An app developed in the Eastern European country helps patients successfully complete their treatment and is being adopted elsewhere in Eurasia.
When a doctor found spots on Tatiana Gangan’s X-ray during a routine checkup, he assumed they were shadows of her long, brown hair. Several tests later, however, it became clear that the 19-year-old Moldovan from the village of Hirbovat had tuberculosis.
“I was shocked and scared,” said Gangan. “My biggest fear was that I wouldn’t get better and could infect my family.”
The young woman’s life changed in an instant. Before the diagnosis, she was starting her third year in medical school and planning to become a doctor. Now she had to take a year off and face a six-month treatment regimen. “I think I cried for a week,” she recalled.
Gangan was one of more than 2,000 TB cases diagnosed in Moldova in 2021. Fortunately, her disease was caught early, before the onset of symptoms. Passed on by a simple cough or sneeze, TB is an infectious disease that usually attacks the lungs, resulting in coughing, chest pain, lack of appetite, weight loss, fever, and night sweats. Left untreated, active TB is fatal. In fact, it is the world’s deadliest infectious disease after COVID-19, claiming more than 1.5 million lives per year.
The small Eastern European country of Moldova has a longstanding problem with TB. On average, more than 150 people die from it every year. In 2019, at 71 cases per 100,000 residents, Moldova had one of the highest incidences in Europe. This public health challenge dates back to the economic crisis in the 1990s following the collapse of the Soviet Union, said Dr. Valentina Vilc, the country’s national TB program coordinator.
“Back then, there were few anti-TB drugs in the entire post-Soviet space, including here,” Vilc said. “You can’t treat TB with a single drug; you need four or five drugs, and there were moments when doctors had only one or two. They prescribed what they had, but the bacteria were adjusting.” As a result, Moldova has become one of 30 countries in the world with a high burden of multidrug-resistant tuberculosis (MDR-TB) – a type of TB that is more difficult and costly to treat.
TB treatment is notoriously complex and tedious. It requires daily administration of multiple antibiotics for an extended period: from six months, in case of regular TB, to up to two years for resistant strains of the disease. In addition, the medication can have unpleasant side effects, such as nausea, headache, itchy skin, and joint pain. If the treatment is erratic or incomplete, the condition becomes even tougher to treat.
To ensure that patients receive the medication, many countries, including Moldova, follow a treatment strategy called directly observed treatment, or DOT. Under DOT, patients must come to a clinic daily and take their pills under medical supervision.
Adhering to DOT can be quite inconvenient. “Some patients are employed and need to be at work by 8 a.m., the same time the TB clinics open,” explained Svetlana Doltu, pulmonologist and director of Act for Involvement (AFI), an NGO specialized in increasing access to medical services for vulnerable groups. “Others, despite state reimbursements for travel, just can’t afford the daily trips.” This is a major reason only about 84 percent of patients with the regular form of the disease complete the treatment. Success in treating drug-resistant forms is even lower, at 59 percent, according to figures provided by Vilc.
Motivating Patients is Key
For years, health experts have been trying to understand the reasons for these disappointing outcomes and find ways to improve them. “In the 2000s, Moldova already had the necessary antibiotics, qualified doctors, motivational packages for patients to increase adherence – for example, food vouchers – but something was not working,” said Cristina Celan, program coordinator at PAS Center, a local NGO working on TB control, capacity building, and advocacy for public health issues. “We still had patients who couldn’t stick to the regimen and whose treatment failed.”
Successful applications developed in the United States and used worldwide couldn’t be used because they were subscription-based, she said. “We would have to pay monthly for each patient. It wasn’t sustainable, and we knew that Moldova couldn’t afford it, so we decided to develop our country’s own application.”
PAS and AFI decided to try a different approach. In 2014, following the World Health Organization’s recommendation to use more digital solutions, the two NGOs teamed up with the Ministry of Health and UNDP Moldova. Together, they developed a basic application that allowed TB patients to record videos of themselves taking the pills and send them via tablets to doctors. This treatment strategy was called video-supported treatment, or VST.
Two years later, the organizations ran a trial to test the efficacy of this method with a sample group of 178 patients in the Moldovan capital, Chisinau. Half of the group took traditional daily trips to the clinic, while the other half used the VST application. The results were impressive: VST almost doubled the adherence compared to DOT, from 44 percent to 84 percent. In addition, remote patients spent considerably less time (23 versus 81 hours) and money ($11 versus $42) traveling between home and clinic over the four months of the trial.
Once the pilot proved VST’s viability in Moldova, the NGOs and the national TB program looked for ways to improve the application and get health professionals on board. However, to introduce VST on a large scale, the experts knew the country needed more than a digital tool. It required training for doctors, technical support for the platform, mobile phones for the patients, and legislative changes. To cover costs, the organizations applied for and won a substantial grant of over $380,000 from the TB REACH Initiative of the Stop TB Partnership, funded by the government of Canada and the Bill & Melinda Gates Foundation. About $40,000 of the funds were allocated to an improved VST application.
In 2018, PAS, AFI, and the national TB program started working on an advanced application called I Like VST. The platform consists of a free mobile app used by patients and a website operated by doctors. To use the application, the patient receives an account on the website. A doctor enters information about the patient’s treatment regimen, and the patient receives a two-week supply of pills. Participants take their medication at home, record the process, and upload daily videos for review by a nurse or doctor.
Designed in bright orange colors, the application was meant to save time for both doctors and patients. It would end up having a greater role during the global pandemic.
The Game-Changing App
In March 2020, when COVID-19 hit the world and the first case was confirmed in Moldova, I Like VOT (as the app was originally called) was still waiting for registration at the National Center for Personal Data Protection. In the meantime, TB patients found themselves in an increasingly vulnerable situation. The lockdown made it difficult for them to take daily trips to the clinic, and many doctors were reassigned as front-line workers to combat the coronavirus.
As a result, like other countries affected by tuberculosis, Moldova saw a significant drop in TB patients. “Usually, we have an 8-10 percent decline in new TB cases and relapses,” said TB program coordinator Vilc. “This is normal; these are the yearly goals. But then in 2020, the number decreased by 39 percent. We understand that it happened not because there weren’t any cases of TB. We simply didn’t manage to detect them.”
Multi-drug resistant tuberculosis (MDR-TB) – the most serious form of the disease – affects 3-4% of people diagnosed with TB for the first time and around 20% of those previously treated for TB. Ten of the 30 countries with the highest burden of MDR-TB, listed below, are in Eastern Europe and Eurasia.
Source: WHO Global Tuberculosis Report 2021
With the situation rapidly deteriorating, action had to be taken. In a matter of weeks, the Ministry of Health issued an ordinance, and a rapid rollout of the VST tool started in Chisinau, the northern city of Balti, and 14 other locations. The NGOs and the national TB program provided training and ongoing technical support to patients and staff, while equipping over 35 medical facilities with internet access and laptops. Meanwhile, health officials included video-supported treatment in the national clinical protocols, giving it official standing as an alternative treatment method. In the following year, I Like VST gradually expanded across the country, and since April 2021 has been available nationwide.
Both patients and doctors call the video-supported treatment a game-changer. “VST improved treatment adherence by circa 10 percentage points,” Vilc said. “It now reaches 93 percent among drug-sensitive TB patients, and 69 percent among drug-resistant ones.” Since the beginning of the program, over 550 Moldovans have benefited from it: 390 TB patients completed their regimens using I Like VST, and another 160 are currently enrolled in remote treatment.
Tatiana Gangan, the 19-year-old from Hirbovat, is one of the beneficiaries. “Taking the pills is so easy! I don’t have to go to the hospital every day, which saves me both time and money,” said Gangan, who was offered VST after being diagnosed. Her doctor explained how the application worked and gave her a free mobile phone, purchased from grant funds. Now, I Like VST is a part of her daily routine: “I eat a hearty lunch, and then I record myself taking my six pills. I send the video, and I’m done!”
Gangan’s doctor, Carolina Stratan, leads the tuberculosis service in Anenii Noi, a city in east-central Moldova. She has been treating TB patients for almost 15 years. Since VST implementation, more than 10 patients in her department have accepted remote TB treatment.
“My patients say this method is very convenient for them,” Stratan said. “A man I treated took his pills wherever he went, even in a taxi.” VST saves her time as well. When she has a packed schedule, Stratan can watch the patients’ videos at the end of the working day. “If I notice something amiss, I can call the patient right away,” she said. And she has more time for patients who do come to the clinic.
VST is now available to any TB doctor and eligible patient in Moldova. To qualify for VST, the patient must be over 18, prove reliability by taking the pills at the clinic for two weeks, not require hospitalization, and own a mobile phone. At least for now, the last point is flexible. “Thanks to foreign funds, we can provide phones to patients who don’t have them,” said Celan. “Patients keep them as a motivation to stick to the treatment.” More than 700 phones and about 50 laptops have been distributed to patients and doctors.
Labor Migrants at High Risk
VST has enormous potential to improve treatment adherence among the hundreds of thousands of Moldovans who regularly go abroad for work. This segment of the population accounts for an estimated 15 percent of TB patients in Moldova. Often housed in crowded apartments and working in harsh conditions, these men and women are especially vulnerable to infection. They often don’t know how to access healthcare in foreign countries or are reluctant to approach authorities for fear of losing their jobs or being deported. “When they start TB treatment, some notice that they feel better after several months and think they have recovered, so they leave everything and go back to work abroad,” Celan said. Unfortunately, TB usually comes back, more resistant and dangerous.
Stefan Ciobanu, a 31-year-old construction worker from Straseni, has contracted the disease twice. The first time, in 2018, he spent six months in a hospital and another three at home, receiving daily medication at a doctor’s office. “Every day, I walked 3 kilometers, regardless of rain or snow,” he recalled.
After getting well, Ciobanu worked on a construction site in Russia and later in a meat factory in Poland. “It was hard labor; it was freezing,” he said. “When I returned home, I was feeling bad.” The disease returned, accompanied by fever, weakness, and dizziness. After two months in the hospital, Ciobanu switched to video-supported treatment. Now he receives medicine a month in advance. “It is much easier this way, and I feel much better. I want to finish the treatment successfully, and I know that I will take better care of myself in the future,” he said.
While it’s not known how many short-term or permanent migrants have benefited from remote treatment, VST gives the patients the possibility to receive treatment from any corner of the globe. “According to the regulations, the patients can receive pills for up to a month. But if they are trustworthy and plan to go abroad, the doctor can decide to offer more medication in advance,” Celan explained. “The priority is to complete the treatment.”
‘It Pays Off’
Other countries in Europe and Central Asia also experimented with video-supported treatment in the mid-2010s. A small pilot study in Minsk in 2016 convinced Belarus to expand its VST program nationwide. Georgia’s VST application, called Adhere2Tx-TB, has been available since 2017. Several hundred patients in each of those countries have used these applications. Kazakhstan replicated Georgia’s tool and rolled it out in June 2020.
The I Like VST platform developed for Moldova also has gained popularity elsewhere. Tajikistan, Uzbekistan, and Turkmenistan have asked the Moldovan NGOs and national TB program to tailor the application to their requirements. The organizations also are currently adapting the app for opioid substitution therapy programs in Moldova, which have similar challenges in treatment adherence. The tool “can be adjusted not only for other countries but also for other diseases,” Celan said.
Experts agree that implementing VST is a lasting solution. “It requires money and political will, but it pays off,” said AFI director Doltu, noting that human resources are the most expensive element.
A feasibility study conducted by PAS revealed that the method saves patients time and money. For example, it takes only two minutes a day for VST patients to take their medication while the others spend over 45 minutes reaching the clinic and taking the pills supervised by medical staff. Travel expenses have fallen as well, by nearly 66 percent. Drug-sensitive TB patients spend on average $94 on transport per one course of treatment if enrolled in DOT. By switching to VST, they take only $30 out of their pockets.
The study doesn’t address the psychological costs, which also are important. There is the stigma of TB, a phenomenon more frequent in rural areas, Celan said. When people notice someone going to the clinic every day, they know it might be TB and treat them differently. VST allows the patients to decide with whom to share their health status.
Tatiana Gangan doesn’t hide that she has TB. She is five months into her treatment regimen and says she feels great. Her doctor hopes she will be cured in a few weeks. Until then, Gangan spends her time reading novels and learning foreign languages.
Gangan still doesn’t know how she contracted the disease. It just shows, she said, that anyone can get it. The experience did help her make an important decision. “I decided to specialize in pulmonology in medical school.”
Victoria Colesnic is a freelance journalist based in Chisinau.