Measuring and Understanding Delays in Multidrug-Resistant Tuberculosis Care in India

Background: India carries 27% of the global tuberculosis (TB) burden with a regional increase in multidrug-resistance (MDR) over the last decade. We aimed to characterize MDR-TB patient risk factors, delays in care and pathways to diagnosis and treatment in Pune, India. Methods: Between Jan-2018 and Sep-2019, we conducted structured and unstructured interviews with patients (>=15 years age) registered with the National TB Elimination Program (NTEP) for MDR (n=128) and non-MDR TB (n=269) treatment. We collected treatment record and GeneXpert-TB/RIF resistance probe binding data. Findings: MDR-TB was associated with continuous residence in a crowded locality [adjusted-OR (aOR) =2.02, 95%CI 1.12-3.63] and young age (aOR= 0.71, 95%CI 0.57-0.89 per 10-year increase). GeneXpert binding patterns demonstrated low diversity with 72.5% (n=233) of MDR isolates losing Probe-E binding. Median time from symptom onset to diagnosis was longer for MDR than non-MDR-TB (90 days, IQR 60-180 vs. 60 days IQR 30-90, Wilcoxon P<0.01). Pathways to care were complex with a median number of encounters of 4 (IQR 3-5) and 3 (IQR 2-4) for MDR and non-MDR respectively. The majority, 68% and 72% respectively, first sought care in the private sector and this was associated with a larger number of subsequent healthcare encounters and high out of pocket expenses. Only 9% received their MDR diagnosis in the private sector. Interpretation: The association of MDR-TB with younger age and crowding in Pune, along with low genotypic diversity of MDR isolates raises concerns of ongoing MDR transmission. Pathways analysis revealed points of intervention including the need to expedite patient referral to and improve retention in the NTEP. Funding Statement: Harvard-Dubai Centre for Global Health Delivery (MF, SA). Boston Children’s Hospital Global Health Program (AD). Declaration of Interests: None to declare. Ethics Approval Statement: We secured approvals from the Indian Ministry of Health and Family Welfare, Central TB Division, the State and local NTEP, Harvard Medical School’s Institutional Review Board and the institutional ethics committee of Dr. D.Y. Patil Vidyapeeth.