Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis

Costs incurred by patients with tuberculosis co-infected with human immunodeficiency virus in Bhavnagar, western India: a sequential explanatory mixed-methods research

BACKGROUND

India reports the highest number of tuberculosis (TB) and second-highest number of the human immunodeficiency virus (HIV) globally. We hypothesize that HIV might increase the existing financial burden of care among patients with TB. We conducted this study to estimate the costs incurred by patients with TB co-infected with HIV and to explore the perspectives of patients as well as program functionaries for reducing the costs.

METHODS

We conducted a descriptive cross-sectional study among 234 co-infected TB-HIV patients notified in the Bhavnagar region of western India from 2017 to 2020 to estimate the costs incurred, followed by in-depth interviews among program functionaries and patients to explore the solutions for reducing the costs. Costs were estimated in Indian rupees (INR) and expressed as median (interquartile range IQR). The World Health Organization defines catastrophic costs as when the total costs incurred by patients exceed 20% of annual household income. The in-depth interviews were audio-recorded, transcribed, and analyzed as codes grouped into categories.

RESULTS

Among the 234 TB-HIV co-infected patients, 78% were male, 18% were sole earners in the family, and their median (IQR) monthly family income was INR 9000 (7500-11,000) [~US$ 132 (110-162)]. The total median (IQR) costs incurred for TB were INR 4613 (2541-7429) [~US$ 69 (37-109)], which increased to INR 7355 (4337-11,657) [~US$ 108 (64-171)] on adding the costs due to HIV. The catastrophic costs at a 20% cut-off of annual household income for TB were 4% (95% CI 2-8%), which increased to 12% (95% CI 8-16%) on adding the costs due to HIV. Strengthening health systems, cash benefits, reducing costs through timely referral, awareness generation, and improvements in caregiving were some of the solutions provided by program functionaries and the patients.

CONCLUSION

We conclude that catastrophic costs due to TB-HIV co-infection were higher than that due to TB alone in our study setting. Bringing care closer to the patients would reduce their costs. Strengthening town-level healthcare facilities for diagnostics as well as treatment might shift the healthcare-seeking of patients from the private sector towards the government and thereby reduce the costs incurred.

Abdominal tuberculosis misdiagnosed as acute surgical abdomen and carcinomatosis

Tuberculosis is a major public health problem worldwide. Tuberculosis can be confused with other diseases and its diagnosis is frequently delayed, especially in areas of low prevalence. Abdominal tuberculosis includes involvement of the gastrointestinal tract, peritoneum, lymph nodes, and/or solid organs; and accounts for 5% of all cases of tuberculosis. We report two cases of young patients who presented preoperatively as acute abdomen due to acute appendicitis. During surgery, these cases were misdiagnosed as "carcinomatosis", and in the postoperative period these cases were complicated with septic shock. In both cases, histopathology showed caseating granulomas which suggested tuberculous peritonitis and enteritis. Subsequently, RT-PCR in peritoneal fluid confirmed  Mycobacterium tuberculosis. In one case the clinical response to treatment was excellent, and the other case was fatal. The aim of this report is to bring attention to the spectrum of tuberculosis, and to serve as a reminder of tuberculosis as the great imitator that can masquerade as cancer. Most tuberculous patients erroneously diagnosed as cancer have extensive "neoplastic" lesions that would suggest an advanced-stage malignancy. Assuming a case as an advanced cancer would reduce the chance of performing more exhaustive studies to get a definitive diagnosis and clinicians would be tempted to offer only palliative treatments.