Studies say costs double as TB patients with HIV or diabetes opt for private care

According to recent studies, nearly 20 per cent of TB patients in India suffer from diabetes, with nine times higher odds of treatment failure, 1.6 times higher odds of relapse and 1.9 higher odds of death. As per the India TB Report 2020, HIV co-infection rate among TB patients is 3.4 per cent and people living with HIV (PLHIV) are 21 times at higher risk of developing TB, with the bacteria causing nearly 25 per cent of deaths among them.

Costs were categorised as direct medical, direct non-medical, and indirect costs. Direct medical costs included hospitalisation, consultation, procedures, medicines and supplements. Direct non-medical costs include that of travel, food and accommodation. Indirect costs were the sum of wage loss of the patient, wage loss of accompanying members and income loss of the family. The total costs were the sum of all these.

The studies were conducted by Dr Mihir Rupani of the ICMR-National Institute of Occupational Health (NIOH) in Ahmedabad, along with Dr Sheetal Vyas from the community medicine department at AMC-MET Medical College in Ahmedabad. Rupani was earlier with the department of community medicine at the Government Medical College Bhavnagar.

According to Rupani, the two studies are an attempt to highlight the need for special attention and policies that are tailored to reducing the cost borne by TB comorbid patients.

The study covered 234 TB patients with HIV and 304 TB patients with diabetes having a median monthly income of Rs 9,000. A key reason for increased cost for TB-HIV patients was the lack of decentralised care and the inaccessibility of tertiary care hospitals in rural areas.

“A TB-HIV patient at Mahuva will have to come to Bhavnagar city, which is 100 kilometres away, for their antiretroviral therapy (ART). Patients who are stable on ART are given a stock for three months. There are link ART centres that should be scaled up to primary health centres or at least community health centres,” said Rupani.

Reasons for TB-HIV patients to seek private care also include stigma, fear of disclosure and lack of awareness, while TB-diabetes patients preferred private set-ups mostly due to the unavailability of the two-drug combination.

As the study notes, “Patients with diabetes are conventionally put on a two-drug regimen, the combination of which is available as a single tablet in the private sector but not at government health centres. Patients prefer consuming a single tablet for diabetes …” The study recommends that making this drug available at government facilities would help cut costs of treatment of TB-diabetes patients.

The study suggests creating awareness about the relationship between TB and diabetes as well as testing all TB patients and managing them for diabetes and managing each diabetic patient for TB. The study suggested need to improve screening, which sees good compliance among patients with TB and HIV, said Rupani.

On poor compliance of bidirectional screening for TB-diabetes, Dr Rupani said, “Among TB patients, diagnosis of diabetes should include fasting blood sugar levels and what is being done is random blood-sugar level testing. Also, incomplete data entry for patients with TB and diabetes lead to under-representation…”

Rupani said as per their study, TB-diabetes prevalence was only about four per cent. “Clinicians should be made aware of the TB-diabetes bidirectional screening and they need to adhere to a universal method,” Rupani said.

The studies conclude that for TB-HIV patients, strengthening town-level healthcare facilities for diagnostics and treatment may lead patients from the private sector towards government facilities. Bringing care closer to the patients would reduce their direct non-medical as well as indirect costs, the studies say and suggest tailoring the cash transfer scheme for comorbid patients.