The effects of war on digital adherence technology engagement for TB treatment in Ukraine

BACKGROUND: The Russian invasion of Ukraine in February 2022 has disrupted TB care. We examine the effects of the war on people with drug-susceptible TB (PWTB) and health care worker (HCW) engagement with a digital adherence technology (DAT). METHODS: We conducted a cluster-randomised trial of a DAT intervention in Ukraine. In the intervention arm, PWTB received a pillbox with a daily treatment reminder. Pillbox openings were captured real-time onto a platform, accessed by HCWs who could add manual doses where relevant. We compared DAT engagement in pre-, early-, and later-war periods. RESULTS: From June 2021 to 2022, 816 PWTB (32% women, median age 44 years) were enrolled. DAT engagement varied across regions and time period, with a decline in engagement post-February 2022. PWTB DAT engagement was 78%-84% of treatment-days. There was a three- to four-fold increase in unknown dose or delays in manual reporting of adherence (>7 days) post-February 2022 versus pre-war in Mykolaivska and Donetska oblasts and a two-fold increase in Odeska, Lvivska, and Zakarpatska oblasts. CONCLUSION: The war significantly disrupted DAT engagement, particularly in regions heavily affected by the conflict. Reduced engagement was likely due to migration and communication challenges. There is a critical need for resilient TB care in conflict settings.