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How to Get TB Patients to Take Their Pills?

Nag With Texting and a ‘Winners Circle’

The hardest part of curing tuberculosis, doctors say, is getting patients to take all their pills every day for at least six months. Even the easiest regimens of four antibiotics can cause nausea, fevers, rashes and stomach pain. Yet adherence is crucial in tuberculosisbecause patients who miss too many pills often develop drug-resistant strains. Recently, a powerful three-drug regimen was developed that can cure even extensively drug-resistant TB, the most lethal strain. The catch: it means taking five pills a day without fail for six months.

Now researchers have come up with findings that point to a possibly effective adherence tactic: A program based on nagging cellphone texts succeeded in goading patients into taking their drugs in a preliminary test, according to a study published in the correspondence section of last week's New England Journal of Medicine.

Patients enrolled in the phone program experienced 68% fewer bad outcomes—death, treatment failure or loss of contact with the clinic—compared to patients who were not.

The new program, called Keheala and created by a company with the same name, asks patients each day to actively verify that they have taken their pills. If they do, they are thanked and told where they stand in an “adherence contest” against other patients. A 90% ranking earns a spot in the “winners’ circle.” This is social comparison psychology put into action.

If patients do not verify, they get more texts, then two phone calls. Finally, the clinic is alerted that a patient is not responding, which triggers further efforts by medical workers to find them.

Jon Rathauser, Keheala’s founder, said he developed the idea after watching a documentary about tuberculosis in the Solomon Islands. The best adherence strategy, endorsed by the World Health Organization, is “directly observed therapy,” in which patients are assigned trained caretakers and must swallow their pills in front of them every day. “It didn’t make sense, especially in those islands,” Mr. Rathauser said. “Patients didn’t show up and couldn’t be found.”

He later studied behavior therapy and looked at telephone-based programs used in wealthy countries to encourage obese people to exercise.

Part of the Keheala program includes issuing wristbands to patients so they can feel part of a larger group, and sending messages to remind them that taking the drugs protects their families and friends, too.

In the trial, 1,104 patients were enrolled at 17 clinics in Nairobi. Only 4% of the patients in the Keheala program had bad outcomes, while 13% of those in the control group did.

Dr. Pauline Howell, a South African tuberculosis specialist, said the Keheala strategy was “more intensive” than others she had seen but seemed to work.

She warned, however, that patients might be tempted to lie about taking pills, either to score higher in the competition or just to stop the barrage of texts. And a strategy that worked in a clinical trial might not work when it was turned over to “a normal health care system where health workers continuously move in and out of departments,” she said.

In the United States, tuberculosis is rare, but public health laws written in the 19th century give officials powerful tools for use when patients are uncooperative.

In New York City in the early 1990s, for example, there was a large outbreak of multidrug-resistant tuberculosis, and dozens of victims failed or refused to take their drugs. Some were homeless or mentally ill; others were dying of AIDS and had lost hope.

As a last resort, the city confined many of them under guard in public hospitals until they were cured.

Source: New York Times, Sept. 4


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