BackgroundTuberculosis (TB) patients face substantial delays prior to treatment initiation, and out of pocket (OOP) expenditures often surpass the economic productivity of the household. We evaluated the pre-diagnostic cost and health seeking behaviour of new adult pulmonary TB patients registered at Primary Health Centres (PHCs) in Vellore district, Tamil Nadu, India.MethodsThis descriptive study, part of a randomised controlled trial conducted in three rural Tuberculosis Units from Dec 2012 to Dec 2015, collected data on number of health facilities, dates of visits prior to the initiation of anti-tuberculosis treatment, and direct OOP medical costs associated with TB diagnosis. Logistic regression analysis examined the factors associated with delays in treatment initiation and OOP expenditures.ResultsOf 880 TB patients interviewed, 34.7% presented to public health facilities and 65% patients sought private health facilities as their first point of care. The average monthly individual income was $77.79 (SD 57.14). About 69% incurred some pre-treatment costs at an average of $39.74. Overall, patients experienced a median of 6 days (3–11 IQR) of time to treatment initiation and 21 days (10–30 IQR) of health systems delay. Age ≤ 40 years (aOR: 1.73; CI: 1.22–2.44), diabetes (aOR: 1.63; CI: 1.08–2.44) and first visit to a private health facility (aOR: 17.2; CI: 11.1–26.4) were associated with higher direct OOP medical costs, while age ≤ 40 years (aOR: 0.64; CI: 0.48–0.85) and first visit to private health facility (aOR: 1.79, CI: 1.34–2.39) were associated with health systems delay.ConclusionThe majority of rural TB patients registering at PHCs visited private health facilities first and incurred substantial direct OOP medical costs and delays prior to diagnosis and anti-tuberculosis treatment initiation. This study highlights the need for PHCs to be made as the preferred choice for first point of contact, to combat TB more efficiently.

Background: In April 2018, the Government of India launched ' Nikshay Poshan Yojana ' (NPY), a cash assistance scheme (500 Indian rupees [~8 USD] per month) intended to provide nutritional support and improve treatment outcomes among tuberculosis (TB) patients. Objective: To compare the treatment outcomes of HIV-infected TB patients initiated on first-line anti-TB treatment in five selected districts of Karnataka, India before (April–September 2017) and after (April–September 2018) implementation of NPY. Methods: This was a cohort study using secondary data routinely collected by the national TB and HIV programmes. Results: A total of 630 patients were initiated on ATT before NPY and 591 patients after NPY implementation. Of the latter, 464 (78.5%, 95% CI: 75.0%–81.8%) received at least one installment of cash incentive. Among those received, the median (inter-quartile range) duration between treatment initiation and receipt of first installment was 74 days (41–165) and only 16% received within the first month of treatment. In 117 (25.2%) patients, the first installment was received after declaration of their treatment outcome. Treatment success (cured and treatment completed) in 'before NPY' cohort was 69.2% (95% CI: 65.6%–72.8%), while it was 65.0% (95% CI: 61.2%–68.8%) in 'after NPY' cohort. On adjusted analysis using modified Poisson regression we did not find a statistically significant association between NPY and unsuccessful treatment outcomes (adjusted relative risk-1.1, 95% CI: 0.9–1.3). Conclusion: Contrary to our hypothesis and previous evidence from systematic reviews, we did not find an association between NPY and improved treatment outcomes.

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Sikkim, India, has the highest proportion of tuberculosis (TB) patients on first-line anti-tuberculosis regimens with the outcome 'failure' or 'shifted to regimen for multidrug-resistant TB (MDR-TB)'. Objective: To assess the factors associated with non-response to treatment, i.e., 'failure' or 'shifted to MDR-TB regimen'. Methods: We conducted a retrospective cohort study using Revised National Tuberculosis Control Programme data of all TB patients registered in 2015 for first-line TB treatment. In addition, we interviewed 42 patients who had not responded to treatment to ascertain their current status. Results: Of 1508 patients enrolled for treatment, about 9% were classified as non-response to treatment. Patient factors associated with non-response were urban setting (adjusted odds ratio [aOR] 2.39, 95%CI 1.22-4.67), ethnicity (being an Indian tribal, aOR 1.73, 95%CI 1.17-2.57, Indian [other] aOR 1.83, 95%CI 1.29-2.60 compared to patients of Nepali origin) and those on retreatment (aOR 2.40, 95%CI 1.99-2.91). Of the patients interviewed, 28 (67%) had received treatment for drug-resistant TB. Conclusion: In Sikkim, one in 11 patients had not responded to first-line anti-tuberculosis treatment. Host-pathogen genetics and socio-behavioural studies may be required to understand the reasons for the differences in non-response, particularly among ethnic groups. * Data for 26 patients were not available and were therefore not included in the table. RNTCP = Revised National Tuberculosis Control Programme; TB = tuberculosis; MDR-TB = multidrug-resistant TB.

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