Even the staunchest advocates admit that the approach needs to be revised.
For more than a decade, the World Health Organization (WHO) has relied on Direct Observed Therapy Short-course, or DOTS, to fight tuberculosis (TB)—and for nearly as long, the strategy has been controversial.
The idea behind DOTS is that a healthcare worker should directly observe those infected swallow the TB drugs at least for the first two months of the six-month therapy. As the WHO likes to point out, the approach has successfully treated more than 22 million individuals worldwide. “In countries where they have done DOTS well, you don't see a high rate of drug resistance,” says Chris Dye, coordinator of TB monitoring and evaluation for the WHO's Stop TB program.
Implementing DOTS well, however, is no easy task.
“DOTS as a strategy has its limitations.” Chris Dye, WHO's Stop TB program
Activists and many on the ground have long argued that the DOTS approach is patronizing and impractical, and that it doesn't take individual circumstances into account. But in the past few years, it's become apparent to even the staunchest DOTS advocates that at least in Africa, the approach needs to be revised. “DOTS as a strategy has its limitations,” says Dye.
For example, one TB clinic in Durban, South Africa, saw 9,000 infected individuals last year, nearly double compared with four years earlier. The HIV epidemic has also complicated matters, partly because HIV-positive individuals are at greater risk of TB infection and because the DOTS-recommended diagnostic method for TB, the smear test, detects fewer than 40% of TB infections in HIV-infected individuals.
“DOTS will meet its goals everywhere but in Africa,” says Richard Chaisson, director of the Johns Hopkins Center for TB Research. “If activities in Africa are ramped up substantially it might not, but based on current projections, it will fail.”
The WHO's new global plan to stop TB, launched last year, is seen by many as a long-overdue concession to the reality on the ground, acknowledging that “addressing TB/HIV, multidrug resistant-TB and other challenges requires much greater action and input than DOTS implementation.”
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Mandavilli, A. Health agency pulls back on 'patronizing' approach to TB treatment. Nat Med 13, 269 (2007). https://doi.org/10.1038/nm0307-269