Video Observed Therapy (VOT) for People with Tuberculosis (TB): A Scoping Review

Background Tuberculosis (TB) remains a significant cause of morbidity and mortality globally, disproportionately affecting low- and middle-income countries (LMIC). Accessing Directly Observed Therapy (DOT) is associated with out-of-pocket costs and stigma. Video-observed therapy (VOT) is an alternative to DOT but evidence from LMIC with high TB burden is limited. To make recommendations for future VOT-related research and inform the design of a pilot implementation of VOT for people with multi-drug resistant TB (MDR-TB) in Mozambique, we did a scoping review of the evidence on VOT for people with TB. Methodology We systematically searched five scientific databases and key grey literature repositories to identify eligible abstracts. Abstracts were reviewed and full-text records were identified and evaluated. Data from full-text records were extracted into four implementation theme categories: Feasibility, Acceptability, Cost, and Effectiveness (FACE). Content analysis was used to describe implementation successes and challenges, comparing VOT versus DOT where possible. The Crowe Critical Appraisal Tool (CCAT) was used to evaluate the quality of studies. Results In total, 66 records were identified: 47 primary research studies, 13 reviews, and six grey literature documents. All studies were graded as moderate to high quality and reported against at least one FACE category. Studies from urban settings (n=34) and HIC (n=33) predominated. Where measured and described, VOT implementation was reported to be feasible (43/43, 100%) and acceptable (43/44, 97%). Of the 18/20 (90%) studies describing cost data, VOT was reported to offer savings to the health system compared to DOT. Patient costs were under-reported. Of the 21/23 (91%) studies describing effectiveness to improve adherence to TB treatment, VOT was reported to be non-inferior to DOT. Conclusion In HIC settings, VOT was reported as feasible, acceptable, and similarly effective alternative to DOT. Further evidence on VOT is needed from LMIC with high TB burden. Author Summary Directly Observed Therapy (DOT) remains widely used to monitor treatment adherence of people living with tuberculosis (TB). Since COVID-19, there has been a massive increase in digital health technologies, mobile phone ownership, and internet connectivity, including in high TB burden low- and middle-income countries (LMIC), highlighting the potential for Video Observed Therapy (VOT) as a suitable alternative to DOT. We did a scoping review of studies reporting the implementation and evaluation of VOT for people with TB using a novel thematic framework consisting of feasibility, acceptability, cost and effectiveness (FACE). We identified 20 VOT applications (45% freely available) used by studies. Most VOT studies were conducted in urban settings of low TB burden, High Income Countries (HIC), and did not include cost-effectiveness analyses from a patient perspective or participants from key, underserved groups such as pregnant women or people with TB/HIV. The available evidence suggested that, in mainly HIC with low TB burden, VOT was a feasible, acceptable and effective alternative to DOT which could provide cost savings to the healthcare provider. There is an urgent need for robust evidence of effectiveness, cost-effectiveness, and equity of VOT in LMICs with high TB burden and among key, underserved populations. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was nested within the larger “SAFEST-1 MDR-TB” programme of research, which includes an implementation study of VOT for people with MDR-TB in Mozambique. SAFEST-1 MDR-TB was approved by Research Ethics Committees at the Liverpool School of Tropical Medicine, UK (23-008) and the Comité Institucional de Ética do Instituto Nacional de Saude, Mozambique (148/CIE-INS/2023, 15th of November, 2023). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data are available from the corresponding author (email address) upon reasonable request.