Video-Directly Observed Therapy (V-DOT) is a promising solution for monitoring TB and HIV treatment adherence for binational patients in the U.S.-Mexico border region.

1. TB
“Video-Directly Observed Therapy:
A promising solution for monitoring TB and HIV
treatment adherence for binational patients in the
U.S.-Mexico border region”
Muñoz F., Collins K., Moser K., Cerecer-Callú P., Sullivan M.,
Chockalingam G., Rios P., Zúñiga M.L., Burgos J.L., Rodwell T., Rangel
M., Patrick K., Garfein R.
Division of Global Public Health
School of Medicine
University of California, San Diego
Sixth Annual CFAR International HIV/AIDS Research Day
San Diego, CA
September 18th, 2012

2. TB/HIV Syndemic TB
 Human immunodeficiency virus (HIV) and tuberculosis (TB)
syndemic that cause high morbidity and mortality worldwide
 TB is the leading cause of
death among persons
with HIV (PWHIV)
 TB disease in PWHIV can
be prevented with
effective treatment
MMWR, CDC, 2012; WHO, 2012; Kwan & Ernst, 2011; Garfein 2010

3. Tuberculosis Burden TB
TB
 A bacterial infection caused by M. tuberculosis (Mtb)
 TB usually affects the lungs but can spread to other
parts of the body
 TB is the 2nd leading cause of death from infectious
diseases worldwide
— 1/3 of the world’s population is
infected with Mtb
— Worldwide there are 9 million new
cases and 1.4-2 millions deaths from
TB annually
— Each infected person will spread TB
to 10-15 other individuals before
death or cure
Estimated number of persons
infected with TB –worldwide,
WHO 2010 MMWR, CDC, 2012; WHO, 2012 &2010

4. Mexico and U.S. TB Incidence Rates*
By State
Cases Rate*
NATIONAL 13,142 4.2
BORDER 4,180 6.8
CA
7.0 AZ
NM
San Diego: 8.4 3.5
3.0
Tijuana: 46.1 40.5 TX
B.C. 6.2
26.4
SON 17.1
16.5
CHI
Cases Rate* COH
NATIONAL 15,649 14.1 NL
TAM
BORDER 4,290 25.7 19.9 31.9
CDC, 2008; CDPH, 2008; DGEPI Mexico, 2008; INEGI, 2005; SINAVE, 2007.
* Rate = cases per 100,000 population Adapted from: Schneider E, et al. Rev Panam Salud Publica. 2004;16(1):23–34.

5. TB treatment
• Curable with antibiotics, but takes >6 months to treat
– Side effects common
– Contraindicated with other medications and alcohol
– Careful monitoring is necessary to assure medication
adherence
• Poor adherence  drug resistance (MDR/XDR-TB)
– Delayed resolution or worsening symptoms
– Resistant strains can be transmitted
– Drastically increases treatment costs
– Increase probability of death
MMWR, CDC, 2012; WHO, 2012 &2010

6. Directly Observed Therapy (DOT)
• Preferred treatment strategy for all
patients
– Improves adherence
– Reduce acquired drug resistance,
treatment failure, and relapse
Provider visits the patient
– DOT saved 6.8 million lives in 1995-2010
• Care provider observes patient
taking every medication dose until
treatment is completed
Patient goes to the clinic
CDC, 2007; WHO, 2012

7. TB treatment: DOT
However, DOT is …
o Costly
o Labor intensive and time consuming
o Limit patient mobility
o Logistically difficult to administer for binational patients
o May not be feasible for patients in rural areas
o Potentially jeopardizes patient privacy and
confidentiality
o Patient stigmatization

8. Technology to Improve Medication
Adherence
• New opportunities to reach and improve the level of
care for underserved population worldwide
• Previous studies
• Monitoring medication adherence, patient education,
motivation and health messaging, frequent communication
with patient, reminder system and data gathering.
• Broader range of diseases (TB, HIV/AIDS, Diabetes)
• Technology previously used
• MEMS caps
• short message system (SMS)
• text messages
• phone reminders
Pellowski & Kalichman, 2012; Hoffman et al, 2010

9. 1st Generation Technology
• Count the number of doses dispensed
(MEMS Caps, GlowCap, etc.)
2nd Generation Technology
• Drug metabolite testing (blood, urine, hair, toenails)
• Patient-facilitated tracking (Adhere.IO, Pill Apps)
• Embedded sensors (Proteus, SmartPill)

10. Video Phone Experiment
• Landline-based system
• First 33 patients in 9 months
• Advantages:
– High patient acceptance
– Saved $$$
– 27,840 miles saved ($10,161)
– 795 hours saved ($15,000)
• Disadvantages:
– Limited to business hours
– Must take meds while at home
– Won’t work for San Diego’s binational patients

11. “Mobile Phone‐Based Video Directly Observed
Therapy (VDOT) for Tuberculosis”

12. Objectives
• To develop and pilot test the mobile phone-
based video direct observed therapy (VDOT)
program among TB patients in a bi-national
border region.
• To assess the feasibility and acceptability of
VDOT among patients, providers, and health
officials.

13. Methods
 Two phased pilot study in San Diego, CA and
Tijuana, BC, Mexico (4/1/2009-10/1/2012)
 Phase I: Focus Groups
 Phase II: Pilot VDOT trial
 Both phases conducted in San Diego and
Tijuana to evaluate VDOT simultaneously in
high and low economic resource areas.
 Pilot study approved by the UCSD Human
Research Protection Program and the Bioethics
Committee of COLEF.
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14. Phase I: Focus Group Design
• Participants: TB patients who recently completed in-person
DOT, TB care providers and health officials.
• Explored feasibility, acceptability and general perceptions of
VDOT.
San Diego Tijuana
# of # of # of # of
Groups Participants Groups Participants
Providers 2 14 1 19
Patients 4 14 1 9
Promotores 0 1 14
– Participants’ ages ranged from 24-88 years (mean 47) and did not
differ by city.
– In both cities, approximately half (49% overall) of the patients and
providers were male; over half (67% overall) were Hispanic.

15. Focus Groups Results
Providers Patients
• Solve transportation problems, • Save transportation cost as well
save patients money, as alleviate stigma.
Feasibility • Protect patient privacy from “With the demonstration that’s
neighbors and friends, been shown I think it’s really easy.”
• Alleviate risk of stigma.
‐Both providers and patients felt they could easily do it.
• Wait to eat until his “promotor“
• Better option than the current showed up, which sometimes
system of “in‐person” DOT and did not happen until 2pm.
Acceptability “landline” video‐DOT. “You’re not locked to your house,
and you’re not locked to the time of
the day that you have to take your
medication.”
‐Both providers and patients had a little concern about using cell phones.

16. Video DOT Flow Diagram
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Copyright © 2012 The Regents of the University of California. All Rights Reserved.

17. Phase II: Pilot Study Design
• Population:
– Newly diagnosed pulmonary TB patients selected by TB Control Program
– San Diego (n=40) and Tijuana (n=10)
• Patients provide informed consent
• Patients taught to use phone by DOT case worker
• Videos observed and tracked by TB Program staff
• Patient interviews conducted pre and post treatment
• $25 given for each interview, but nothing for doing VDOT
• Planned to follow patients for 4-9 months on VDOT
• Data Collection:
– Interviews assessed demographics, attitudes about TB, study
satisfaction and experience/comfort using technology including
smart phones, number of doses observed by VDOT

18. Results
San Diego Tijuana
Number enrolled 43 9
Number of bi-national participants* 6 0
Cell phones lost/stolen/broken 2 2
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*Participants reported spent time in both cities

19. Pilot study: Patient characteristics
San Diego Bi‐national Tijuana
Socio‐demographics
n=37 (%) n=6 (%) n=9 (%)
Age: Mean (range) 39 (18‐86) 37.5 (22‐50) 28 (19‐65)
Gender 20 (54.1) 3 (50.0) 5 (55.6)
Male 17 (45.9) 3 (50.0) 4 (44.5)
Female
Hispanic or Latino 12 (32.4) 6 (100) 9 (100)
Race
Asian 13 (35.1) 0 (0) 0 (0)
African American/Black 3 (8.1) 0 (0) 0 (0)
Caucasian/White 10 (27.0) 0 (0) 3 (33.4)
Other/Mixed Race 11 (29.7) 6 (100) 6 (66.6)
Educational Attainment
Illiterate 0 (0) 0 (0) 1 (11.1)
< High School 6 (16.2) 2 (33.3) 3 (33.3)
> High School 28 (75.7) 4 (66.7) 5 (55.6)
Had employment (last 3 months) 35 (94.6) 3 (50.0) 4 (44.4)
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20. Pilot Study:
Medication Doses by VDOT
San Diego Bi‐national Tijuana
Medication doses by VCP‐DOT n=37 n=6 n=9
Mean (range) Mean (range) Mean (range)
Total medication doses expected 88.4 (10‐202) 107 (40‐107) 92.5 (2‐168)
Total medication doses observed 84 ( 9‐200) 96.1(21‐153) 88.4 (2‐165)
Proportion of total medication
94% (50‐100) 84% (52‐96) 95%(88‐100)
observed/ total medication expected (%)
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21. Pilot Study:
Post-test survey results
San Diego Bi‐national Tijuana
Experience with VDOT
n=35 (%)* n=6 (%) n=9 (%)
>½ the Time 3 ( 8.6) 0 (0) 1 (11.1)
Had problems recording a video Rarely 17 (48.6) 5 (83.3) 5 (55.6)
Never 15 (42.9) 1 (16.7) 3 (33.3)
>½ the Time 6 (17.1) 0 (0) 1 (11.1)
Had problems sending a video Rarely 23 (65.7) 5 (83.3) 6 (66.7)
Never 6 (17.1) 1 (16.7) 2 (22.2)
Unable to send a video due to poor reception 10 (28.6) 4 (66.7) 5 (55.6)
Yes, Always 6 (17.1) 4 (66.7) 2 (22.2)
Able to send videos while
Yes, Sometimes 2 (5.7) 2 (33.3) 1 (11.1)
traveling outside of SD or TJ Never Tried 27 (77.2) 0 (0) 6 (66.7)
1 20 (57.1) 5 (83.3) 1 (11.1)
Days practicing with a DOT worker 2 6 (17.1) 0 (0) 0 (0)
before recorded a video alone 3 2 (5.7) 0 (0) 3 (33.4)
>4 6 (17.1) 1 (16.7) 5 (55.6)
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22. Pilot Study:
Post-test survey results
San Diego Bi‐national Tijuana
Convenience of VDOT n=35 (%) n=6 (%) n=9 (%)
More 27 (77.1) 7 (77.8) 6 (100)
VDOT more confidential that In‐
No Difference 6 (17.1) 2 (22.2) 0 (0)
Person DOT Less 2 (5.8) 0 (0) 0 (0)
VDOT 33 (94.4) 8 (88.9) 5 (83.3)
To redo TB treatment, they choose In‐person DOT 1 (2.8) 1 (11.1) 0 (0)
No Preference 1 (2.8) 0 (0) 1 (16.7)
Inconvenient 3 (8.6) 0 (0) 0 (0)
Convenience using VDOT compared Neutral 0(0) 0 (0) 0 (0)
with In‐person DOT Convenient 32 (91.4) 6 (100) 9 (100)
Concern of people watching take a video 11 (31.4) 2 (33.3) 6 (66.7)
Recommend VDOT to other TB patients 35 (100) 6 (100) 9 (100)
VDOT allowed more freedom to travel outside of
31 (88.6) 6 (100) 8 (88.9)
home than in‐person DOT 22

23. Opportunities, Challenges
and Observations
 Patients, nurses, DOT workers/promotor and health officials
considered VDOT to be highly feasible and acceptable
 High patient satisfaction and appreciation for mobility that VDOT
allows
 Considerable savings in staff time and travel reported in both
cities
 SMS reminders lapse when cell/WiFi was unavailable
 Some video uploads delayed by cell/WiFi limitations
 2 patients preferred in-person DOT
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24. Conclusions
- Results showed VDOT to be feasible and acceptable in
both high and low resource settings
- VDOT allows all doses taken by bi-national patients to be
counted, even when they were traveling
- VDOT is a promising mobile solution to monitoring TB and
other conditions such as HIV that require strict treatment
adherence
- Future research is needed to test VDOT among patients
with TB/HIV co-infection
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25. Acknowledgements
UCSD Division of Global Public Health
Richard Garfein (PI), Jazmine Cuevas-Mota , Kelly
Collins, Fatima Munoz, Maria Luisa Zuniga, Jose Luis
Burgos, Timothy Rodwell, Maureen Clark
UCSD Department of Family and Preventive
Medicine
Kevin Patrick
UCSD Calit2
Kevin Patrick, Fredric Raab, Mark Sullivan, Phillip
Rios, Alison Flick, Ganz Chockalingam
San Diego County Health and Human Services
Agency
Kathleen Moser, Christine Kozik, Krystal Liang,
Deborah McIntosh
ISESALUD, Tijuana, BC, Mexico
Paris Cerecer, Cristhian Ambriz
El Colegio de la Frontera Norte, BC, Mexico
Maria Gudelia Rangel
* Funded by the National Institutes of Health (R21-AI088326) and Alliance Healthcare Foundation.
* Premium QIK membership accounts provided at no cost by QIK.COM.

26. GRACIAS
Fátima Muñoz, M.D., M.P.H.
Email: famunoz@ucsd.edu
Phone: 619-534-9670
Division of Global Public Health
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