TB Treatment under NTEP — Drug-Sensitive 2HRZE/4HRE, Diagnosis by NAAT, BPaLM and Shorter Oral DR-TB Regimens

India's TB programme began as the National TB Programme in the 1960s, became the Revised National TB Control Programme (RNTCP), and was renamed the National Tuberculosis Elimination Programme (NTEP) with effect from 1 January 2020. The new name reflects the shift from control to elimination. The programme ran under the National Strategic Plan for TB Elimination 2017–2025, which set the goal of ending TB in India by 2025 — five years ahead of the Sustainable Development Goal target of 2030.

• Pradhan Mantri TB Mukt Bharat Abhiyaan: a 100-day intensified campaign was launched on 7 December 2024 in 347 high-priority districts and expanded to all districts after March 2025.
• Case finding: vulnerability mapping, systematic screening of high-risk groups, AI-enabled hand-held X-rays, and upfront NAAT for everyone with presumptive TB.
• Scale: in 2023, of 25.52 lakh people diagnosed with TB, 95.5% were put on treatment; treatment success with the 6-month drug-sensitive regimen was 85% (public) and 87% (private).
• Prevent–Detect–Treat–Build: the four pillars of the National Strategic Plan.

NTEP now follows upfront molecular testing for all presumptive TB — a nucleic acid amplification test (NAAT) is the first test, not sputum microscopy. A NAAT confirms M. tuberculosis and detects rifampicin resistance at the same time, so every diagnosed patient is screened for drug resistance from day one.

The standard of care for drug-sensitive TB is a 6-month daily regimen: an intensive phase of 2 months of isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E), followed by a continuation phase of 4 months of HRE. It is written 2HRZE/4HRE. Drugs are given as fixed-dose combination (FDC) tablets according to body weight.

• Weight change: if a patient gains or loses 5 kg or more and crosses a weight band, the dose is changed.
• Daily, not intermittent: WHO recommends daily dosing throughout; thrice-weekly dosing is not recommended, and patients on thrice-weekly regimens had 3.3 times the rate of acquired drug resistance.
• Pyridoxine: isoniazid is given with pyridoxine 10 mg daily to prevent peripheral neuropathy; established neuropathy needs 50–75 mg daily.
• Rifampicin in pregnancy: safe; infants born to mothers on rifampicin should receive vitamin K.

WHO also lists two 4-month options: 2HPMZ/2HPM (isoniazid, rifapentine, moxifloxacin, pyrazinamide) for people aged 12 years or older with drug-sensitive pulmonary TB, and 2HRZ(E)/2HR for children and adolescents aged 3 months to 16 years with non-severe TB. In people living with HIV, TB treatment is at least as long as in HIV-negative patients, and ART starts within two weeks of TB treatment regardless of CD4 count.

Extrapulmonary TB uses the same four first-line drugs; what changes is the length of the continuation phase. The NTEP extrapulmonary TB training module gives these durations:

In 2023 India notified 63,929 MDR/RR-TB patients, including 11,749 pre-XDR-TB and 114 XDR-TB. In August 2024 the national expert group recommended the CBNAAT MTB/XDR cartridge to detect resistance to isoniazid, fluoroquinolones, second-line injectables and ethionamide rapidly.

The 2025 NTEP DR-TB guidelines rank three all-oral options. BPaLM is the first choice for eligible patients aged 14 years or more with MDR/RR-TB, regardless of fluoroquinolone resistance or HIV status. Patients not eligible for BPaLM are assessed for the 9–11 month shorter oral regimen; those ineligible for both get an 18–20 month longer oral regimen designed from the drug-susceptibility pattern.

• BPaLM exclusions: age below 14; documented resistance to Bdq, Lzd or Pa; significant liver dysfunction; severe extrapulmonary disease (CNS, spinal or skeletal, disseminated TB); significant conduction abnormalities or a QTcF above 450 ms (men) or 470 ms (women) that does not correct.
• Pregnancy: BPaLM is not used in pregnancy (except before 20–24 weeks in a woman opting for termination); the Lzd-containing 9–11 month regimen can be given at any gestational age with safety monitoring.
• Moxifloxacin in BPaLM: NTEP keeps moxifloxacin for the full course irrespective of baseline fluoroquinolone resistance. WHO allows dropping it (BPaL) when fluoroquinolone resistance is documented.
• Linezolid change: the shorter regimen now uses 2 months of linezolid instead of 4 months of ethionamide, which also removes the need for a baseline thyroid test.
• Administration: all DR-TB doses, including BPaLM, are taken under direct observation at least 6 days a week; BPaLM is taken with food.

• Ni-kshay Poshan Yojana (NPY): direct benefit transfer for nutrition, introduced for all patients notified on or after 1 April 2018 at five hundred rupees per month of treatment; under the TB Mukt Bharat Abhiyaan it was doubled to one thousand rupees per month per patient.
• Ni-kshay Mitra: community supporters, including MY Bharat volunteers, provide nutritional food baskets and psychosocial support on top of NPY; the initiative was expanded to cover household contacts of TB patients.
• TB preventive treatment (TPT): being scaled up for household contacts and eligible vulnerable groups.
• Differentiated TB care: every patient is assessed for the right regimen and for hospital admission using the differentiated TB care approach.