Lessons Learned From a Peer-Supported Differentiated Care and Nutritional Supplementation for People With TB in a Southern Indian State

INTRODUCTION

In Tamil Nadu, a southern Indian state with a population of about 72 million, 322 persons per 100,000 population (2019–2021) are estimated to have TB, making it one of the high-burden states in India.¹ Due to the COVID-19 pandemic, the reported TB death rate in Tamil Nadu increased to 6.4%, and more than 70% of deaths were within 2 months (early deaths).²

India’s National Strategic Plan for TB Elimination (2017–2025) proposes a community-based and patient-centric approach to achieve the 2030 Sustainable Development Goals TB targets by 2025.³ Two of the 9 patient support system components in the plan include (1) initial and frequent follow-up counseling for the person with TB and their family and (2) locally managed supplementary nutritional support, in addition to financial aid in the form of direct benefit transfer of INR500 per month through the Ni-kshay Poshan Yojana.⁴ The first step in achieving this is to involve and empower TB champions in routine TB program settings.³ The national strategic plan recommends that there must be at least 2 TB champions in every village in India. With an average population of 2,000 per village, 1,300,000 TB champions will be required.⁵

A TB champion is a person who has been affected by TB and has completed the treatment and subsequently been trained using the National TB Elimination Program’s (NTEP) standard “TB survivor to TB champion” curriculum.⁵ Trained TB champions draw on their personal lived experiences of TB to act as a link between people with TB and the TB program. In addition to providing considerable knowledge on TB for treatment literacy, they also provide emotional support, linkages to care, treatment adherence support, stigma reduction support, and practical assistance, as well as link those affected with resources, benefits, schemes, and opportunities.⁵ They also take ownership and participate in community engagement activities like active case-finding, observing World TB day, and sensitizing Panchayat raj (local government) institutions and village health nutrition and sanitation committees. There could be an overlap of roles with existing community health workers. However, the TB champions’ focused approach toward TB and lived experience can effectively motivate TB patients by narrating their personal journey.

PEER SUPPORT AND NUTRITIONAL SUPPLEMENTATION PILOT EXERCISE

Between January and June 2023, as a pilot exercise, TN-KET collaborated with the ALLIES project to ensure triage-positive people with TB at diagnosis received counseling by TB champions. The baseline counseling (residence or hospital, in person or over the phone) to triage-positive at diagnosis was provided in addition to the routine counseling and information provided by district NTEP staff to all people with TB. As part of baseline counseling, TB champions counseled triage-positive people with TB to begin or continue treatment, advised family members of the care and support required, and provided guidance on the importance of nutrition during TB treatment. TB champions drew on their own personal experiences of TB, sharing how they were impacted by the disease and subsequently recovered. They served as friends and counselors, clarifying any misconceptions that people with TB and their families had. They also facilitated local ambulance services for the severely ill and provided continued support through phone follow-ups.

They supported those not completing the TN-KET care cascade by providing additional counseling to ensure they completed the admission process and were successfully discharged for ambulatory directly observed treatment. Some common reasons for people with TB refusing to get admitted included the unavailability of a family member to accompany them (mandatory for admissions), fear they would lose income during the admission period, and reluctance to get admitted to public health facilities. TB champions provided counseling that addressed these specific concerns.

There exists a bidirectional solid causal link between TB and undernutrition.¹¹ The World Health Organization recommends that all persons with active TB receive appropriate counseling based on their nutritional status at diagnosis and throughout treatment.¹² Hence, we intended to prioritize nutritional supplementation (covering around one-third of daily calorie and protein requirement) for at least 3 months among people with TB with severe undernutrition (BMI 16 kg/m² or less) at diagnosis. The district strategist and TB champion visited the patient’s home to assess their health and family condition. If nutritional supplementation was needed, potential donors were identified with the help of TB champions. Donors included local panchayat leaders, local philanthropists, industries, and nongovernmental organizations. They collected the nutritional supplementation (dry rations) from the donors and distributed it at the patient’s home in the first month, followed by health facility-based distribution and nutritional counseling by the NTEP team.

In the 6 districts, 24 TB champions (district-wise range: 3–5, 22 female and 2 male) received a fixed monthly honorarium from the project. Additionally, they were given an incentive of INR300 for every successful admission of a severely ill TB patient at the TN-KET nodal facilities and INR200 for every home-based counseling, mobilization of resources for nutrition support, and distribution.