A neglected research approach to prevent acquired drug resistance when treating new tuberculosis patients.

The occurrence of significant drug resistance in many countries, coupled with known problems in delivering directly observed therapy (DOT), calls for a re-examination of tuberculosis (TB) treatment delivery strategies. Electronic medication monitors, devices that determine when medication is removed from containers, and videophone-based strategies are being introduced to determine if they can effectively differentiate 1) patients who are adequately adherent to self-administered treatment (SAT), 2) less reliable patients who could be successfully treated with SAT if given more intensive counseling and 3) patients who require DOT. The adherence record could be used in deciding on compensatory longer treatment when poor adherence occurs. The time saved not giving DOT to all patients could be used to retrieve defaulters. Together these components constitute a monitor-based strategy. The program could be extended to supervise the adherence of private patients to medication provided by trained and subsidized pharmacies with the physicians or, when necessary, health departments managing poorly adherent patients. When patients move, the device could transfer essential data to the new care giver. To obtain optimal results, the requirements for the best possible devices and procedures for dealing with poor adherence need to be carefully evaluated.