Expanding directly observed therapy: tuberculosis to human immunodeficiency virus

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The resurgence of tuberculosis and the association between poor treatment adherence and drugresistant tuberculosis in the 1990s emphasized the importance of identifying ways to improve medication adherence. In particular, directly observed therapy improved adherence to tuberculosis therapy for several groups of patients, including those with frequent drug use, mental illness, and unstable housing, thereby contributing to the control of drug-resistant tuberculosis in New York City (1,2). This success was later extended to the delivery of isoniazid preventive therapy to similar patients (3). Still, nonadherence remains the Achilles’ heel of medical treatment for many diseases, including tuberculosis. In this issue of The American Journal of Medicine, Chaisson and colleagues (4) report on a three-arm, random assignment trial of isoniazid adherence. Injection drug users were randomly assigned to directly observed therapy, self-administered therapy with peer counseling and education, or self-administered therapy alone. All participants received either immediate or delayed cash incentives to promote adherence. The study adds two new contributions to the body of adherence research. First, directly observed therapy improved adherence among injection drug users. Second, injection drug users were successfully maintained in monthly care for more than 6 months, perhaps as a result of the cash incentives. This study raises several important questions for adherence strategists. First, why does directly observed therapy yield better results than psychoeducational interventions? Second, what is the role of incentives, especially cash, in improving adherence? Finally, should incentivebased directly observed therapy be used for patients with chronic diseases for which lifetime adherence is required, such as antiretroviral therapy for patients with human immunodeficiency virus (HIV) infection? DIRECTLY OBSERVED THERAPY VERSUS PSYCHOEDUCATIONAL APPROACHES