An exploration of the concept of directly observed treatment (DOT) for tuberculosis patients: from a uniform to a customised approach.

Tuberculosis (TB) management has moved from chaotic systems and low patient adherence with treatment regimens to the directly observed therapy, short course (DOTS) strategy, which has been described as a new paradigm of TB control. Directly observed treatment (DOT) is only one component of the full DOTS strategy. DOT versus self-administered treatment (SAT) has been the subject of extensive debate, particularly about what approach improves treatment adherence. This debate has been complicated by different case-holding rates and cure outcomes in different contexts where DOT is in place. The increasing range of DOT applications in different settings, including the choice of provider, place, target population, and the extent to which DOT is part of a wider approach, has not been sufficiently taken into account. However, the concrete reality of DOT is an important determinant of the overall success or failure of the programme, and has implications in terms of equity and accessibility of care during treatment. This article aims to go beyond the frequently polarised debate of DOT versus SAT and document the diversity of ways in which DOT has been implemented internationally. We also aim to raise key issues for further discussion, including 1) viewing DOT as part of a complex and lengthy set of interventions that are context-specific, 2) incorporating an equity approach that discusses individual patients' needs and the relationship between the patient and provider, and 3) the role of incentives and enablers. It is anticipated that this exchange of opinion and experiences from different parts of the world will be useful for those involved in the policy formulation and practice of TB management.