Can guardians supervise TB treatment as well as health workers? A study onadherence during the intensive phase

SETTING: In sub-Saharan Africa, tuberculosis (TB) has increased over the la st two decades due to the human immunodeficiency virus pandemic. In Malawi, 20630 new TB patients were notified to the National Tuberculosis Programme in 1996, a fourfold increase since 1986. Due to this increase in cases and lack of resources (both human and monetary) it is becoming more difficult to ensure directly observed treatment (DOT) in the TB wards. METHODS: In Ntcheu district, Malawi, a new TB regimen was introduced from A pril 1996 in which patients received supervised treatment by either a healt h worker or a guardian (i.e., family member). Adherence to the different tr eatment options was measured by form checks, tablet counts, and tests for d etecting isoniazid in the urine. Adherence was measured at 2, 4 and 8 weeks after onset of TB treatment. RESULTS: Overall adherence rate was 95-96%. Inpatients showed the highest a dherence rates. Patients on guardian-based DOT (GB-DOT) (n = 35) showed 94% adherence, while patients on health centre based DOT (n = 40) showed more non-adherent behaviour: 11% according to monitoring forms, 14% according to tablet counts and 16% according to urine tests. DISCUSSION: The results suggest that decentralised care is a feasible optio n for anti-tuberculosis treatment and that guardians can supervise TB treat ment just as well as health workers during the intensive phase of TB treatm ent.