DAT Implementation Toolkit

Background

For patients who initiate treatment, adherence and persistence (retention in care) to current TB treatment regimens remains very challenging. At present, few TB programs use Digital Adherence Technologies (DAT) to make informed decisions about patients who need either more or less intensive follow up to maximize treatment success rates. In reality, we know that health system resources are spread thinly across all patients on treatment regardless of their risk for poor outcomes causing inefficiencies in the system. Therefore effective implementation of digital health adherence technologies requires consideration of the larger context of the health system and patient population in which they will operate. Adherence monitoring technologies can be used to build a detailed dosing history for individual patients, so data-driven decisions about differentiation of TB care services can be made to maximize treatment success rates.

Figure 1. Using dosing histories to inform individualized care

 

What is the DAT Implementation Toolkit?

This implementation guide and toolkit is software agnostic and is developed to be an enabler for countries who want to make this inevitable switch to the use of digital adherence technology as part of the health system to support differentiation of patient care.

This is a holistic toolkit (not a checklist), and can be used to guide an end-to-end implementation from inception through the planning and preparation phases to the scale up and eventual use of data to support and adjust differentiation of patient care. This DAT toolkit presents a step-wise approach to help implementers think systematically through the preparatory steps needed for successful selection and implementation of any digital adherence technology.

The five phases of a digital health assessment( https://kncvtbc.atlassian.net/wiki/spaces/ADHERENCE/pages/236650559/Assessing+the+digital+health+landscape ) will help identify opportunities and gaps along the critical steps of the patient pathway: care-seeking, diagnosis, treatment and follow up. This allows mapping of needs along the entire pathway to match with existing and potential digital health solutions and informing how to select, adapt and implement appropriate digital health solution(s).

Each section of this toolkit provides information on how to achieve specific goals and objectives, based on available literature and case studies from countries who have implemented DAT interventions.

The DAT toolkit includes generic, easy to adapt tools such as questionnaires, checklists and terms of references that can be used to form the basis for implementing adherence technologies in any setting.

Who can use the DAT toolkit?

This DAT toolkit is publicly accessible and information can be used freely by anybody. The DAT toolkit is aimed towards usage by National TB Programs (NTP) and implementing partners introducing DAT interventions in projects and development of scale-up strategies.

When can the toolkit be used?

The DAT toolkit can be used at various points during the implementation of an DAT intervention. We advise to start using the DAT toolkit during the development phase of a project or road map development for the implementation of a DAT intervention, as the DAT toolkit provides practical guidance for the preparation and planning, and to support the design of a fit for purpose system that is scalable and sustainable. In addition the DAT toolkit can be used during the maintenance of the DAT intervention.

From proof of concept to scale-up of DAT interventions

Digital adherence technologies aren’t the latest innovations in health or in TB for that matter. However in the last 10 years there has been a significant increase in the use and generation of evidence on the implementation of DAT’s in low income settings. Figure 2 shows the three main phases:

Proof of concept

Initial work was focused on proof of concept. With the start of a randomized control trial (RCT) on the effectiveness of EMM boxes in China and several RCT's on the use of VOT in the United Kingdom, Moldova and Belarus. During this period the first EMM sleeves were developed as well. There was not much global and national guidance yet on the use of DAT’s.

Early policy adoption and initial scale-up

During this phase, more evidence has become available related to the effectiveness of DATs on treatment outcomes and adherence. WHO published the digital adherence technology implementation handbook and made the first conditional recommendation (very low certainty in evidence) to use tracers or digital medication monitors to support patient on TB treatment. India and China started scale-up of DAT interventions and adopted the use of DATs in their national policy document.

Broad implementation and scale-up

Multiple countries started demonstration projects on the use of DAT’s as part of the TB REACH funding mechanisms with one of the main goals to generate evidence in a variety of settings. The UNITAID funded ASCENT project started as well, with the aim (1) to create conditions for scale-up to enable countries to scale-up DAT interventions as part of Global Fund and domestic funding, (2) create evidence on feasibility, acceptability and (cost) effectiveness of DAT interventions and (3) overcome global and national barriers in terms of market access, procurement and supply chain.

Figure 2. Timeline for evidence generation on implementation of DATs

This DAT implementation toolkit is developed by KNCV Tuberculosis Foundation. All information and materials can be used freely. With input from many countries NTP’s, implementing partners and DAT vendors.