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By Shobha Shukla, Bobby Ramakant
The risk of getting TB disease is among the highest in unhoused and other marginalised persons. Still, the likelihood of them seeking public TB services is low, and finishing lifesaving TB therapy is even lower. The delay is long – very long – for them to receive the correct diagnosis (if at all), and so are the catastrophic costs they may incur until they are correctly diagnosed. Not being able to finish lifesaving TB treatment is not helping either- the person suffers and so does the TB response – because we collectively fail to disrupt TB transmission.
At the world’s largest conference on TB and lung diseases, a couple of scientific presentations provide a strong beam of light to address TB with success (and in a person-centred manner) among those who are at one of the highest risks (of getting the disease, as well as of being left behind).
Jahangeer Alam, a TB survivor and champion himself, made two important scientific presentations at the World Conference on Lung Health in Copenhagen, Denmark. He works with Humana People to People India (HPPI).
Journeying from shadow to light
It is humbling to listen to the real experiences of unhoused persons of their journeys from dark shadows in the lung towards treatment and care, and from services that were inaccessible earlier towards receiving person-centred care and getting cured of TB – thanks to HPPI and support and partnership of the Indian government’s National TB Elimination Programme (NTEP) and its partners on the ground.
Jahangeer shared with the delegates of the world conference some of the key learnings from HPPI’s experiences of working with unhoused persons in India since 2017.
Timeless wisdom of Margaret Mead’s words comes to life when we hear Jahangeer speak: “Never doubt that a small group of thoughtful committed individuals can change the world. In fact, it’s the only thing that ever has.”
HPPI implemented 7 initiatives during 2017-2025 to find more TB among the unhoused persons in Delhi, India, and link them to public services. HPPI developed a person-centred, rights-based, and gender transformative model to do so. There were estimates that the number of unhoused persons in Delhi could be around 300,000.
During 2017-2025, frontline healthcare workers of HPPI reached out to 225,022 unhoused persons who were highly vulnerable to TB and hard to reach. Out of those screened for TB, 10,976 people were found with presumptive TB and offered a (free) confirmatory TB test in a government facility. 2283 unhoused persons were found to have active TB disease, and 53 of them had a very serious form of TB, referred to as drug-resistant TB (where TB bacteria become resistant to some of the most powerful anti-TB medicines).
Overall, for every 99 unhoused persons screened for TB, 1 was found with active TB disease between 2017-2025 by HPPI. However, in some areas or projects, this rate was alarmingly high: 1 in every 44 screened for TB had the disease.
Making a difference
When HPPI began working with unhoused persons in 2017, a lot of them dropped out of care. 15% was the loss to follow-up rate. And dropping out of lifesaving TB treatment meant that the person continues to suffer, has a higher risk of TB death, and the disease keeps spreading to others (if the person had lung TB). The death rate among the unhoused people in 2017 who were on TB treatment was 8.8%.
The HPPI model demonstrated that it is possible to reduce human suffering and save lives: loss to follow-up rate dropped to 1.7% by 2024 (from 15% in 2017), and TB death rate dropped to 2.5% by 2024 (from 8.8% in 2017).
Jahangeer explained that there were 3 groups of unhoused persons HPPI was working with: those living on the roadside, in shelters, and in temporary slums (referred to as ‘jhuggi’).
“Unhoused persons had higher TB vulnerability because of several reasons: higher substance use (such as alcohol, tobacco, or drugs), living in unhygienic conditions, low TB awareness and health literacy, and a range of access barriers to reach public health services. Lack of government identity documents, gender identities, fear of discrimination, or losing daily wage were other barriers we found that blocked access to existing services,” said Jahangeer.
In-person follow-up and support to unhoused persons based on the HPPI model was a game-changer.
Jahangeer Alam shared that trained frontline healthcare workers to implement the HPPI model were critical to follow up and support unhoused persons. Those with TB disease and receiving treatment could finish the therapy successfully, thanks to the workers on the ground.
HPPI had established a flexible partnership with local private X-Ray laboratories so that unhoused persons could be brought by their workers to get X-Ray screening at a community-convenient time (for example, early morning or late evening if convenient to the person being screened). “A typical 9 am to 5 pm would not work for most of them. Community-convenient and friendly timing must be adopted,” said Jahangeer.
HPPI workers helped collect and take quality sputum samples of unhoused persons to government laboratories for confirmatory testing. For those with active TB disease, workers accompanied them for initiation of treatment from the nearest government centre.
Daily follow-up during the first 2 weeks after initiation of TB treatment, and then at least once weekly follow-up till the person is cured, proved very helpful to ensure the unhoused person could adhere to TB therapy. Counselling, facilitating medical consultations in government centres as needed for side effect management or other healthcare needs, facilitating access of unhoused persons to social welfare schemes such as nutrition, financial support directly transferred by the government of India to their bank account during TB treatment every month, and other such benefits could also happen because of the assistance provided by HPPI workers on the frontline.
Linkage to local community people also proved important because the location of unhoused persons kept changing on an ongoing basis. HPPI workers identified such local allies and fostered these relationships. These allies included unhoused persons who were cured of TB (TB survivors who became TB champions), local vendors, caretakers of night shelter homes, among others. These allies were very helpful for HPPI workers to follow up with unhoused persons on an ongoing basis.
“Intensified treatment adherence support is a lifeline. We need to make this available to every unhoused person if we want them to adhere to the treatment and finish it. Field officer is needed on the ground if we want favourable TB programme outcomes from high-risk TB populations,” stressed Jahangeer.
HPPI screened unhoused persons for TB using a range of approaches: verbal screening, X-Ray screening, and AI-based cough screening (cough screening is being tested currently, showing promising initial results, but is not yet a part of the government programme).
Those who were found presumptive for TB were offered a confirmatory TB test at the nearest government-run facility (thanks to NTEP).
But even sputum collection could become a challenge. Multiple efforts were needed in some instances, and support of local communities remained vital, said Jahangeer, reemphasising the need for trained frontline workers to support unhoused persons regularly.
Reducing diagnostic delays is key.
Leveraging, Engaging and Advocating to Disrupt TB transmission (LEAD) is another flagship initiative of HPPI that has demonstrated robust impact in reaching unhoused and other marginalised persons in urban areas of India. “According to several studies in India, delay in TB diagnosis contributes to increased TB transmission, morbidity, and higher mortality, especially among marginalised populations, such as those living on the roadside, under flyovers, or in very temporary structures,” said Jahangeer Alam at the World Conference on Lung Health 2025. “Reducing diagnostic delays also reduces out-of-pocket expenses.” Delay in diagnosis also fails us in breaking the chain of infection transmission. We cannot end TB unless we disrupt TB transmission and take care of everyone with the TB bacteria in a science-based and person-centred manner.
There is also a deadly synergy between diagnostic delays and catastrophic costs – both need to be eliminated if we are to ensure all those in need can access public services in a person-centred manner.
“In 2024-2025, the turnaround time from identifying a person with presumptive TB to a correct diagnosis for 75% of people was less than 5 days, and for 92% of them it was less than 10 days,” said Jahangeer. “The remaining 8% people took a longer time as they needed further medical tests.”
Three-fold increase in molecular testing
During May 2023 and April 2024, LEAD-1 was first implemented, during which 30% of those with presumptive TB were offered WHO-recommended upfront molecular testing in the nearest government-run health facility (thanks to NTEP). The rest of them were offered microscopy (or were bacteriologically not confirmed and put on treatment upon expert medical advice).
But in LEAD-2 (October 2024-January 2025, which was disrupted due to funding cuts and reinitiated recently), upfront molecular testing increased by almost 3 times to around 90%.
This is a major science- and evidence-based difference HPPI could demonstrate with support from NTEP. Sputum microscopy underperforms in diagnosing TB (misses 50-60% of TB cases). That is why the WHO called upon countries in 2018 to completely replace microscopy by 2027 with upfront molecular testing (that finds almost all TB and also tests if the TB bacteria are resistant or sensitive to rifampicin – one of the most powerful anti-TB drugs). Political Declaration adopted at the 2023 United Nations General Assembly High Level Meeting on TB re-echoes this promise to offer upfront molecular testing to 100% of those with presumptive TB. We cannot miss TB if we are to end TB. Right and timely diagnosis is the entry gate to the right treatment, care, and support.
Jahangeer underlines HPPI’s approach of encouraging unhoused persons to seek healthcare, be aware of their rights, and seek public services, including social welfare support. Street plays to engage people, especially the cured ones, in public awareness rallies and other such initiatives have proven helpful.
If we are to end TB and deliver on the SDG-3 goal of ensuring all are healthy, where no one is left behind, we need to scale up proven initiatives like that of HPPI and serve those who are most underserved.
