Pursue high-quality DOTS expansion and enhancement
Element 3: Standardized treatment, with supervision and patient support
The mainstay of TB control is organizing and administering standardized treatment across the country for all adult and paediatric TB cases – sputum smear-positive, smear-negative, and extrapulmonary. In all cases, WHO guidelines on patient categorization and management should be followed.1 These guidelines emphasize use of the most effective standardized, short-course regimens, and of fixed-dose drug combinations (FDCs) to facilitate adherence to treatment and to reduce the risk of the development of drug resistance. Separate WHO guidelines are also available for management of patients with drug-resistant TB.2
Supervision and patient support
Services for TB care should identify and address factors that may make patients interrupt or stop treatment. Supervised treatment, which may have to include direct observation of therapy (DOT), helps patients to take their drugs regularly and complete treatment, thus achieving cure and preventing the development of drug resistance. Supervision must be carried out in a context-specific and patient-sensitive manner, and is meant to ensure adherence on the part both of providers (in giving proper care and support) and of patients (in taking regular treatment). Depending on the local conditions, supervision may be undertaken at a health facility, in the workplace, in the community or at home. It should be provided by a treatment partner or treatment supporter who is acceptable to the patient and is trained and supervised by health services. Patient and peer support groups can help to promote adherence to treatment. Selected patient groups, for example prisoners, drug users, and some people with mental health disorders, may need intensive support including DOT.
Improving access to treatment
Locally appropriate measures should be undertaken to identify and address physical, financial, social and cultural barriers – as well as health system – barriers to accessing TB treatment services. Particular attention should be given to the poorest and most vulnerable population groups. Examples of actions that may be appropriate include expanding treatment outlets in the poorest rural and urban settings, involving providers who practise close to where patients live, ensuring that services are free or heavily subsidized, offering psychological and legal support, addressing gender issues, improving staff attitudes, and undertaking advocacy and communication activities.