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The effects of war on digital adherence technology engagement for TB treatment in Ukraine SUMMARYBACKGROUNDThe 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).METHODSWe 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.RESULTSFrom 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.CONCLUSIONThe 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. https://journals.theunion.org/content/ijtldo/3/1/24