Video Observed Therapy (VOT) for People with Tuberculosis (TB): A Scoping Review

BackgroundTuberculosis (TB) remains a significant cause of morbidity and mortality globally, disproportionately affecting low- and middle-income countries (LMIC). Accessing Directly Observed Therapy (DOT) is associated with out-of-pocket costs and stigma. Video-observed therapy (VOT) is an alternative to DOT but evidence from LMIC with high TB burden is limited. To make recommendations for future VOT-related research and inform the design of a pilot implementation of VOT for people with multi-drug resistant TB (MDR-TB) in Mozambique, we did a scoping review of the evidence on VOT for people with TB. MethodologyWe systematically searched five scientific databases and key grey literature repositories to identify eligible abstracts. Abstracts were reviewed and full-text records were identified and evaluated. Data from full-text records were extracted into four implementation theme categories: Feasibility, Acceptability, Cost, and Effectiveness (FACE). Content analysis was used to describe implementation successes and challenges, comparing VOT versus DOT where possible. The Crowe Critical Appraisal Tool (CCAT) was used to evaluate the quality of studies. ResultsIn total, 66 records were identified: 47 primary research studies, 13 reviews, and six grey literature documents. All studies were graded as moderate to high quality and reported against at least one FACE category. Studies from urban settings (n=34) and HIC (n=33) predominated. Where measured and described, VOT implementation was reported to be feasible (43/43, 100%) and acceptable (43/44, 97%). Of the 18/20 (90%) studies describing cost data, VOT was reported to offer savings to the health system compared to DOT. Patient costs were under-reported. Of the 21/23 (91%) studies describing effectiveness to improve adherence to TB treatment, VOT was reported to be non-inferior to DOT. ConclusionIn HIC settings, VOT was reported as feasible, acceptable, and similarly effective alternative to DOT. Further evidence on VOT is needed from LMIC with high TB burden. Author SummaryDirectly Observed Therapy (DOT) remains widely used to monitor treatment adherence of people living with tuberculosis (TB). Since COVID-19, there has been a massive increase in digital health technologies, mobile phone ownership, and internet connectivity, including in high TB burden low- and middle-income countries (LMIC), highlighting the potential for Video Observed Therapy (VOT) as a suitable alternative to DOT. We did a scoping review of studies reporting the implementation and evaluation of VOT for people with TB using a novel thematic framework consisting of feasibility, acceptability, cost and effectiveness (FACE). We identified 20 VOT applications (45% freely available) used by studies. Most VOT studies were conducted in urban settings of low TB burden, High Income Countries (HIC), and did not include cost-effectiveness analyses from a patient perspective or participants from key, underserved groups such as pregnant women or people with TB/HIV. The available evidence suggested that, in mainly HIC with low TB burden, VOT was a feasible, acceptable and effective alternative to DOT which could provide cost savings to the healthcare provider. There is an urgent need for robust evidence of effectiveness, cost-effectiveness, and equity of VOT in LMICs with high TB burden and among key, underserved populations.