Costs of Digital Adherence Technologies for Tuberculosis Treatment Support, 2018–2021

Digital adherence technologies are increasingly used to support tuberculosis (TB) treatment adherence. Using microcosting, we estimated healthcare system costs (in 2022 US dollars) of 2 digital adherence technologies, 99DOTS medication sleeves and video-observed therapy (VOT), implemented in demonstration projects during 2018–2021. We also obtained cost estimates for standard directly observed therapy (DOT). Estimated per-person costs of 99DOTS for drug-sensitive TB were $98 in Bangladesh (n = 719), $119 in the Philippines (n = 396), and $174 in Tanzania (n = 976). Estimated per-person costs of VOT were $1,154 in Haiti (87 drug-sensitive), $304 in Moldova (173 drug-sensitive), $452 in Moldova (135 drug-resistant), and $661 in the Philippines (110 drug-resistant). 99DOTS costs may be similar to or less expensive than standard DOT. VOT is more expensive, although in some settings, labor cost offsets or economies of scale may yield savings. 99DOTS and VOT may yield savings to local programs if donors cover infrastructure costs.


99DOTS
The study was done in mining communities in Tanzania in four districts and four regions.The intervention involves (i) provision of medication in 99DOTS sleeves, (ii) delivery of reminders via SMS to patients, (iii) dosing histories used for counselling and for differentiated care (more intensive patient management), and (iv) targeted educational messaging based on adherence and risk factors via SMS or IVR.
Total TB incidence 132,000 Measured concordance with urine testing 95% of doses reported using 99DOTS were confirmed by urine testing .This concordance was highest (98%) in patients who were in their first 2 mo of treatment.§ (3) currency used in the country Text 8. Date the questionnaire was filled YYYY -MM -DD 9. Was anything donated to the project?(e.g., equipment, technical support, training sessions offered as donations, etc.) Yes, No 10.List detailed items and services that were donated to the project Text Population I. Number of patients who used 99DOTS during the project N a) Phone and accessories For patients A1.Number of phones that were purchased N A2.Unit cost of phone purchased $ A3.Number of SIM cards that were purchased N A4.Unit cost of SIM card $ A5.Number of charger or solar batteries that were purchased N A6.Unit cost of charger or solar batteries $ A7.Number of phone lines provided with airtime N A8.Total cost for airtime per phone line for the entire duration of the project $ A9.Total cost of phones (includes phone, SIM card and airtime) (A1*A2) + (A3*A4) + (A5*A6) + (A7*A8) Per patient cost for phone and accessories A9/I b) Platform / infrastructure costs B1.Initial configuration/customization costs (setting up phonelines and or platform at sites) $ B2.Type of configuration (portable, toll-free or SMS) Text B3.Total fixed cost of renting toll free phone lines / SMS line or any other system used to support 99DOTS platform for the entire duration of the project $ Per patient fixed cost of the platform/infrastructure (B1 + B3)/I c) Medication sleeves C1.Total cost of 99DOTS medication sleeve printing (including secondary packaging, labels, etc.) $ C2.Total cost for shipping of 99DOTS medication sleeves (including customs, etc.) $ Per patient cost for medication sleeves (C1+C2)/I d) Medication Preparation D1.Typical amount of time to wrap and prepare one medication medication sleeve (in minutes) Minutes D2.Type of staff wrapping medication Job Category D3.Wage of staff (per hour) $ D4.Cost of labor for wrapping per medication sleeve (Total time for wrapping an medication sleeve) D1*D3/60 Cost components Details/Formula * D5.Number of medication sleeves required per patient for the entire duration of treatment N Per patient preparation cost for entire duration of treatment D4*D5 e) 99DOTS Calls/SMS costs E1.Average number of calls/SMS made by a patient to 99DOTS during the entire duration of treatment N E2.Amount the project paid per call/SMS made by a patient to 99DOTS $ E3.Per patient call/SMS to 99DOTS cost for entire duration of treatment E1*E2 E4.Average number (per patient) of 99DOTS reminder/education SMS sent by the system for missed doses N E5.cost the project has to pay per 99DOTS system SMS $ E6. per patient cost of 99DOTS adherence reminders for the entire duration of treatment E4*E5 Total per patient cost (TO AND FROM) 99DOTS system call/SMS for entire duration of treatment E3 + E6 f) Adherence monitoring by HCW using 99DOTS platform F1.Type of HCW who does adherence monitoring using 99DOTS platform Job Category F2.HCW wage (per hour) $ F3.Typical amount of time (in min) spent by HCW monitoring adherence on the platform per patient (duration of project) N Per patient cost of 99DOTS adherence monitoring F3*F2/60 g) Systems, Data management and technical support G1. Amount spent for staff working on data management for 99DOTS platform (salaries paid for support of DAT platform) $ G2.Number of days that technical support was provided, or number of times specific technical services were provided (beyond initial setup) N G3.Cost per day or per activity reported in G2 $ G4.Total cost of technical support for 99DOTS platform G2*G3 G5.Amount paid for health facility hardware (laptops, desktop, or tablet computer to track adherence) $ G6.Payments made for monthly plans for technical services such as data plans and phone plans for HCW and health facility $ Per patient cost for Systems, Data management and technical support (G1 + G4 + G5 + G6)/I h) Escalation in case of non-adherence and HCW response (improve adherence) Escalation related phone calls: H1.Number of patients who required follow up by phone as part of adherence escalation procedure N H2.Average number of phone calls made by HCW per patient (for entire duration of the project) N H3.Average HCW time per call (in minutes) required to speak to a patient who requires adherence follow up minutes H4.Total time (in minutes) spent by HCW with patients on a phone for adherence follow up H1*H2*H3 H5.Type of HCW who usually makes phone calls Job Category H6.Average HCW wage (per hour) $ H7.Additional fees associated with phone call follow up (per call) $ H8.Total cost for Phone calls (H4*H6/60min) + (H1*H2*H7) Escalation related Home Visits: H9.Number of patients who required a home visit as part of escalation procedure N H10.Average number of home visits per individual who requires home visits N H11.Amount of time per visit (including travel) minutes H12.Total time (in minutes) spent by HCW on home visits for patients who required adherence follow up H9*H10*H11 H13.Type of HCW doing home visit Job Category H14.HCW wage (per hour) $ H15.Additional costs for HCW per visit (e.g., Travel/transport costs, incentives, etc.amount of time for training (in minutes) (per HCW in category 1) Minutes I1.3 Total time in minutes for training all HCW in category 1 I1.1*I1.2I1.4 HCW wage (per hour) $ I1.5 Total cost for training all HCW in category 1 I1.

Table 4 .
Additional expenditures related to training (including travel, training venue, subsistence for trainers and trainees, etc. but not time spent by, or salary paid to trainers or trainees)?Specify in column C and enter the cost in column C Per person costs of 99DOTS during the implementation projects, without and with annuitization of capital costs § Equipment cost annuitized over a 5-y life span (phones, tablets and computers).#Fixed cost consists of fixed cost of the platform/infrastructure.
*Text in blue Indicates calculated fields -indicates non applicable components.N = Numeric.*

Table 10 .
Adherence Using 99DOTS calls as a proxy for adherence resulted in a 94% sensitivity using a urine test for isoniazid metabolites (IsoScreen) as the reference standard.§Similarurinalysis approach used in Tanzania to that in the Philippines to assess adherence.DAT; Digital adherence technology.DR-TB; drug resistant TB.DS-TB; drug susceptible TB.Icddr,b; International Centre for Diarrheal Disease Research, Bangladesh.KNCV; Koninklijke Nederlandse Centrale Vereniging tot bestrijding der Tuberculose.TB; Tuberculosis.VOT; video-observed treatment *Adherence was measured by the proportion of days that a person with TB was observed ingesting medication during the planned treatment period Appendix DOT schedules and duration in the study settings -from the costing tool #