DR-TB HIV Coordinator: Intensified Case Finding

Intensified Case Finding (ICF) in TB-HIV Collaboration

ICF is the systematic screening for evidence of Tuberculosis (TB) in people infected with Human Immunodeficiency Virus (HIV), at high risk of HIV, or living in congregate settings. It helps in the early detection and treatment of TB, thereby reducing morbidity and mortality due to HIV-TB co-infection. It also prevents ongoing TB transmission and is an initial step to rule out active TB disease to enable early IPT initiation. 

All individuals who visit a HIV-testing site should be screened for presence of for the 4 TB symptoms (4S) at every encounter:

4S in adults and adolescents - Current cough, fever, weight loss and/or night sweats

4S in children - Current cough, fever, poor weight gain and/or history of contact with a TB case 

The presence of at least one symptom is considered as 4S+ve.

ICF at Integrated Counselling and Testing Centres (ICTCs)

• Systematic TB screening should be integrated and offered at all HIV testing facilities and to all populations receiving HIV testing, irrespective of their test results. 
• All ICTC clients should be screened by the ICTC counsellors for the presence of the symptoms of TB disease (at pre, post, and follow-up counselling). 
• All clients who have symptoms or signs of TB disease, irrespective of their HIV status, should be referred to the nearest facility providing National TB Elimination Programme (NTEP) diagnostic and treatment services. 
• For better coordination in the field between the two programmes, NACP and NTEP promotes the establishment of co-located facilities.

ICF in HIV Congregate Settings (ART Plus Centres, ART Centres, Link ART Centres, Community Care Centres (CCC))

• HIV-infected clients with undiagnosed and untreated TB can be expected to seek care in ART or CCCs, posing the risk of exposing other HIV-infected persons to TB. 
• All people living with HIV (PLHIV) should be regularly screened for TB using 4S at the time of initial presentation and follow-up visits. 
• During each visit, 4S screening is done by all personnel involved in the following order: 
  • Care coordinator --> Staff Nurse --> Counsellor --> Medical Officer. 
  • 4 S screening is first done by the care coordinator. According to the results, they apply a "4S positive"(Red) or "4S negative" (Blue) seal. 
  • In the next station, a 4-symptom seal is applied by the nurse who does a detailed screening and positive symptoms are tick marked. 
  • In the next two stations, the counsellor and medical officer also perform 4S screening. 
  • Screening at multiple levels ensure that no symptoms are missed.
• PLHIV/ children living with HIV (CLHIV) found positive for any of the four symptoms (4S+), should be considered presumptive TB and fast-tracked for TB diagnostic work-up using molecular diagnostic tests by the medical officer.

ICF among HIV High-risk Groups (HRG) 

• Operational research conducted in high HIV prevalent states has shown that HRGs like female sex workers (FSW), men who have sex with men (MSM), injecting drug users (IDU), etc. are more likely to have TB compared to the general population. 
• Also, it is known that HIV prevalence among HRGs is several times higher than in the general population. 
• Among the HRGs, IDUs have the highest HIV prevalence thus provision of ICF services and prompt linkage to care support and treatment to IDUs is treated as a priority at the centres.

References

• National Guidelines for HIV Care and Treatment, NACO, MoH, GoI, 2021.
• National Framework for Joint HIV/TB Collaborative Activities, Department of AIDS Control, MoHFW, GoI, 2009.
• WHO Consolidated Guidelines on Tuberculosis: Module 2: Screening: Systematic Screening for Tuberculosis Disease.

Assessment

Recording and Reporting of Intensive Case Finding (ICF) among People Living with HIV (PLHIV)

Reporting of ICF is an important activity for coordination between NACP and NTEP. Since ICF activities occur at the ICTCs, LAC and ART centres, the recording and reporting of the same should be done to the NTEP using line lists and consolidated reports. The details about referrals have to be filled by the ART staff (counsellor/nurse), and details about TB diagnosis and treatment initiation have to be filled by the NTEP staff (STS). These records are validated during monthly HIV/TB coordination meetings. It helps to maintain continuum of care between the two programs.

Integrated Counselling and Treatment Centres (ICTCs) and Link Antiretroviral Treatment (ART) Centre (LAC)

In all ICTCs and LAC (because ICTC counsellor operated the LAC), referrals of TB suspects should be recorded on the ICTC line list to facilitate coordination with National TB Elimination Programme (NTEP) to determine TB diagnosis and initiation of DOTS of the referred patients. 

To streamline this process further NTEP staff should stay in touch with ICTC counsellors to complete the exchange of information in time.

It is crucial that the ICTC counsellor attends the NTEP monthly meeting for coordination with NTEP staff to validate the line lists, and monthly HIV/ TB reports and solve operational issues if any. 

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Figure 1:  Line-list of persons referred from ICTC to NTEP; Source: National Framework for Joint HIV-TB Collaborative Activities, 2013.

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Figure 2: ICTC TB-HIV Monthly Report; Source: National Framework for Joint HIV-TB Collaborative Activities, 2013.

ART Centres/ LAC Plus 

All referrals of presumptive TB cases from ART Centre/ LAC plus centres should be recorded on an ART centre TB-HIV line list to facilitate coordination with NTEP programme staff and to track the patient closely through the process of TB diagnosis and DOTS initiation. It is also crucial that ART centre staff members attend monthly HIV/TB coordination meetings. 

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Figure 3: Line-list of persons referred from ART centre to NTEP; Source: National Framework for Joint HIV-TB Collaborative Activities, 2013.

The HIV/TB monthly reporting format generated at ART centres is incorporated into the ART centre monthly report (CMIS). 

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Figure 4: ART Centre Monthly TB-HIV Report; Source: National Framework for Joint HIV-TB Collaborative Activities, 2013.

Information about all HIV-infected TB patients in HIV care should be recorded in the ART centre's HIV/TB register. These include:

• TB patients detected by ART/ LAC plus centre staff
• TB patients found HIV-infected while on DOTS treatment and referred to ART centre by the RNTCP

TB-HIV register is an important monitoring tool to track the timeliness of initiation of Cotrimoxazole Preventive Therapy (CPT) and ART, and also the TB treatment outcome so as to modify Antiretroviral (ARV) regimens as per guidelines. 

It is important that ART centre staff carry this register when they attend monthly HIV/TB coordination meetings to update information on TB treatment outcomes from NTEP staff and share information pertaining to CPT and ART with them for recording into NTEP TB registers.

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Figure 5: ART Centre TB-HIV Register; Source: National Framework for Joint HIV-TB Collaborative Activities, 2013.

References

• National Framework for Joint HIV-TB Collaborative Activities, Department of AIDS Control, CTD, MoHFW, GoI, 2013.
• Operational Guidelines for ART Services, NACO, 2012.

Assessment