Comparing adherence strategies and facility DOT in TB care: a systematic review with meta-analysis

Adherence to TB treatment is crucial for successful outcomes. While facility-based directly observed therapy (FB-DOT) is a common strategy, recognition of its limitations has spurred the development of flexible approaches. We have compared the effectiveness of alternative adherence-enhancing strategies with FB-DOT.We searched three databases and four registries from June 2013 to May 2025. We included comparative studies evaluating interventions designed to improve adherence to TB treatment in people aged 15 years or older, excluding adherence to multiple therapies. Meta-analyses were conducted for treatment success, treatment completion, cure rate, and loss to follow-up.Twenty-five studies involving 19,103 participants were included. Self-administered treatment and reminder-based interventions achieved treatment success comparable to FB-DOT. Community-based DOT showed similar cure and completion rates but was effective at reducing loss to follow-up (71% reduction). Video-supported treatment and digital adherence technologies demonstrated neutral effects across treatment outcomes. Multicomponent strategies showed heterogeneous results.Alternative adherence strategies can offer improvements over FB-DOT in specific contexts. However, their variable effectiveness limits universal implementation. Adherence support, community engagement, and social determinants should guide programmatic design and implementation..