Does provision of cash incentive to HIV-infected tuberculosis patients improve the treatment success in programme settings? A cohort study from South India

Abstract

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.

Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? – A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India

“…The present study found 91% of the patients with TB receiving DBT during the study period of January-September 2019 suggesting an improvement in the cash transfer process in due course of time. Also, the previous studies reported a median delay of 74-156 days in the receipt of the first installment, 13 , 14 , 23 while this delay was found to be reduced to 56 days in the present study. However, the present study also found 49% of the patients receiving the last installment after treatment completion, which was reported to be 25% in a previous study.…”

“…However, the present study also found 49% of the patients receiving the last installment after treatment completion, which was reported to be 25% in a previous study. 23 The authors believe that the low figures for the delay reported in the previous study 23 might be due to more intense follow-up and monitoring among TB-HIV co-infected patients compared to patients with TB alone. The primary purpose of DBT is to buy nutritious food for a patient with TB, which helps them to have better compliance with the adverse drug reactions of anti-TB drugs and thereby improve their treatment outcomes.…”

“…Studies assessing the DBT in the initial months of the launch of the program in 2018, reported the coverage to be as low as 29%, 13 which increased to 53%-79% 14 , 23 , 32 in the next few months of rollout. The present study found 91% of the patients with TB receiving DBT during the study period of January-September 2019 suggesting an improvement in the cash transfer process in due course of time.…”

“…15,[17][18][19][20][21][22] Previous studies determining this association in India found conflicting results -one study reported no association, whereas another reported a significant association with 4 times more chances of unfavorable treatment outcomes among non-recipients of DBT. 14,23 The study populations and comparison groups for both of these studies were different -the study which reported a positive association was conducted among patients with TB and the outcomes were compared within the same cohort (after adjusting for their HIV status); whereas, the study reporting no association was conducted among patients with TB co-infected with HIV and the outcomes were compared before and after implementation of the DBT scheme. Also, both these studies were conducted in the initial months of the roll-out of the DBT scheme.…”

“… 13 , 14 Studies do report an improvement in treatment outcomes due to cash transfer schemes and lack of money among patients with TB as a reason for treatment interruption, 15 - 22 however evidence from India provides conflicting results regarding the same. 14 , 23 DBT, being a comparatively new initiative in India, it was important to understand the perspectives of NTEP program functionaries as well as patients regarding the program. With this background, we conducted this study to determine whether non-receipt of DBT under the nutritional support program was associated with unfavorable treatment outcomes among patients with TB.…”