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Moïse Desvarieux, MD, PhD, Warren D. Johnson, Jr, MD and Jean W. Pape, MD

Moïse Desvarieux is with the University Of Minnesota, Minneapolis. Warren D. Johnson, Jr, is with Cornell University Medical College, New York, NY. Jean W. Pape is with the Haitian Study Group on Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, and Cornell University Medical College, New York, NY.

Correspondence: Requests for reprints should be sent to Moïse Desvarieux, MD, PhD, Division of Epidemiology, School of Public Health, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN 55454-1015 (e-mail: desvarieux{at}epi.umn.edu).

We appreciated the cogent comments of Long et al. regarding our report on deferred directly observed therapy (D-DOT) for tuberculosis treatment in Haiti.¹ Although universal and full-duration DOT may be successfully implemented in a rural area like Deschapelles, where Long and Scalcini have been performing their excellent work, it is unrealistic to implement it in the urban setting of revolving addresses prevalent in Port-au-Prince. In this setting, the cost of transportation surpasses the cost of drugs, rendering the initial phase of daily treatment extremely costly to either the patient or the program. We therefore opted for a middle ground, allowing for supervision of this initial phase of treatment, short of direct observation. Indeed, patients were required to come to the clinic weekly to replenish their drug supply, allowing our social workers to rapidly identify patients who would miss an appointment. Additionally, in the initial phase, noncompliant patients are more likely to be betrayed by the persistence of signs and symptoms, and our staff carefully monitored improvement in clinical signs at each weekly visit.

Our dose of isoniazid (600 mg; i.e., 10 mg/kg for a 60-kg patient) in the twice-weekly protocol does not contradict the recommendations of the American Thoracic Society. In the publication cited by Long et al., which also informed our dosage decisions,² 15 mg/kg is the maximum dosage allowable for twice-weekly protocols. (Of further note, the average weight of our population was closer to 50 kg, and a default isoniazid dose of 900 mg would have exceeded the maximum recommended dosage.) Nevertheless, the focus of our report was not on the treatment regimen but on the delivery of treatment by what we think is a novel method using behavioral knowledge in other fields.

We are not the first to suggest flexibility and adaptation to local circumstances in the implementation of DOT.^3–5 Uplekar et al.,⁵ for example, have suggested that "the answer might lie in allowing limited local flexibility and encouraging innovation" in the goal of achieving the completion of tuberculosis treatment. We submit the D-DOT approach as an option to be added to the repertoire of available methods to optimize patient adherence. Long et al. are right in surmising that the conditions of urban Haiti dictated our flexibility and led us to be creative rather than stick with an ideal but unsuccessful DOT program.

References

1. Desvarieux M, Hyppolite P-R, Johnson WD Jr, Pape JW. A novel approach to directly observed therapy for tuberculosis in an HIV-endemic area. Am J Public Health.2001;91:138–141.[Abstract]

2. American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med.1994;149:1359–1374.[Abstract]

3. Bayer R, Stayton C, Desvarieux M, Healton C, Landesman S, Tsai WY. Directly observed therapy and treatment completion for tuberculosis in the United States: is universal supervised therapy necessary? Am J Public Health.1998;88:1052–1058.[Abstract/Free Full Text]

4. Zwarenstein M, Schoeman JH, Vundule C, Lombard CJ, Tatley M. Randomized controlled trial of self-supervised and directly observed treatment of tuberculosis. Lancet.1998;352:1340–1343.[Medline]

5. Uplekar M, Walley J, Newell J. Directly observed treatment for tuberculosis [letter, comment]. Lancet.1999;353:145, 147–148.

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