Diagnostic and Treatment Initiation Delays Among Patients With Drug-Resistant Tuberculosis in North India: A Mixed-Methods Study

Background: Delays in diagnosis and treatment initiation of drug-resistant tuberculosis (DR-TB) persist in India despite scale-up of rapid diagnostics.We estimated the magnitude and determinants of these delays and explored barriers.Methods: This mixed-methods study was conducted (October 2021-June 2022) at three district DR-TB centres in Delhi and Faridabad, India.Diagnostic and treatment initiation turnaround times (D-TAT and TI-TAT) were calculated for 158 patients.Delays were defined per NTEP as D-TAT >15 and TI-TAT >7 days.Logistic regression assessed determinants.In-depth interviews with 16 patients/caregivers and 16 programme officials explored barriers.Results: Median D-TAT was 24 days (IQR 7-67) and TI-TAT 5 days (IQR 3-11); 60.1% had diagnostic delay and 33.5% treatment initiation delay.Diagnostic delay was associated with line probe assay use (aOR 6.6, 95% CI 1.7-26.2) and inversely with cartridge-based nucleic acid amplification test (CBNAAT) use (aOR 0.2, 95% CI 0.1-0.9).Treatment initiation delay was associated with residence in Faridabad (aOR 3.1, 95% CI 1.4-6.4)and, imprecisely, with age ≤ 18 years (aOR 6.4, 95% CI 1.0-39.6;p = 0.045).Qualitative findings identified insufficient CBNAAT availability, intermediate reference laboratory (IRL) backlogs, poor awareness, stigma, and weak private-to-public referrals.Conclusions: Six in 10 patients experienced diagnostic delay, and one in three experienced treatment initiation delay.Expanding rapid molecular diagnostics at peripheral levels and strengthening referral mechanisms are essential to reducing delays.