diverse needs and evolving challenges.

Contributors

B.B.D. and B.B.A. conceptualized and designed the manuscript. B.B.D. conducted the literature review, drafted the manuscript, and participated in revisions. K.V.S., J.C., E.L.N.M., and R.A.A. contributed to the literature review and refinement of the manuscript. B.B.A. supervised the overall project, contributed to the manuscript draft, and participated in revisions. All authors have reviewed and approved the final manuscript. B.B.D. and B.B.A. take full responsibility for the integrity of the work.

Declaration of interests

B.B.D., K.V.S., J.C., R.A.A., E.L.N.M., and B.B.A. declare no competing interests.