Video DOT and Economic Incentives to promote adherence to LTBI therapy

Tuberculosis (TB), a highly contagious disease caused by Mycobacterium tuberculosis, remains a major public health concern in the United States. Identifying and treating individuals with latent TB is a key strategy to achieve the goal of TB elimination in the US but there are many challenges to achieving this goal. In Baltimore, where this research will be conducted, more than one-third of non-US-Born individuals have latent TB, and they are disproportionately affected by co-morbidities that increase the risk of progression to active TB, such as diabetes and HIV. However, socioeconomic factors such as poverty, access to care, health literacy, and language or cultural barriers present obstacles to treatment. Treatment for an asymptomatic condition, such as latent TB, is rarely a priority for patients with many other competing needs. The length of treatment (several months for standard “short-course” regimens) is also problematic, particularly for patients experiencing housing or financial instability. Therefore, the majority of individuals infected with latent TB do not complete treatment. We propose to evaluate novel and scalable smartphone enabled interventions to promote completion of treatment for latent TB. Video-directly observed therapy (vDOT) provides multi-faceted adherence support by allowing real-time monitoring of adherence coupled with case-management feedback, is available in patient's preferred languages, and delivers electronic reminders. Likewise, behavior economic (financial) incentives, in which patients receive incentives contingent on ingesting prescribed medications, could mitigate financial stress associated with medical care and lost wages, a common concern among many patients with latent TB infection. Adults with latent TB (N=399) will be randomized to a Usual Care Control, or vDOT, or a vDOT Plus Incentives group. Usual Care Control participants will receive standard care for latent TB. VDOT participants will receive the same Usual Care, but will use smartphones and a commercially available application to receive electronic reminders, submit video-observations to document adherence, and receive case-management real-time feedback. VDOT plus Incentives participants will receive further support through contingent financial incentives (up to $35 per week) for taking prescribed medications under the vDOT system. The primary outcome measure, completion of treatment for latent TB, will be assessed for all participants through MEMS caps (Aim 1). We will also determine the costs, budgetary impact, and incremental cost-effectiveness of the vDOT and vDOT plus incentives interventions (Aim 2). If this intervention is effective in promoting completion of treatment for latent TB and is economically sound, it could prove to be a scalable and effective intervention to promote completion of treatment for latent TB in high-risk populations in Baltimore and in other populations around the world.