Mentors Comments:
1. Present some statistics on the state of TB in India
2. What are the challenges faced by TB regimen
3. Provide suitable solutions

Answer:
India has the highest TB burden in the world. In 2018, 2.15 million TB case were reported. The SDG 3 aims to end the epidemics of tuberculosis by 2030. While, the GoI has set the goal to end the epidemic by 2025.

Inspite of efforts by central and state governments like DOTS strategy, Nikshay, National Strategic Plan (NSP) for TB Elimination etc, reports after reports present the bleak picture. For instance, there has been a 1.7% reduction in tuberculosis cases and 3% reduction in deaths from 2016. Further, India has 24% of the world’s drug-resistant TB burden- the highest in the world.

Issues with TB Control in India and Reasons for its continued prevalence:
1. Social conditions and co-morbidities: The social conditions and co-morbidities that fuel the TB have been poorly addressed in India. Poverty remains a stark reality in India with associated problems of hunger, undernourishment and poor and unhygienic living conditions. According to Global TB Report, 2018, a majority of TB patients (6lakhs) in India are attributable to undernourishment
2. Underreporting and un-diagnosis: According to Global TB Report 2018, India is one of the major contributors to under-reporting and under-diagnosis of TB cases in the world, accounting for 26% of the 3.6 million global gap in the reporting of tuberculosis cases 
3. Diagnosis: Biomarkers and other diagnostics that identify individuals at highest risk of progression to disease are inadequate. 
4. Treatment: Inequitable access to quality diagnosis and treatment remains a major issue in combating tuberculosis. Further, the private sector which contributes a major part of TB care is fragmented, made up of diverse types of healthcare providers, andlargely unregulated. Also, standard TB treatment is not followed uniformly across the private sector, resulting in the rise of drug resistance. 
5. Follow-up treatment: Though the reporting of TB cases has increased lately, the reporting of treatment outcomes has not been robust. The absence of consistent follow-up of treatment regimens and outcomes may result in relapse of cases and MDR-TB and XDR-TB. India has already been facing the problem of increasing MDR-TB cases
6. Funds: The RNCTP remains inadequately funded. There has been a growing gap between the allocation of funds and the minimum investment required to reach the goals of the national strategic plan to address tuberculosis.
7. Issues with RNCTP: Weak implementation of RNCTP at state level is another major concern. The Joint Monitoring Mission report of 2015 pointed out that
 The RNCTP failed to achieve both the main goals of NSP 2012-2017- Providing universal access to early diagnosis and treatment and improving case detection.
 Major issues with RNCTP include: human resource crunch, payment delays, procurement delays and drug stock-outs
8. R&D: R&D for new methods and technologies to detect the different modes of TB, new vaccines, and new drugs and shorter drug regimens have been slow, as compared to other such diseases like HIV/AIDS.
9. Social Stigma: According to a study which assessed social stigma associated with TB, India had the highest social stigma index. Patients often hesitate to seek treatment or deny their condition altogether for fear of social discrimination and stigmatization.

Way forward
1. The need is to give impetus to WHO’s four sub-themes under the “Unite to End TB” to tackle TB which are-
 By stamping out poverty.
 By better test, treat, and cure.
 By stopping social stigma and discrimination.
 By driving research and innovation.
2. Integration of TB services with the primary health system will lead to early diagnosis and help cut the transmission cycle.
3.  Need to scale up access to TB services for all those seeking them, optimise engagement of private sector providers and guarantee universal access to drug susceptibility testing and second line TB drugs.
4. Adopting a rights-based, community-led, gender-sensitive and person-centred approach is central to reducing stigma and discrimination.
5. Need to sensitise healthcare providers to issues faced by those with TB and ensure they act in a non-discriminatory manner.

Ending TB by 2025 is ambitious which will require robust system and coordinated efforts of all stakeholders.