Background: TB is a preventable and treatable disease. Yet, successful treatment outcomes at desired levels are elusive in many national TB programs, including India. We aim to identify risk factors for unfavourable outcomes to TB treatment, in order to subsequently design a care model that would improve treatment outcomes among these at-risk patients. Methods: We conducted a cohort analysis among TB patients who had been recently initiated on treatment. The study was part of the internal program evaluation of a USAID-THALI project, implemented in select towns/cities of Karnataka and Telangana, south India. Community Health Workers (CHWs) under the project, used a pre-designed tool to assess TB patients for potential risks of an unfavourable outcome. CHWs followed up this cohort of patients until treatment outcomes were declared. We extracted treatment outcomes from patient’s follow-up data and from the Nikshay portal. The specific cohort of patients included in our study were those whose risk was assessed during July and September, 2018, subsequent to conceptualisation, tool finalisation and CHW training. We used bivariate and multivariate logistic regression to assess each of the individual and combined risks against unfavourable outcomes; death alone, or death, lost to follow up and treatment failure, combined as ‘unfavourable outcome’. Results: A significantly higher likelihood of death and experiencing unfavourable outcome was observed for individuals having more than one risk (AOR: 4.19; 95% CI: 2.47-7.11 for death; AOR 2.21; 95% CI: 1.56-3.12 for unfavourable outcome) or only one risk (AOR: 3.28; 95% CI: 2.11-5.10 for death; AOR 1.71; 95% CI: 1.29-2.26 for unfavourable outcome) as compared to TB patients with no identified risk. Male, a lower education status, an initial weight below the national median weight, co-existing HIV, previous history of treatment, drug-resistant TB, and regular alcohol use had significantly higher odds of death and unfavourable outcome, while age >60 was only associated with higher odds of death. Conclusion: A rapid risk assessment at treatment initiation can identify factors that are associated with unfavourable outcomes. TB programs could intensify care and support to these patients, in order to optimise treatment outcomes among TB patients.

Background:Tuberculosis Health Action Learning Initiative (THALI) funded by USAID is a person-centered initiative, supporting vulnerable urban populations to gain access to TB services. THALI trained and placed 112 Community health workers (CHWs) to detect and support individuals with TB symptoms or disease within urban slums in two cities, Hyderabad and Bengaluru, covering a population of about 3 Million. Method: CHWs visited the slums once in a fortnight. They conducted TB awareness activities. They referred individuals with TB symptoms for sputum testing to nearest public sector labs. They visited those testing TB positive, once a fortnight in the intensive phase, and once a month thereafter. They supported TB patients and families with counselling, contact screening and social scheme linkages. They complemented the shortfall in urban TB government field staff numbers and their capacity to engage with TB patients. Data on CHWs’ patient referral for TB diagnosis and treatment support activities was entered into a data-base and analyzed to examine CHWs’ role in the cascade of TB care. We compared achievements of six monthly referral cohorts from September 2016 to February 2019.Results:Overall, 31617 (approximately 1%) of slum population were identified as TB symptomatic and referred for diagnosis. Among the referred persons, 23976 (76%) underwent testing of which 3841 (16%) were TB positive. Overall, 3812 (99%) were initiated on treatment and 2760(72%) agreed for regular followed up by CHWs. Fifty-seven percent of 2952 referred were tested in the first cohort, against 86% of 8315 in the last cohort. The annualized case detection rate through CHW referrals in Bengaluru increased from 5.5 to 52.0 per 100000 during the period, while in Hyderabad it was 35.4 initially and increased up to 118.9 per 100000 persons. The treatment success rate was 87.1% among 193 in the first cohort versus 91.3% among 677 in the last cohort. Conclusions CHWs in urban slums augment TB detection to care cascade. Their performance and TB treatment outcomes improve over time. It would be important to examine the cost per TB case detected and successfully treated.

Background India’s National Strategy to ‘End TB by 2025’ aims to reduce unfavourable TB treatment outcomes. There is need for innovative approaches to improve TB treatment outcomes. Methods Under a USAID-THALI, Community Health Workers using a pre-designed tool assessed TB patients in three states in south India for risks of non-adherence and risk of unfavourable outcomes. We examined whether those with identified risk had higher levels of two unfavourable treatment outcomes; death and unfavourable outcome including death, lost to follow up and failure, as compared to no risk. Bivariate and multivariate logistic regression was used to assess each of the individual risks and the combined risk, for experiencing death or unfavourable outcome as described earlier, after initiation of TB. Results A significantly higher likelihood of death and experiencing unfavourable outcomes was observed for individuals having one risk (AOR: 3.28; 95% CI: 2.11-5.10 for death; AOR 1.71; 95% CI: 1.29-2.26 for unfavourable outcome) and more than one risk (AOR: 4.19; 95% CI: 2.47-7.11 for death; AOR 2.21; 95% CI: 1.56-3.12) as compared to TB patients with no identified risk. In addition to the risk characterisation, TB patients with initial weight below the national median weight were 2.1 times and 2.0 times more likely to die and experience unfavourable outcomes, as compared to patients with initial weight equal to the median or higher. Conclusion The results of our analysis point to the need for a ‘differentiated care model’, beginning with a risk and needs assessment and continuing with tailored care and support for TB patients, based on their identified risk. While all TB patients require a minimum package of care and support there are a substantial proportion who require more specific interventions and services in order to successfully complete their treatment. We identified a number of important risk factors that could be predictive of an unfavourable outcome and which could be used by TB programs in order to optimize patient treatment outcomes.