Doubts about DOT: Antiretroviral therapy for resource-poor countries

Introduction: Directly observed therapy programs developed for tuberculosis (TB) have been suggested as a model for the provision of HIV medications in resource-poor countries in order to ensure adherence and prevent drug resistance. Methods: Opinions were formed based on a review of scientific literature regarding the effectiveness of witnessed dosing in directly observed TB therapy programs, adherence to HIV antiretroviral therapy in resource-rich and resource-poor settings, relationship between adherence and HIV antiretroviral drug resistance, HIV viral load and risk of HIV transmission, and stigmatization concerns related to HIV and TB in resource-poor settings. Results/conclusions: We suggest that the enthusiasm for HIV directly observed therapy programs is premature based on: equivocal evidence that witnessed dosing is superior to self administered therapy; mistaken assumptions that resource-poor countries are a 'special case' with respect to adherence; possible paradoxical impact of good adherence on HIV drug resistance; unproven efficacy of antiretroviral therapy in preventing HIV transmission; and potential stigmatization of daily antiretroviral dosing.