amfAR, The Foundation for AIDS Research

Evaluating the Need for Directly Observed Antiretroviral Therapy


July 2010 - An approach known as directly observed therapy (DOT), in which a healthcare worker or someone else witnesses a patient taking medications, has been proposed as a possible strategy for improving adherence to antiretroviral therapy (ART). DOT has been of particular interest for populations judged to be at high risk for poor adherence, including injecting drug users. But questions and concerns have remained about the cost-effectiveness and benefit of such an intervention.

red tubes
Medicines are set aside for each patient at a Thai orphanage for HIV-positive children.

Recently, researchers from Médecins Sans Frontières gathered multiple studies on this issue and evaluated them as a group as part of a meta-analysis. They found that there was generally minimal patient benefit from the added supervision provided through DOT.1

Using changes in viral load level as the measurement of a successful outcome, the study found that overall, patients on DOT did not have lower viral loads than those who took ART without additional supervision. However, there did appear to be some benefit from DOT in groups of patients considered to be at higher risk of poor adherence. The authors suggested that future studies should consider looking into the effectiveness of DOT for specific groups, rather than for all patients.

Although adherence support is a critical component of successful ART, the authors concluded that the limited added benefit of DOT, together with the extra burden it places on patients and health systems, is reducing confidence in this approach. In addition to the costs for travel, as well as patient and provider time, the rights and responsibilities of patients to manage their own care should also be considered. Efforts need to be made to prioritize patient-led and patient-controlled adherence strategies.

1. Ford N, Nachega JBE, Mark E, Mills EJ. Directly observed antiretroviral therapy: A systematic review and
meta-analysis of randomized clinical trials. The Lancet. 2009 Dec. 19/26; 374.