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Charalambous S, Maraba N, Jennings L, Rabothata I, Cogill D, Mukora R, Hippner P, Naidoo P, Xaba N, Mchunu L, Velen K, Orrell C, Fielding KL. Treatment adherence and clinical outcomes amongst in people with drug-susceptible tuberculosis using medication monitor and differentiated care approach compared with standard of care in South Africa: a cluster randomized trial. EClinicalMedicine 2024; 75:102745. [PMID: 39170937 PMCID: PMC11338121 DOI: 10.1016/j.eclinm.2024.102745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/25/2024] [Accepted: 07/02/2024] [Indexed: 08/23/2024] Open
Abstract
Background Poor treatment adherence contributes to lower treatment completion and higher loss to follow-up among people with tuberculosis (PWTB). Medication monitors have shown some evidence of improved adherence. Methods We conducted a cluster randomised trial in 18 primary health clinics in South Africa between May 2019-February 2022. Persons (aged ≥ 2 years) with drug-sensitive tuberculosis (DS-TB) were enrolled. All participants were provided with monitors which were silent in the standard of care (SoC) arm. In the intevention arm, weekly adherence reports were reviewed and participants received intensified support as appropriate (text, phone call, home visit, motivational counselling). The primary outcome was adherence, which was calculated as days box was opened (proxy for drug taken)/total expected treatment days as a binary variable (<80% versus ≥80%). Analysis took into account clustered design. The trial was registered with the Pan African Trial Registry PACTR20190268115772. Findings We enrolled 2727 participants (38% women, median age 36 (IQR 27-45 years), of whom 2584 had available adherence data. The primary outcome (measured as ≥80% adherence) was higher in intervention versus SoC arm (81.0% versus 50.8%, adjusted risk ratio (ARR) 1.51 (1.36-1.66). Similarly, overall percentage adherence was higher in intervention versus SoC arm (88.5% versus 69.7%, adjusted risk difference 16.8% (13.3%-20.4%)). Interpretation People with DS-TB had improved treatment adherence in the intervention arm. We believe the effect on adherence is important and warrants continued use and evaluation of these technologies. Funding The study is funded by Bill & Melinda Gates Foundation, Uinted States, the Stop TB Partnership, Switzerland, and the South African Medical Research Council, South Africa.
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Affiliation(s)
- Salome Charalambous
- The Aurum Institute, Aurum House, Parktown, Johannesburg 2193, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg 2193, South Africa
| | - Noriah Maraba
- The Aurum Institute, Aurum House, Parktown, Johannesburg 2193, South Africa
| | - Lauren Jennings
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine & Department of Medicine, University of Cape Town, 7925, South Africa
| | - Israel Rabothata
- The Aurum Institute, Aurum House, Parktown, Johannesburg 2193, South Africa
| | - Dolphina Cogill
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine & Department of Medicine, University of Cape Town, 7925, South Africa
| | - Rachel Mukora
- The Aurum Institute, Aurum House, Parktown, Johannesburg 2193, South Africa
- University of Witwatersrand, School of Public Health, Johannesburg 2193, South Africa
| | - Piotr Hippner
- The Aurum Institute, Aurum House, Parktown, Johannesburg 2193, South Africa
| | - Pren Naidoo
- Interactive Research and Development, Durban 4001, South Africa
| | - Nokhanyo Xaba
- Interactive Research and Development, Durban 4001, South Africa
| | - Lihle Mchunu
- The Aurum Institute, Aurum House, Parktown, Johannesburg 2193, South Africa
| | - Kavindhran Velen
- The Aurum Institute, Aurum House, Parktown, Johannesburg 2193, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine & Department of Medicine, University of Cape Town, 7925, South Africa
- Stellenbosch University, Stellenbosch 7602, South Africa
| | - Katherine L. Fielding
- London School of Hygiene and & Tropical Medicine, London WC1E 7HT, United Kingdom
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
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2
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Lienhardt C, Dooley KE, Nahid P, Wells C, Ryckman TS, Kendall EA, Davies G, Brigden G, Churchyard G, Cirillo DM, Di Meco E, Gopinath R, Mitnick C, Scott C, Amanullah F, Bansbach C, Boeree M, Campbell M, Conradie F, Crook A, Daley CL, Dheda K, Diacon A, Gebhard A, Hanna D, Heinrich N, Hesseling A, Holtzman D, Jachym M, Kim P, Lange C, McKenna L, Meintjes G, Ndjeka N, Nhung NV, Nyang’wa BT, Paton NI, Rao R, Rich M, Savic R, Schoeman I, Makokotlela BS, Spigelman M, Sun E, Svensson E, Tisile P, Varaine F, Vernon A, Diul MY, Kasaeva T, Zignol M, Gegia M, Mirzayev F, Schumacher SG. Target regimen profiles for tuberculosis treatment. Bull World Health Organ 2024; 102:600-607. [PMID: 39070602 PMCID: PMC11276158 DOI: 10.2471/blt.24.291881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 07/30/2024] Open
Abstract
Simpler, shorter, safer and more effective treatments for tuberculosis that are easily accessible to all people with tuberculosis are desperately needed. In 2016, the World Health Organization (WHO) developed target regimen profiles for the treatment of tuberculosis to make drug developers aware of both the important features of treatment regimens, and patient and programmatic needs at the country level. In view of recent ground-breaking advances in tuberculosis treatment, WHO has revised and updated these regimen profiles. We used a similar process as for the 2016 profiles, including a baseline treatment landscape analysis, an initial stakeholder survey, modelling studies estimating the impact and cost-effectiveness of novel tuberculosis treatment regimens, and an extensive stakeholder consultation. We developed target regimen profiles for the treatment of rifampicin-susceptible and rifampicin-resistant tuberculosis, as well as a pan-tuberculosis regimen that would be appropriate for patients with any type of tuberculosis. We describe the revised target regimen profile characteristics, with specific minimal and optimal targets to be met, rationale and justification, and aspects relevant to all target regimen profiles (drug susceptibility testing, adherence and forgiveness, treatment strategies, post-tuberculosis lung disease, and cost and access considerations). We discuss the trade-offs of proposed characteristics for decision-making at developmental or operational levels. We expect that, following these target regimen profile revisions, tuberculosis treatment developers will produce regimens that are quality-assured, affordable and widely available, and that meet the needs of affected populations.
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Affiliation(s)
- Christian Lienhardt
- French National Research Institute for Sustainable Development, Montpellier, France
| | - Kelly E Dooley
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, United States of America (USA)
| | - Payam Nahid
- Institute for Global Health, University of California San Francisco, San Francisco, USA
| | - Charles Wells
- Bill & Melinda Gates Medical Research Institute, Boston, USA
| | - Theresa S Ryckman
- Infectious Disease Division, School of Medicine, John Hopkins University, Baltimore, USA
| | - Emily A Kendall
- Infectious Disease Division, School of Medicine, John Hopkins University, Baltimore, USA
| | - Gerry Davies
- Institute of Infection and Global Health, University of Liverpool, Liverpool, England
| | - Grania Brigden
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | | | - Daniela Maria Cirillo
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Scientific Institute, Milan, Italy
| | - Eugenia Di Meco
- European Medicines Agency, Amsterdam, Kingdom of the Netherlands
| | - Ramya Gopinath
- Division of Anti-Infectives, Food and Drug Administration, WashingtonDC, USA
| | | | | | | | | | - Martin Boeree
- University Medical Center, Radboud University, Amsterdam, Kingdom of the Netherlands
| | | | | | - Angela Crook
- MRC Clinical Trials Unit, University College of London, London, England
| | - Charles L Daley
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, USA
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, University of Cape Town, Cape Town, South Africa
| | | | | | - Debra Hanna
- Global Health Division, Bill & Melinda Gates Foundation, Seattle, USA
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, LMU University Hospital, LMU, Munich, Germany
| | - Anneke Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Stellenbosch, South Africa
| | - David Holtzman
- Bill & Melinda Gates Medical Research Institute, Boston, USA
| | - Mathilde Jachym
- Centre Hospitalier de Bligny, Fontenay-lès-Briis, Paris, France
| | - Peter Kim
- French National Research Institute for Sustainable Development, Montpellier, France
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, United States of America (USA)
| | - Christoph Lange
- French National Research Institute for Sustainable Development, Montpellier, France
- Institute for Global Health, University of California San Francisco, San Francisco, USA
| | - Lindsay McKenna
- French National Research Institute for Sustainable Development, Montpellier, France
- Bill & Melinda Gates Medical Research Institute, Boston, USA
| | - Graeme Meintjes
- French National Research Institute for Sustainable Development, Montpellier, France
- Infectious Disease Division, School of Medicine, John Hopkins University, Baltimore, USA
| | - Norbert Ndjeka
- French National Research Institute for Sustainable Development, Montpellier, France
- Institute of Infection and Global Health, University of Liverpool, Liverpool, England
| | - Nguyen Viet Nhung
- French National Research Institute for Sustainable Development, Montpellier, France
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Bern-Thomas Nyang’wa
- French National Research Institute for Sustainable Development, Montpellier, France
- Aurum Institute, Johannesburg, South Africa
| | - Nicholas I Paton
- French National Research Institute for Sustainable Development, Montpellier, France
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Scientific Institute, Milan, Italy
| | - Raghuram Rao
- French National Research Institute for Sustainable Development, Montpellier, France
- European Medicines Agency, Amsterdam, Kingdom of the Netherlands
| | - Michael Rich
- French National Research Institute for Sustainable Development, Montpellier, France
- Division of Anti-Infectives, Food and Drug Administration, WashingtonDC, USA
| | - Rada Savic
- Institute for Global Health, University of California San Francisco, San Francisco, USA
| | - Ingrid Schoeman
- French National Research Institute for Sustainable Development, Montpellier, France
- School of Medicine, Harvard Medical School, Boston, USA
| | | | - Mel Spigelman
- French National Research Institute for Sustainable Development, Montpellier, France
- Indus Hospital, Karachi, Pakistan
| | - Eugene Sun
- French National Research Institute for Sustainable Development, Montpellier, France
- Indus Hospital, Karachi, Pakistan
| | - Elin Svensson
- University Medical Center, Radboud University, Amsterdam, Kingdom of the Netherlands
| | - Phumeza Tisile
- French National Research Institute for Sustainable Development, Montpellier, France
- School of Medicine, Harvard Medical School, Boston, USA
| | - Francis Varaine
- French National Research Institute for Sustainable Development, Montpellier, France
- ChinaCat Enterprises, Gig Harbor, USA
| | - Andrew Vernon
- French National Research Institute for Sustainable Development, Montpellier, France
- University Medical Center, Radboud University, Amsterdam, Kingdom of the Netherlands
| | - Mukadi Ya Diul
- French National Research Institute for Sustainable Development, Montpellier, France
- Clinton Health Access Initiative, Boston, USA
| | - Tereza Kasaeva
- French National Research Institute for Sustainable Development, Montpellier, France
- Wits Health Consortium, Johannesburg, South Africa
| | - Matteo Zignol
- French National Research Institute for Sustainable Development, Montpellier, France
- Wits Health Consortium, Johannesburg, South Africa
| | - Medea Gegia
- French National Research Institute for Sustainable Development, Montpellier, France
- Wits Health Consortium, Johannesburg, South Africa
| | - Fuad Mirzayev
- French National Research Institute for Sustainable Development, Montpellier, France
- Wits Health Consortium, Johannesburg, South Africa
| | - Samuel G Schumacher
- French National Research Institute for Sustainable Development, Montpellier, France
- Wits Health Consortium, Johannesburg, South Africa
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Chen H, Zhang H, Cheng J, Sun D, Wang Q, Wu C, Liu Y, Xia Y, Xu C, Zhang C. Adherence to preventive treatment for latent tuberculosis infection in close contacts of pulmonary tuberculosis patients: A cluster-randomized controlled trial in China. Int J Infect Dis 2024; 147:107196. [PMID: 39074738 DOI: 10.1016/j.ijid.2024.107196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/14/2024] [Accepted: 07/25/2024] [Indexed: 07/31/2024] Open
Abstract
OBJECTIVES This study examined adherence rates to tuberculosis preventive treatment (TPT) among close contacts of individuals with pulmonary tuberculosis (PTB) and identified factors associated with TPT adherence in China. METHODS A multicenter, cluster-randomized, open-label control trial was carried out across three sites involving 34 counties in China. Close contacts of bacteriologically confirmed rifampin and isoniazid-susceptible PTB cases were identified and screened for latent tuberculosis infection (LTBI). Eligible participants were randomly assigned to either the 3H2P2 group, which consisted of a 3-month, twice-weekly regimen of rifapentine and isoniazid, or the 6H group, which entailed a 6-month daily regimen of isoniazid. To assess the factors influencing adherence, a two-level logistic regression model was utilized. RESULTS Out of the 2434 close contacts who initiated TPT, 2121 (87.1%) completed the regimen. Of the 313 individuals who did not complete TPT, 60.1% refused to continue, and 27.8% discontinued due to adverse effects. The two-level logistic regression model revealed several factors associated with enhanced TPT adherence: enrollment in the 3H2P2 group (odds ratio [OR] = 2.09), management by a TB dispensary responsible for TPT (OR = 2.55), supervision by healthcare workers (OR = 6.40), and clinician incentives (OR = 2.49). Conversely, the occurrence of any adverse effects (OR = 0.08) was identified as a risk factor for nonadherence. CONCLUSION Administering TPT to individuals with LTBI is feasible among close contacts. Adherence to TPT can be enhanced through shorter, safer treatment regimens and supportive interventions, such as directly supervised therapy for TPT recipients and incentives for healthcare providers managing TPT.
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Affiliation(s)
- Hui Chen
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hui Zhang
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jun Cheng
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Dingyong Sun
- Henan Provincial Center for Disease Control and Prevention, Zhengzhou, China
| | - Qiaozhi Wang
- Hunan Institute for Tuberculosis Control, Changsha, China
| | - Chengguo Wu
- Chongqing Municipal Institute of Tuberculosis, Chongqing, China
| | - Yushu Liu
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yinyin Xia
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Caihong Xu
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Canyou Zhang
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
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Leung CL, Alacapa J, Tasca BG, Villanueva AD, Masulit S, Ignacio ML, Uy KN, Pell C, van Kalmthout K, Powers R, Fielding K, Jerene D. Digital Adherence Technologies and Differentiated Care for Tuberculosis Treatment and Their Acceptability Among Persons With Tuberculosis, Health Care Workers, and Key Informants in the Philippines: Qualitative Interview Study. JMIR Hum Factors 2024; 11:e54117. [PMID: 39042889 PMCID: PMC11303897 DOI: 10.2196/54117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Digital adherence technologies (DATs) are being studied to determine their potential to support tuberculosis (TB) treatment and address the shortcomings of directly observed therapy. Previous research has shown inconclusive results on whether DATs can enhance medication adherence among persons with TB. OBJECTIVE This study aims to understand the acceptability of DATs, namely, medication labels and smart pillboxes, among persons with TB, health care workers (HCWs), and key informants (KIs) in the Philippines. The objective is to gain valuable insights that can inform the design and implementation of DATs in the Southeast Asian region, which meet the needs and preferences of end users. METHODS Persons with TB, HCWs, and KIs were recruited from intervention facilities to participate in in-depth interviews conducted between March 2022 and January 2023. These interviews were transcribed and translated into English. A thematic analysis was carried out using NVivo software (Lumivero) to identify and analyze themes. Themes were then structured within a modified social-ecological model. RESULTS A total of 25 persons with drug-sensitive TB and 20 HCWs or KIs were interviewed. Both groups emphasized that users' technology literacy level, financial conditions, and motivation to be cured determined how they interacted with the DAT. They also acknowledged that DATs helped foster their relationship with HCWs and enabled efficient treatment support. Concerning technology, persons with TB found DATs easy to use and able to reduce clinic visits. HCWs mentioned that DATs added to their workload but also allowed them to support users who missed doses. However, both groups experienced technical challenges with DATs. Regarding program implementation, users appreciated the clear explanations and demonstrations provided by HCWs. Yet, some users reported inconsistencies between DAT settings and the information provided. HCWs stressed the importance of comprehensive training and sufficient resources for effective program implementation in the future. At the community level, both groups noted that DATs and program design protected users' privacy and reduced the risk of stigma. Finally, users and HCWs shared various contextual factors that influenced their experience with DAT, including infrastructure challenges and the impact of the COVID-19 pandemic. CONCLUSIONS In the Philippines, persons with TB and HCWs showed a high level of acceptance and satisfaction with the impact of DAT and program design. They expressed a desire for the continuation of DATs. The challenges encountered underscore the need for ongoing technological development to minimize malfunctions, enhance the capacity of health facilities, and improve infrastructure. DATs have demonstrated their ability to strengthen user-HCW relationships and protect users from stigmatization. Additional efforts are required to scale up the DAT program in the Philippines.
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Affiliation(s)
| | - Jason Alacapa
- KNCV Tuberculosis Foundation Philippines, Metro Manila, Philippines
| | | | | | - Saniata Masulit
- KNCV Tuberculosis Foundation Philippines, Metro Manila, Philippines
| | | | | | | | | | | | - Katherine Fielding
- TB Centre and Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Degu Jerene
- KNCV Tuberculosis Foundation, Den Haag, Netherlands
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5
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Sweeney S, Fielding K, Liu X, Thompson JA, Dong H, Jiang S, Zhao Y, Huan S, Vassall A. Unit costs and cost-effectiveness of a device to improve TB treatment adherence in China. IJTLD OPEN 2024; 1:299-305. [PMID: 39035432 PMCID: PMC11257087 DOI: 10.5588/ijtldopen.23.0451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 05/27/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Adherence to TB drugs is crucial for improving treatment outcomes. Digital adherence technologies can improve adherence; however, there is a lack of evidence on cost-effectiveness. This study aimed to explore the cost-effectiveness of medication event reminder monitors (MERM) in China compared with the standard of care, using results from a pragmatic, cluster-randomised superiority trial of an electronic MERM in China. METHODS We collected primary unit cost data from the societal perspective, both at and above the health facility level. We estimated the incremental cost-effectiveness of MERM using a Markov model with a 20-year time horizon; a 3% discount rate was applied to costs and outcomes. We explored uncertainty through a series of sensitivity and scenario analyses. RESULTS The incremental cost of MERM was $27.22 per patient. Probabilistic sensitivity analysis showed significant uncertainty about the intervention's cost-effectiveness. Changing assumptions around key parameters substantially affected our estimated incremental cost-effectiveness ratio. CONCLUSIONS Although the incremental cost of the MERM box was low, current evidence does not indicate that the intervention would be cost-effective. However, the intervention's cost-effectiveness could improve if implemented as part of a broader strategy, including enhanced patient management.
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Affiliation(s)
- S Sweeney
- London School of Hygiene & Tropical Medicine, London, UK
| | - K Fielding
- London School of Hygiene & Tropical Medicine, London, UK
| | - X Liu
- National Center for TB Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - J A Thompson
- London School of Hygiene & Tropical Medicine, London, UK
| | - H Dong
- PATH China Office, Beijing, China
| | - S Jiang
- National Center for TB Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Y Zhao
- National Center for TB Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - S Huan
- Bill & Melinda Gates Foundation China Office, Beijing, China
| | - A Vassall
- London School of Hygiene & Tropical Medicine, London, UK
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Hafez G, Aarnio E, Mucherino S, Kamusheva M, Qvarnström M, Potočnjak I, Trečiokiene I, Mihajlović J, Ekenberg M, van Boven JFM, Leiva-Fernández F. Barriers and Unmet Educational Needs Regarding Implementation of Medication Adherence Management Across Europe: Insights from COST Action ENABLE. J Gen Intern Med 2024:10.1007/s11606-024-08851-2. [PMID: 38941058 DOI: 10.1007/s11606-024-08851-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/31/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Medication adherence is essential for the achievement of therapeutic goals. Yet, the World Health Organization estimates that 50% of patients are nonadherent to medication and this has been associated with 125 billion euros and 200,000 deaths in Europe annually. OBJECTIVE This study aimed to unravel barriers and unmet training needs regarding medication adherence management across Europe. DESIGN A cross-sectional study was conducted through an online survey. The final survey contained 19 close-ended questions. PARTICIPANTS The survey content was informed by 140 global medication adherence experts from clinical, academic, governmental, and patient associations. The final survey targeted healthcare professionals (HCPs) across 39 European countries. MAIN MEASURES Our measures were barriers and unmet training needs for the management of medication adherence across Europe. KEY RESULTS In total, 2875 HCPs (pharmacists, 40%; physicians, 37%; nurses, 17%) from 37 countries participated. The largest barriers to adequate medication adherence management were lack of patient awareness (66%), lack of HCP time (44%), lack of electronic solutions (e.g., access to integrated databases and uniformity of data available) (42%), and lack of collaboration and communication between HCPs (41%). Almost all HCPs pointed out the need for educational training on medication adherence management. CONCLUSIONS These findings highlight the importance of addressing medication adherence barriers at different levels, from patient awareness to health system technology and to fostering collaboration between HCPs. To optimize patient and economic outcomes from prescribed medication, prerequisites include adequate HCP training as well as further development of digital solutions and shared health data infrastructures across Europe.
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Affiliation(s)
- Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Emma Aarnio
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | - Maria Kamusheva
- Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Miriam Qvarnström
- Department of Pharmacy, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Ines Potočnjak
- Sestre Milosrdnice University Hospital Center, School of Medicine Catholic University of Croatia, Zagreb, Croatia
| | | | - Jovan Mihajlović
- Mihajlović Health Analytics, Novi Sad, Serbia
- University of Novi Sad, Medical Faculty, Novi Sad, Serbia
| | - Marie Ekenberg
- Department of Pharmacy, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, Medication Adherence Expertise Center of the Northern Netherlands (MAECON), University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Francisca Leiva-Fernández
- Andalusian Health Service-Málaga-Guadalhorce Health District-IBIMA-Platform BIONAND-University of Malaga, Malaga, Spain
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7
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Raphael NA, Garraud PA, Roelens M, Alfred JP, Richard M, Estill J, Keiser O, Merzouki A. Evaluating tuberculosis treatment outcomes in Haiti from 2018 to 2019: A competing risk analysis. IJID REGIONS 2024; 11:100350. [PMID: 38577553 PMCID: PMC10993134 DOI: 10.1016/j.ijregi.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/07/2024] [Accepted: 03/09/2024] [Indexed: 04/06/2024]
Abstract
Objectives This study assesses tuberculosis (TB) treatment outcomes in Haiti. Methods Data from drug-susceptible patients with TB (2018-2019) were analyzed using the Fine & Gray model with multiple imputation. Results Of the 16,545 patients, 14.7% had concurrent HIV coinfection, with a 66.2% success rate. The median treatment duration was 5 months, with patients averaging 30 years (with an interquartile range of 22-42 years). The estimated hazard of achieving a successful treatment outcome decreased by 2.5% and 8.1% for patients aged 45 and 60 years, respectively, compared with patients aged 30 years. Male patients had a 6.5% lower estimated hazard of success than their female counterparts. In addition, patients coinfected with HIV experienced a 35.3% reduction in the estimated hazard of achieving a successful treatment outcome compared with those with a negative HIV serologic status. Conclusions Integrated health care approaches should be implemented, incorporating innovative solutions, such as machine learning algorithms combined with geographic information systems and non-conventional data sources (including social media), to identify TB hotspots and high-burden households.
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Affiliation(s)
- Nernst-Atwood Raphael
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Strategic Health Information System, DAI Global LLC, Port-au-Prince, Haiti
| | | | - Maroussia Roelens
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - Milo Richard
- National Tuberculosis Program, Ministry of Health, Port-au-Prince, Haiti
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Aziza Merzouki
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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8
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Ryckman TS, Schumacher SG, Lienhardt C, Sweeney S, Dowdy DW, Mirzayev F, Kendall EA. Economic implications of novel regimens for tuberculosis treatment in three high-burden countries: a modelling analysis. Lancet Glob Health 2024; 12:e995-e1004. [PMID: 38762299 PMCID: PMC11126367 DOI: 10.1016/s2214-109x(24)00088-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/24/2024] [Accepted: 02/21/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND With numerous trials investigating novel drug combinations to treat tuberculosis, we aimed to evaluate the extent to which future improvements in tuberculosis treatment regimens could offset potential increases in drug costs. METHODS In this modelling analysis, we used an ingredients-based approach to estimate prices at which novel regimens for rifampin-susceptible and rifampin-resistant tuberculosis treatment would be cost-neutral or cost-effective compared with standards of care in India, the Philippines, and South Africa. We modelled regimens meeting targets set in the WHO's 2023 Target Regimen Profiles (TRPs). Our decision-analytical model tracked cohorts of adults initiating rifampin-susceptible or rifampin-resistant tuberculosis treatment, simulating their health outcomes and costs accumulated during and following treatment under standard-of-care and novel regimen scenarios. Price thresholds included short-term cost-neutrality (considering only savings accrued during treatment), medium-term cost-neutrality (additionally considering savings from averted retreatments and secondary cases), and cost-effectiveness (incorporating willingness-to-pay for improved health outcomes). FINDINGS Total medium-term costs per person treated using standard-of-care regimens were estimated at US$450 (95% uncertainty interval 310-630) in India, $560 (350-860) in the Philippines, and $730 (530-1090) in South Africa for rifampin-susceptible tuberculosis (current drug costs $46) and $2100 (1590-2810) in India, $2610 (2090-3280) in the Philippines, and $3790 (3090-4630) in South Africa for rifampin-resistant tuberculosis (current drug costs $432). A rifampin-susceptible tuberculosis regimen meeting the optimal targets defined in the TRPs could be cost-neutral in the short term at drug costs of $140 (90-210) per full course in India, $230 (130-380) in the Philippines, and $280 (180-460) in South Africa. For rifampin-resistant tuberculosis, short-term cost-neutral thresholds were higher with $930 (720-1230) in India, $1180 (980-1430) in the Philippines, and $1480 (1230-1780) in South Africa. Medium-term cost-neutral prices were approximately $50-100 higher than short-term cost-neutral prices for rifampin-susceptible tuberculosis and $250-550 higher for rifampin-resistant tuberculosis. Health system cost-neutral prices that excluded patient-borne costs were 45-70% lower (rifampin-susceptible regimens) and 15-50% lower (rifampin-resistant regimens) than the cost-neutral prices that included patient costs. Cost-effective prices were substantially higher. Shorter duration was the most important driver of medium-term savings with novel regimens, followed by ease of adherence. INTERPRETATION Improved tuberculosis regimens, particularly shorter regimens or those that facilitate better adherence, could reduce overall costs, potentially offsetting higher prices. FUNDING WHO.
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Affiliation(s)
- Theresa S Ryckman
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Christian Lienhardt
- Institut de Recherche pour le Développement, Université de Montpellier, Montpellier, France; Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Emily A Kendall
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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9
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Dodd M, Carpenter J, Thompson JA, Williamson E, Fielding K, Elbourne D. Assessing efficacy in non-inferiority trials with non-adherence to interventions: Are intention-to-treat and per-protocol analyses fit for purpose? Stat Med 2024; 43:2314-2331. [PMID: 38561927 DOI: 10.1002/sim.10067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/19/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Non-inferiority trials comparing different active drugs are often subject to treatment non-adherence. Intention-to-treat (ITT) and per-protocol (PP) analyses have been advocated in such studies but are not guaranteed to be unbiased in the presence of differential non-adherence. METHODS The REMoxTB trial evaluated two 4-month experimental regimens compared with a 6-month control regimen for newly diagnosed drug-susceptible TB. The primary endpoint was a composite unfavorable outcome of treatment failure or recurrence within 18 months post-randomization. We conducted a simulation study based on REMoxTB to assess the performance of statistical methods for handling non-adherence in non-inferiority trials, including: ITT and PP analyses, adjustment for observed adherence, multiple imputation (MI) of outcomes, inverse-probability-of-treatment weighting (IPTW), and a doubly-robust (DR) estimator. RESULTS When non-adherence differed between trial arms, ITT, and PP analyses often resulted in non-trivial bias in the estimated treatment effect, which consequently under- or over-inflated the type I error rate. Adjustment for observed adherence led to similar issues, whereas the MI, IPTW and DR approaches were able to correct bias under most non-adherence scenarios; they could not always eliminate bias entirely in the presence of unobserved confounding. The IPTW and DR methods were generally unbiased and maintained desired type I error rates and statistical power. CONCLUSIONS When non-adherence differs between trial arms, ITT and PP analyses can produce biased estimates of efficacy, potentially leading to the acceptance of inferior treatments or efficacious regimens being missed. IPTW and the DR estimator are relatively straightforward methods to supplement ITT and PP approaches.
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Affiliation(s)
- Matthew Dodd
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
| | - James Carpenter
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
- The Medical Research Council Clinical Trials Unit (MRC CTU), UCL, London, UK
| | - Jennifer A Thompson
- Department of Infectious Disease Epidemiology, The London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Williamson
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, The London School of Hygiene & Tropical Medicine, London, UK
| | - Diana Elbourne
- Department of Medical Statistics, The London School of Hygiene & Tropical Medicine, London, UK
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10
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Haldane V, Zhang Z, Yin T, Zhang B, Li Y, Pan Q, Dainty KN, Rea E, Pasang P, Hu J, Wei X. Exploring opportunities to strengthen rural tuberculosis health service delivery: a qualitative study with health workers in Tibet autonomous region, China. BMJ Open 2024; 14:e079062. [PMID: 38740500 PMCID: PMC11097854 DOI: 10.1136/bmjopen-2023-079062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 04/10/2024] [Indexed: 05/16/2024] Open
Abstract
OBJECTIVES This qualitative study aimed to explore opportunities to strengthen tuberculosis (TB) health service delivery from the perspectives of health workers providing TB care in Shigatse prefecture of Tibet Autonomous Region, China. DESIGN Qualitative research, semi-structured in-depth interviews. SETTING The TB care ecosystem in Shigatse, including primary and community care. PARTICIPANTS Participants: 37 semi-structured interviews were conducted with village doctors (14), township doctors and nurses (14), county hospital doctors (7) and Shigatse Centre for Disease Control staff (2). RESULTS The three main themes reported include (1) the importance of training primary and community health workers to identify people with symptoms of TB, ensure TB is diagnosed and link people with TB to further care; (2) the need to engage community health workers to ensure retention in care and adherence to TB medications; and (3) the opportunity for innovative technologies to support coordinated care, retention in care and adherence to medication in Shigatse. CONCLUSIONS The quality of TB care could be improved across the care cascade in Tibet and other high-burden, remote settings by strengthening primary care through ongoing training, greater support and inclusion of community health workers and by leveraging technology to create a circle of care. Future formative and implementation research should include the perspectives of health workers at all levels to improve care organisation and delivery.
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Affiliation(s)
- Victoria Haldane
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tingting Yin
- Liangcheng No 3 Municipal Hospital, Liaocheng, Shandong, China
| | - Bei Zhang
- Weifang Medical College, Weifang, Shandong, China
| | - Yinlong Li
- Jining Medical University, Jining, Shandong, China
| | - Qiuyu Pan
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Katie N Dainty
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Rea
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Toronto Public Health, Toronto, Ontario, Canada
| | - Pande Pasang
- Shigatse Centre for Disease Control and Prevention, Shigatse, Samzhubze, China
| | - Jun Hu
- Shigatse Centre for Disease Control and Prevention, Shigatse, Samzhubze, China
- Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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11
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Wei X, Hicks JP, Zhang Z, Haldane V, Pasang P, Li L, Yin T, Zhang B, Li Y, Pan Q, Liu X, Walley J, Hu J. Effectiveness of a comprehensive package based on electronic medication monitors at improving treatment outcomes among tuberculosis patients in Tibet: a multicentre randomised controlled trial. Lancet 2024; 403:913-923. [PMID: 38309280 DOI: 10.1016/s0140-6736(23)02270-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 02/05/2024]
Abstract
BACKGROUND WHO recommends that electronic medication monitors, a form of digital adherence technology, be used as a complement to directly observed treatment (DOT) for tuberculosis, as DOT is inconvenient and costly. However, existing evidence about the effectiveness of these monitors is inconclusive. Therefore, we evaluated the effectiveness of a comprehensive package based on electronic medication monitors among patients with tuberculosis in Tibet Autonomous Region (hereafter Tibet), China. METHODS This multicentre, randomised controlled trial recruited patients from six counties in Shigatse, Tibet. Eligible participants had drug-susceptible tuberculosis and were aged 15 years or older when starting standard tuberculosis treatment. Tuberculosis doctors recruited patients from the public tuberculosis dispensary in each county and the study statistician randomly assigned them to the intervention or control group based on the predetermined randomised allocation sequence. Intervention patients received an electronic medication monitor box. The box included audio medication-adherence reminders and recorded box-opening data, which were transmitted to a cloud-based server and were accessible to health-care providers to allow remote adherence monitoring. A linked smartphone app enabled text, audio, and video communication between patients and health-care providers. Patients were also provided with a free data plan. Patients selected a treatment supporter (often a family member) who was trained to support patients with using the electronic medication monitor and app. Patients in the control group received usual care plus a deactivated electronic medication monitor, which only recorded and transmitted box-opening data that was not made available to health-care providers. The control group also had no access to the app or trained treatment supporters. The primary outcome was a binary indicator of poor monthly adherence, defined as missing 20% or more of planned doses in the treatment month, measured using electronic medication monitor opening data, and verified by counting used medication blister packages during consultations. We recorded other secondary treatment outcomes based on national tuberculosis reporting data. We analysed the primary outcome based on the intention-to-treat population. This trial is registered at ISRCTN, 52132803. FINDINGS Between Nov 17, 2018, and April 5, 2021, 278 patients were enrolled into the study. 143 patients were randomly assigned to the intervention group and 135 patients to the control group. Follow-up ended when the final patient completed treatment on Oct 4, 2021. In the intervention group, 87 (10%) of the 854 treatment months showed poor adherence compared with 290 (37%) of the 795 months in the control group. The corresponding adjusted risk difference for the intervention versus control was -29·2 percentage points (95% CI -35·3 to -22·2; p<0·0001). Five of the six secondary treatment outcomes also showed clear improvements, including treatment success, which was found for 133 (94%) of the 142 individuals in the intervention arm and 98 (73%) of the 134 individuals in the control arm, with an adjusted risk difference of 21 percentage points (95% CI 12·4-29·4); p<0·0001. INTERPRETATION The interventions were effective at improving tuberculosis treatment adherence and outcomes, and the trial suggests that a comprehensive package involving electronic medication monitors might positively affect tuberculosis programmes in high-burden and low-resource settings. FUNDING TB REACH.
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Affiliation(s)
- Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Joseph Paul Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Pande Pasang
- Shigatse Centre for Disease Control and Prevention, Shigatse, China
| | - Linhua Li
- Shigatse Centre for Disease Control and Prevention, Shigatse, China
| | | | - Bei Zhang
- Weifang Medical College, Weifang, China
| | - Yinlong Li
- Jining Medical University, Jining, China
| | - Qiuyu Pan
- North Sichuan Medical College, Nanchong, China
| | - Xiaoqiu Liu
- National Center for tuberculosis control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - John Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jun Hu
- Shigatse Centre for Disease Control and Prevention, Shigatse, China; Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China.
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12
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Subbaraman R, Fielding K. Putting technology to the test in tuberculosis care. Lancet 2024; 403:878-879. [PMID: 38460978 DOI: 10.1016/s0140-6736(24)00412-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, MA 02111, USA; Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA.
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13
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Maimaiti Z, Li Z, Li Z, Fu J, Xu C, Chen J, Chai W, Liu L. Ortho-digital dynamics: Exploration of advancing digital health technologies in musculoskeletal disease management. Digit Health 2024; 10:20552076241269613. [PMID: 39148814 PMCID: PMC11325473 DOI: 10.1177/20552076241269613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/27/2024] [Indexed: 08/17/2024] Open
Abstract
Background Musculoskeletal (MSK) disorders, affecting billions of people worldwide, pose significant challenges to the healthcare system and require effective management models. The rapid development of digital healthcare technologies (DHTs) has revolutionized the healthcare industry. DHT-based interventions have shown promising clinical benefits in managing MSK disorders, alleviating pain, and improving functional impairment. There is, however, no bibliometric analysis of the overall trends on this topic. Methods We extracted all relevant publications from the Web of Science Core Collection (WoSCC) database until April 30, 2023. We performed bibliometric analysis and visualization using CiteSpace, VOSviewer, and R software. Annual trends of publications, countries/regions distributions, funding agencies, institutions, co-cited journals, author contributions, references, core journals, and keywords and research hotspots were analyzed. Results A total of 6810 papers were enrolled in this study. Publications have increased drastically from 16 in 1995 to 1198 in 2022, with 4067 articles published in the last five years. In all, 53 countries contributed with publications to this research area. The United States, the United Kingdom, and China were the most productive countries. Harvard University was the most contributing institution. Regarding keywords, research focuses include artificial intelligence, deep learning, machine learning, telemedicine, rehabilitation, and robotics. Conclusion The COVID-19 pandemic has further accelerated the adoption of DHTs, highlighting the need for remote care options. The analysis reveals the positive impact of DHTs on improving physician productivity, enhancing patient care and quality of life, reducing healthcare expenditures, and predicting outcomes. DHTs are a hot topic of research not only in the clinical field but also in the multidisciplinary intersection of rehabilitation, nursing, education, social and economic fields. The analysis identifies four promising hotspots in the integration of DHTs in MSK pain management, biomechanics assessment, MSK diagnosis and prediction, and robotics and tele-rehabilitation in arthroplasty care.
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Affiliation(s)
- Zulipikaer Maimaiti
- Department of Orthopedics, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Senior Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhuo Li
- Department of Joint Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhiyuan Li
- Senior Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jun Fu
- Senior Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Chi Xu
- Senior Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jiying Chen
- Senior Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wei Chai
- Senior Department of Orthopaedics, The Fourth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Liang Liu
- Department of Orthopedics, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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14
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Hafez G, van Boven JFM. Digital adherence technologies in tuberculosis. Lancet Glob Health 2023; 11:e1341-e1342. [PMID: 37591581 DOI: 10.1016/s2214-109x(23)00308-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/23/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul 34140, Türkiye.
| | - Job F M van Boven
- Department of Clinical Pharmacy and Pharmacology, Medication Adherence Expertise Center of the Northern Netherlands, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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15
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Jiang W. Addressing the adherence challenge in tuberculosis treatment: more than digital technologies. Lancet Glob Health 2023; 11:e634-e635. [PMID: 37061297 DOI: 10.1016/s2214-109x(23)00160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/15/2023] [Indexed: 04/17/2023]
Affiliation(s)
- Weixi Jiang
- School of Public Health, Fudan University, Shanghai 200031, China.
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