From Tuberculosis › Chapter 13: Adherence to tuberculosis treatment · Médecins Sans Frontières, Current online edition, 2026
MSF guidance on self-administered treatment versus directly observed therapy for tuberculosis patients.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Healthcare workers, TB programme managers, clinicians treating tuberculosis
- Evidence
- Evidence-based recommendations with systematic review citations
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This section of the MSF tuberculosis guideline addresses treatment delivery models, contrasting self-administered treatment (SAT) with directly observed therapy (DOT). SAT involves patients taking treatment autonomously with monthly health facility visits for drug supply and support, whilst DOT requires daily supervision by a third party, which can be facility-based, community/home-based, or remote (video-observed therapy).
For drug-susceptible TB, the guideline notes that DOT has not been proven superior to SAT in controlled trials, and recommends SAT as the default approach when no adherence-complicating factors exist and appropriate support is provided. DOT may be preferred for patients with mental health or serious socioeconomic problems, and for detained persons. For drug-resistant TB, reinforced support is usually required, and if DOT is used, home-based DOT or VOT are preferred over facility-based approaches. Latent TB infection treatment can be self-administered, with DOT considered only for patients with mild hypersensitivity reactions to HP-containing regimens.
The central message is that treatment delivery should be tailored to individual patient circumstances, with SAT as the default for drug-susceptible TB and reinforced, preferably decentralised support for drug-resistant TB.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Self-administered treatment (SAT) is the recommended default for drug-susceptible TB when no adherence-complicating factors exist and appropriate support is provided
- DOT has not been proven to improve treatment outcomes for drug-susceptible TB compared to SAT in controlled trials
- For drug-susceptible TB, DOT may be preferred for patients with mental health problems, serious socioeconomic problems (e.g. homelessness), patients incapable of self-administration, and detained persons
- For drug-resistant TB, patients usually require reinforced support due to lack of fixed-dose combinations, treatment length, adverse effects, and lack of therapeutic alternatives
- If DOT is used for drug-resistant TB, home-based DOT or video-observed therapy (VOT) are preferred over facility-based DOT
- Community and home-based DOT and VOT require fewer resources (personnel and transport) than facility-based DOT
- Latent TB infection treatment can be self-administered; DOT may be considered for patients with mild hypersensitivity reactions to HP-containing regimens
- SMS telephone reminders may be considered to reinforce adherence in self-administered treatment
From the guideline
Verbatim
“DOT has not been proven to improve treatment outcomes for DS-TB when compared to SAT in controlled trials.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia, I recognise that these MSF recommendations directly address a critical challenge in our region, where Georgia and neighbouring countries face substantial MDR-TB burdens. The evidence-based shift away from universal DOT for drug-susceptible TB towards patient-centred SAT represents an important opportunity to reallocate scarce nursing and community health worker resources towards the more intensive support required for our DR-TB patients. I would particularly stress to Georgian clinicians the recommendation for home-based DOT or VOT over facility-based approaches for drug-resistant TB, as this aligns with reducing nosocomial transmission risks whilst improving patient convenience. However, implementation will require realistic assessment of our capacity to train, supervise, and remunerate community treatment supporters in rural areas, and to ensure reliable internet connectivity for VOT in regions beyond Tbilisi and major cities.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia has a significant TB burden, particularly multidrug-resistant TB in the South Caucasus region. These MSF recommendations are highly relevant for Georgian national TB programmes, which must balance resource constraints with treatment effectiveness. The emphasis on SAT for drug-susceptible TB, with DOT reserved for specific vulnerable populations, aligns with resource-efficient approaches. For Georgia’s DR-TB programme, the recommendation for home-based DOT or VOT over facility-based approaches could reduce healthcare system burden whilst maintaining treatment quality. National programmes should assess local infrastructure for VOT implementation, considering smartphone penetration and internet connectivity in rural areas, and evaluate capacity for training and remunerating community treatment supporters for home-based DOT.
Questions this guideline answers
Quick answers
When should directly observed therapy be used instead of self-administered treatment?
For drug-susceptible TB, DOT should be reserved for patients with mental health or serious socioeconomic problems (e.g. homelessness), patients incapable of self-administration, and detained persons. For drug-resistant TB, reinforced support is usually needed, with home-based DOT or video-observed therapy preferred over facility-based approaches.
What is video-observed therapy (VOT) and when is it recommended?
VOT uses secure Internet connections via smartphone or computer applications to remotely supervise patients taking their treatment. It is preferred over facility-based DOT for drug-resistant TB patients when DOT is considered useful, as it requires fewer resources and may be more convenient for patients.
How often should patients on self-administered treatment visit health facilities?
Patients on self-administered treatment should be seen at a health facility at regular intervals, such as monthly, to receive drugs, support, and treatment education. SMS telephone reminders may be considered to reinforce adherence.
Is directly observed therapy more effective than self-administered treatment for drug-susceptible TB?
No. DOT has not been proven to improve treatment outcomes for drug-susceptible TB when compared to self-administered treatment in controlled trials. When no adherence-complicating factors exist and appropriate support is provided, treatment should be self-administered.
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- Immune Reconstitution Inflammatory Syndrome in TB-HIV Co-infection — MSF TuberculosisChapter 12: Tuberculosis and HIV co-infection
- Concomitant treatment of tuberculosis and HIV co-infection — MSF TuberculosisChapter 12: Tuberculosis and HIV co-infection
- Standard treatment regimen for isoniazid-resistant tuberculosis — MSF TuberculosisChapter 11: Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis
- Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis — Introduction — MSF TuberculosisChapter 11: Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis
- Surgery in Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
- Treatment interruptions — MSF TuberculosisChapter 10: Treatment of multidrug-resistant and rifampicin-resistant tuberculosis
Other guidelines on this topic
- Immune Reconstitution Inflammatory Syndrome in TB-HIV Co-infection — MSF Tuberculosis
- Concomitant treatment of tuberculosis and HIV co-infection — MSF Tuberculosis
- Standard treatment regimen for isoniazid-resistant tuberculosis — MSF Tuberculosis
- Treatment of rifampicin-susceptible and isoniazid-resistant tuberculosis — Introduction — MSF Tuberculosis
- Surgery in Multidrug-Resistant and Rifampicin-Resistant Tuberculosis — MSF Tuberculosis
- Issuer
- Médecins Sans Frontières
- Guideline
- Tuberculosis
- Chapter
- Chapter 13: Adherence to tuberculosis treatment
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- Treatment delivery models for tuberculosis: self-administered treatment and directly observed therapy
- Audience
- Healthcare workers, TB programme managers, clinicians treating tuberculosis
- Evidence
- Evidence-based recommendations with systematic review citations
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Treatment delivery model. In: Tuberculosis. Chapter 13: Adherence to tuberculosis treatment, section 13.2. Paris: MSF; 2026.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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