INT J TUBERC LUNG DIS 15(10):1373–1379 © 2011 The Union http://dx.doi.org/10.5588/ijtld.10.0531 ‘Sputnik’: a programmatic approach to improve tuberculosis treatment adherence and outcome among defaulters I. Y. Gelmanova,* D. V. Taran, † S. P. Mishustin, ‡ A. A. Golubkov,* § A. V. Solovyova, † S. Keshavjee* §¶ * Partners In Health, Boston, Massachusetts, USA; † Partners In Health Russia, Moscow, ‡ Tomsk Oblast Tuberculosis Services, Tomsk, Russian Federation; § Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, ¶ Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA Correspondence to: Salmaan Keshavjee, Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02139, USA. Tel: (+1) 617 432 3215. e-mail: Salmaan_Keshavjee@hms.harvard.edu Article submitted 17 August 2010. Final version accepted 13 April 2011. SETTING: A novel patient-centered tuberculosis (TB) treatment delivery program, ‘Sputnik’, was introduced for patients at high risk of treatment default in Tomsk City, Russian Federation. OBJECTIVE: To assess the effects of the Sputnik inter- vention on patient default rates. DESIGN: We analyzed the characteristics of patients re- ferred to the program, treatment adherence of Sputnik program enrollees before and during the intervention, and fnal outcomes for all patients referred to the Sput- nik program. RESULTS: For patients continuing their existing regi- mens after referral to the program (n = 46), mean ad- herence to treatment increased by 56% (from 52% of prescribed doses prior to enrolment to 81%). For pa- tients initiating new regimens after referral (n = 5), mean adherence was 83%. Mean adherence for patients with multidrug-resistant TB (MDR-TB; n = 38) was 79% and for all others (n = 13) it was 89%. The cure rate was 71.1% for patients with MDR-TB, 60% for all others and 68% in the program overall. CONCLUSION: The Sputnik intervention was successful in reducing rates of treatment default among patients at high risk for non-adherence. KEY WORDS: treatment adherence; patient-centered; MDR-TB; Tomsk; Russia TUBERCULOSIS (TB) remains one of the leading causes of adult mortality worldwide, with an esti- mated 9.2 million new cases and 1.7 million deaths annually. 1 Non-adherence to treatment is linked to prolonged infectiousness, mortality and amplifcation of resistance to anti-tuberculosis medications. 2–4 For patients with multidrug-resistant tuberculosis (MDR- TB, defned as resistance to both isoniazid and ri- fampin) and requiring up to 24 months of treatment with second-line drugs, 5,6 default rates range between 10% and 48%. 7–15 In Russia, the collapse of the Soviet Union resulted in increased poverty and a breakdown in health and social services. 16,17 Infectious and non-communicable disease mortality increased markedly. 18–21 Prison- and civilian-based epidemics of TB—driven by a growing pool of vulnerable individuals, often poor and unem- ployed, faced with comorbidities (such as alcoholism, drug abuse, human immunodefciency virus infection and mental illness) and residing in congregate settings —reversed more than 30 years of successful TB con- trol. 22–24 Between 1991 and 2001, TB incidence in Rus- sia increased from 34 to 88 per 100 000 population, while mortality climbed from 8.1 to 19.9/100 000. 25,26 SUMMARY In the face of a growing epidemic of drug-resistant TB, 17,27,28 the western Siberian region of Tomsk Oblast (population in 2006: 1 036 000) expanded its DOTS program in 2000 to include the treatment of MDR- TB.* This integrated approach strengthened program capacity, resulting in a decreased default rate among new smear-positive TB patients to 2.9% in 2004 in the civilian sector. 29 However, as the civilian program expanded, the proportion of MDR-TB patients de- faulting from treatment increased, from 12% in 2001 to almost 30% in 2004. We found that alcohol and drug abuse, history of incarceration, homelessness and urban residence were risk factors for non-adherence to TB treatment, consistent with reports from other projects in Russia. 30–32 In the present study, we describe the impact of an intervention designed for this population based on models used to improve treatment adherence in other settings. 33–36 *A joint program run by the Tomsk Oblast Tuberculosis Services, the Federal Penitentiary Service of the Ministry of Justice and the non-proft Partners In Health that included treatment of MDR-TB in prison and civilian sectors.