Drug-resistant tuberculosis treatment

Video-observed treatment (VOT). For VOT there were only two cohort studies from high-income 
countries and no data from low- and middle-income countries (199, 200). These studies compared 
in-person DOT with VOT done in real time. Patients who were provided with VOT had no statistically 
significant difference in treatment completion and mortality compared to patients who had in-person 
DOT. Based on an assessment of the certainty of the evidence, carried out using predefined criteria 
and documented in GRADEpro, the certainty of the evidence was rated as very low. Although there 
is some concern as to the indirectness of evidence for VOT, as the studies were conducted in high-
income countries and the uncertainty of evidence surrounding the use of VOT, the results from the 
two cohort studies showed that in-person DOT was not better than VOT. DOT has been the standard 
of care that many programmes aim for, even if in practice they have to resort to SAT in many patients 
because of lack of resources. The advantages of using VOT are its potential to observe adherence 
to treatment from a distance – and even when people travel and cannot visit or be visited by a DOT 
provider. VOT is also more flexible to people’s schedules by offering virtual observation at different 
times of the day. VOT could help achieve better levels of patient interaction at a much lower cost 
and less inconvenience when compared with in-person DOT. VOT can be used as an addition to, or 
interchangeable with, in-person DOT or other treatment administration options. For instance, it is 
not expected that a patient receives VOT as the sole option of supervision during the whole duration 
of treatment. Furthermore, the technology required for VOT (broadband Internet and smartphone 
availability) is becoming increasingly available in resource-constrained settings. Moreover, VOT delivery 
options are evolving (e.g. enhanced possibility for real-time communication in addition to recorded 
video), and therefore evidence and best practices are likely to develop further in the coming years, 
especially from ongoing RCTs. The benefits of VOT may become more apparent as programmes are 
able to choose forms of VOT that best meet their needs. In fact, VOT may be particularly useful for 
easing the burden on the health care system in low- and middle-income
countries.

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