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Digital adherence technologies for the management of tuberculosis therapy: mapping the landscape and research priorities
  1. Ramnath Subbaraman1,2,
  2. Laura de Mondesert3,
  3. Angella Musiimenta4,
  4. Madhukar Pai5,
  5. Kenneth H Mayer6,7,
  6. Beena E Thomas8,
  7. Jessica Haberer9
  1. 1 Department of Public Health and Community Medicine and Tufts Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, USA
  2. 2 Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
  3. 3 Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  4. 4 Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
  5. 5 McGill International TB Centre, McGill University, Montreal, Quebec, Canada
  6. 6 The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
  7. 7 Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  8. 8 Department of Social and Behavioural Research, National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
  9. 9 Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Ramnath Subbaraman; ramnath.sub{at}


Poor medication adherence may increase rates of loss to follow-up, disease relapse and drug resistance for individuals with active tuberculosis (TB). While TB programmes have historically used directly observed therapy (DOT) to address adherence, concerns have been raised about the patient burden, ethical limitations, effectiveness in improving treatment outcomes and long-term feasibility of DOT for health systems. Digital adherence technologies (DATs)—which include feature phone–based and smartphone-based technologies, digital pillboxes and ingestible sensors—may facilitate more patient-centric approaches for monitoring adherence, though available data are limited. Depending on the specific technology, DATs may help to remind patients to take their medications, facilitate digital observation of pill-taking, compile dosing histories and triage patients based on their level of adherence, which can facilitate provision of individualised care by TB programmes to patients with varied levels of risk. Research is needed to understand whether DATs are acceptable to patients and healthcare providers, accurate for measuring adherence, effective in improving treatment outcomes and impactful in improving health system efficiency. In this article, we describe the landscape of DATs that are being used in research or clinical practice by TB programmes and highlight priorities for research.

  • tuberculosis
  • medication adherence
  • differentiated care
  • SMS reminders
  • mhealth
  • mobile technologies
  • electronic medication packaging devices
  • digital medication monitors

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  • Handling editor Seye Abimbola

  • Contributors RS, JH, AM and LdM conceived the report. RS, LdM, AM and JH wrote the first draft. LdM and RS conducted the literature search and designed the figures. KHM, MP, JH, BET and AM revised, edited and provided critical additions to the manuscript. All authors approved the final version.

  • Funding RS is supported by a grant from the Bill and Melinda Gates Foundation via The Arcady Group (OPP1154665) and a Doris Duke Clinical Scientist Development Award. He acknowledges prior support for this work through a development award from the Harvard Center for AIDS Research (5P30AI060354-13) and a Harvard Catalyst KL2/CMERIT Award (KL2 TR001100). LdM was supported by a grant from the Harvard Center for AIDS Research (5P30AI060354-13). AM and JH are supported by an Emerging Global Leader Award from the Fogarty International Center (K43TW010388) and a mid-career development award from the National Institute of Mental Health (K24MH114732), respectively. BET conducted research on adherence technologies supported by the Bill & Melinda Gates Foundation (OPP1154670). MP holds a Canada Research Chair award from the Canadian Institutes of Health Research.

  • Disclaimer The funding sources had no role in the conception, design, analysis or writing of the report, or in the decision to submit it for publication.

  • Competing interests BET and RS are currently conducting research evaluating the implementation of 99DOTS and evriMED (a digital pillbox) in India, supported by the Bill and Melinda Gates Foundation; neither has any financial interest in these technologies. AM and JH are currently conducting research on the Wisepill device (a digital pillbox) in Uganda; neither has any financial interest in this technology. JH also consults for Merck and is also conducting research involving the use of evriMED1000 (a digital pillbox); she has no financial interest in this technology. KHM is providing mentorship for research evaluating the use of ingestible sensors; he does not have any financial interest in this technology.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement This is a review article in which all studies described are available as published manuscripts or conference abstracts.