Alcohol accounts for India’s most commonly consumed substance, according to a 2019 report by the Ministry of Social Justice and Empowerment. About 14.6% of India’s population between ages of 10 and 75 regularly consumes alcohol, says the report “ Magnitude of Substance Use in India”.

Unhealthy alcohol consumption is common and affects both socio-economic conditions with long-term effects on well-being. Yet, the effects of alcohol use on diseases such as tuberculosis and acquired immunodeficiency syndrome, or AIDS, caused by the human immunodeficiency virus, are rarely considered.

In India, which has a high tuberculosis burden, unhealthy alcohol use triples the risk of the infectious disease. It increases the chances of more severe tuberculosis and relapse after recovery. How? Intoxicated patients often forget to take their medication and may even stop taking it. Alcohol use can also cause drug resistance to tuberculosis medication because it decreases the body’s ability to absorb them.

This is also true for people living with HIV. Unhealthy alcohol use leads to lower antiretroviral therapy medication use. This interrupts the viral suppression, or keeping the virus in control, needed to manage the disease and can even lead to death.

Less than 3% of tuberculosis patients with alcohol dependence seek treatment or help. This is because the combined stigma of disease and alcohol keeps patients from reporting alcohol consumption to their healthcare providers. Thus, patients do not get screened and referred to alcohol treatment.

A study on alcohol reduction among patients with tuberculosis and AIDS in Pune found that combining two mental health approaches – motivational enhancement therapy and cognitive behavioural therapy – can help address alcohol abuse.

The combined therapy helps patients keep up with their tuberculosis medication, increases the effectiveness of treatment and lowers the risk of death. The results were similar for AIDS patients – they were more likely to stay connected to healthcare services and regularly take their antiretroviral treatment medication. The patients had much better viral suppression rates and overall health.

This shows that changing behaviour is the key. Focusing solely on tuberculosis medications makes it easy to forget that human behaviour, from harmful alcohol use to seeking treatment, is based on individual choices. Counselling services help with problem-solving and coping skills, increase an individual’s commitment to treatment, reduce alcohol-related harm and alcohol use overall.

Including these behavioural approaches in patient care can ensure they receive the full benefit of treatment. In low and middle-income countries like India, there is little investment in behavioural treatment, so approaches that help people make healthier decisions are not often used in patient care.

India’s political commitment to end tuberculosis has been substantial. The national strategic framework to end tuberculosis in India recognises that many health factors – including diabetes, AIDS, smoking, undernutrition, poverty and harmful alcohol use – contribute to the tuberculosis epidemic.

Yet, India still has not adopted patient care guidelines that reduce the harmful use of alcohol among patients. Even though alcohol treatment options – including medicines, support groups, and rehabilitation centres – are effective and available, there is limited patient engagement with these services.

There must be a national commitment to include mental health approaches as essential tuberculosis patient care. Communities and immediate caregivers must be included in creating a foolproof, inclusive framework that addresses social stigma, is patient-sensitive, cost-effective, easy to access and easy for healthcare providers to deliver.

Investments should be made to include behavioural treatment approaches and services in patient care. Every tuberculosis and AIDS unit must include trained counsellors who can help patients address the harmful use of alcohol that prevents them from taking their full course of medications and impedes swift recovery.

If India is serious about addressing tuberculosis and AIDS, alcohol use has to be addressed as well. It is time that behavioural counselling services are adopted as part of India’s national response efforts. If we don’t us every tool available, efforts to fight these diseases will remain ineffective and incomplete.

Nishi Suryavanshi is Deputy Director, BJGMC Clinical Research Site and Johns Hopkins Centre for Infectious Diseases, Pune, India.

Amita Gupta is Co-Chair, Faculty Steering Committee, Gupta-Klinsky India Institute and Professor & Chief of Infectious Diseases, School of Medicine, Johns Hopkins University.

Niteen Abhivant, MD, is Associate Professor, Head of Department of Psychiatry, BJ Government Medical College, and Sassoon General Hospital Pune, India.

Arjun Lal Kakrani, MD, is Professor of Clinical Eminence in Medicine & Director of Academic Collaboration, Dr DY Patil Medical College, Hospital & Research Centre, Pune, India.