DR-TB HIV Coordinator: Integration of TB and HIV Services

The interaction between HIV and TB in co-infected persons is bidirectional and synergistic; on the one hand, HIV infection predisposes the development of active TB, and, on the other, the course of HIV-related immunodeficiency is worsened by active TB infection.

Globally and in India, TB is the most common opportunistic infection seen in HIV patients and a leading cause of death in these patients. The lifetime risk of TB in immune-competent persons is 5-10%, whereas, in an HIV-infected person, the annual risk of TB is 5-15%. Thus, people living with HIV are 18 (15-21) times more likely to develop active TB disease than people without HIV.

TB and HIV Burden Trends in India

India is one of the WHO’s 30 high TB/HIV burden countries; of the 3 million TB incident cases, close to 54000 occurred in HIV-infected persons (See Table 1 for more details). TB and HIV are major public health challenges in India and are leading causes of mortality and morbidity among all other infectious diseases.

Resources

• India TB Report, 2022
• Global TB Report, World Health Organisation, 2022
• Shastri, S., Naik, B., Shet, A. et al. TB treatment outcomes among TB-HIV co-infections in Karnataka, India: how do these compare with non-HIV tuberculosis outcomes in the province?. BMC Public Health 13, 838 (2013)

The primary impact of HIV on TB is that the risk of developing TB becomes higher in patients with HIV. Overall, HIV-infected persons have an approximately 8-times greater risk of TB than persons without HIV infection. 

Screen TB PLHIV patients for symptoms of TB and HIV

Figure: Screening steps for TB - HIV patients

Treatment for TB HIV Patients​

• All TB patients who have been diagnosed and registered under NTEP should be referred for screening for HIV.
• Referral of TB patients for screening for HIV and its recording & reporting is the responsibility of the Peripheral Health Institutions(PHI) where TB treatment is initiated.
• TB patients diagnosed with HIV will receive the same duration of TB treatment with daily regimen as non-HIV TB patients.
• TB patients must be referred to the nearest ART(Anti - Retroviral Treatment) centre for management of HIV.

TB-HIV collaborative activities between the Revised National Tuberculosis Control Programme (RNTCP) and National AIDS Control Programme (NACP) started initially in the year 2001, in the six states with a high prevalence of HIV/AIDS, i.e., Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu. The collaborative activities were extended to 8 additional states in 2004.

NACP and RNTCP developed the “National framework of joint TB/HIV collaborative activities” in 2007 which was revised in February 2008 to redefine the scope of TB/HIV collaborative activities being implemented in the country.

The 2009 revision of the National framework:

• Establishes uniform activities at Antiretroviral Therapy (ART) centres and Integrated Counselling and Testing Centres (ICTCs) nationwide for intensified TB case finding and reporting
• Strengthens joint monitoring and evaluation with specified national TB/HIV programme indicators and performance targets.

The overall purpose of the National framework is to articulate the policy for strengthening TB/HIV collaborative activities between the National TB Elimination Programme (NTEP) and NACP, resulting in the reduction of the TB and HIV burden in India.

Objectives

• To strengthen the mechanisms for coordination between NTEP and NACP at the national, state and district levels
• To decrease morbidity and mortality due to tuberculosis among persons living with HIV/AIDS
• To decrease the impact of HIV on tuberculosis patients and provide access to HIV-related care and support to HIV- infected TB patients

For smooth coordination mechanisms at the national, state and district levels, the National Technical Working Group (NTWG) is constituted at the national level comprising key officials from NACO and Central TB Division (CTD) dealing with TB/HIV collaborative activities;  State Coordination Committees (SCC) at the state level chaired by the Principal Health Secretary ; State Working Group (SWG) composed of key officials from State AIDS Prevention and Control Society (SACS) and State TB Cell; and district level coordination committees are established.

Resources

• National Framework For Joint HIV/TB Collaborative Activities, NACO, CTD, MoHFW, GoI, 2009.

Assessment

 TB-HIV collaborative activities are the first among the TB comorbidities-specific interventions started in India and globally. In India, structured and systematic TB and HIV collaborative efforts were started in 2001. 

The scope of work for collaboration between the National AIDS Control Programme (NACP) and the National TB Elimination Programme (NTEP) includes:

1. Establish/ strengthen NACP-NTEP coordination mechanisms at the national, state and district levels

2. Scaling up of intensified TB/HIV package of services across the country

3. Joint monitoring and evaluation including standardised reporting shared between the two programmes

 4. Training of the programme and field staff on TB/HIV

 5. TB and HIV service delivery coordination by:

• Offering HIV testing to TB patients
• Intensified TB case finding at Integrated Counselling and Testing Centres (ICTCs), Antiretroviral Therapy (ART) and Community Care Centres
• Linking of HIV-infected TB patients to NACP for HIV care and support (including ART) and to NTEP for TB treatment
• Provision of Cotrimoxazole Prophylactic Treatment (CPT) for HIV-infected TB patients

6. Implementation of feasible and effective infection control measures

7. Involvement of Non-government Organisations (NGOs)/ Community Based Organisations (CBOs) and affected communities working with NACP and NTEP for all activities on TB/HIV collaboration

8. Operational research to improve the implementation and impact of TB/HIV collaborative activities

Intensified efforts are required for addressing the TB Burden among PLHIV. The three “I” s to reduce the burden of TB among PLHIV include:

• ICF: Intensified (TB) Case Finding at ICTC, ART centres and Link ART Centres (LAC)
• IC-AIC: Air-borne Infection Control measures for prevention of TB transmission in HIV care settings
• IPT: Implementation of Isoniazid Preventive Treatment for all PLHIV (on ART + Pre-ART

Resources

• National Framework for Joint HIV/TB Collaborative Activities, NACO, CTD, MoHFW, GoI, 2009.
• Training Modules (1-4) for Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

Assessment

There is a well-structured system of National AIDS Control Programme (NACP) and National TB Elimination Programme (NTEP) coordination at the national, state and district levels which includes the following:

1. National Level

• National Technical Working Group (NTWG): At the national level, a technical working group comprising key officials from NACO and Central TB Division (CTD), dealing with TB/HIV collaborative activities and experts from World Health Organisation (WHO), is in place. The purpose of the TWG, which meets at least quarterly, is to review, optimise and plan for future TB/HIV coordination activities.

2. State Level

• State Coordination Committees (SCC): To ensure smooth implementation and regular review of TB/HIV collaborative activities, SCCs chaired by the Principal Health Secretary are established at the state level. These coordination committee meetings are organised by the State AIDS Control Society (SACS) on a biannual basis.
• State Working Group (SWG): At the state level, SWG is composed of key officials from SACS and State TB Cell (State TB Officer, second Medical Officer, if present), along with other officials dealing with TB/HIV collaborative activities and consultants involved in HIV/TB collaborative activities. The SWG is organised by SACS at least once in a quarter to review and streamline the collaborative activities.

3. District Level

• District Coordination Committees (DCCs): To ensure smooth implementation and regular review of TB/HIV collaborative activities, coordination committees are established at the district level. These coordination committees meet on a quarterly basis. DCCs are organised by District AIDS Prevention Control Unit (DAPCU) Nodal Officers or District TB Officers (DTOs) (in districts where there is no DAPCU).
• Monthly meeting at the District level: A monthly meeting of the DTO and the District Nodal Officer (DNO) is held with the participation of key staff from both programmes. Monthly key staff meetings for NTEP are already being conducted at the district level. It is envisaged that during these monthly key staff meetings, additional sessions be organised for TB/HIV which should be attended by the key district staff of NACP. In these monthly meetings, a review of the ongoing TB/HIV collaborative activities and discussion on key issues emerging from the field is done.

4. Annual Review of TB/HIV Collaborative Activities at National and State Level

• NTEP conducts regular programme reviews at the national and state levels. It is planned that at one of these reviews at the national level, an annual review of the TB/HIV collaborative activities is held with the participation of State Programme Managers of both programmes. The annual review is held in close coordination between NACO and CTD. Similar annual reviews are also held at the state level.

5.  Dedicated Positions Sanctioned to Facilitate Coordination and Successful Implementation of TB/HIV Collaborative Activities

• Full-time regular government officer would be in charge of TB/HIV collaborative activities in the programmes at the national and state level in NACP and NTEP
• National consultants for TB/HIV (NACP & NTEP)
• Technical Officers at SACS for basic services (including TB/HIV) are available across the country (1-2 per state)
• State TB/HIV Coordinators
• District level DR-TB HIV Coordinator

Resources

• National Framework for Joint HIV/TB Collaborative Activities, NACO, CTD, MoHFW, GoI, 2009.

Assessment

National AIDS Control Organisation (NACO) provides leadership to HIV/AIDS Control Programme in India, implementing one National Plan within one monitoring system. State AIDS Prevention and Control Societies (SACS) implement the NACO programme at the state level, but have functional independence to upscale and innovate.

SACS Structure

SACS are autonomous and decentralised. Each SACS has a governing body, its highest policy-making structure, headed either by the minister in charge of health or the chief secretary. 

It has onboard representatives from key government departments, civil society, trade and industry, the private health sector and  People Living with HIV/AIDS (PLHA) networks, who meet twice a year. 

It approves new policy initiatives, annual plans and budget, appoints statutory auditors and accepts the annual audit report. For better financial and operational efficiency, administrative and financial powers are vested in the Executive Committee and the Programme Director.

Functions of SACS 

•      Medical and public health service
•      Communication and social sector services
•      Administration, planning, coordination, monitoring and evaluation, finance and procurement.

With the setting up of the District AIDS Prevention and Control Unit (DAPCU) under the National AIDS Control Programme-III (NACP-III), there will be an increased emphasis on improving coordination functions at the state level in supporting the programme implementation at the district level.

The specific roles of SACS with respect to TB and HIV collaborative activities are:

1.       SACS ensures smooth implementation and regular review of TB/HIV collaborative activities, chaired by the Principal Health Secretary by organising coordination committee meetings twice on a biannual basis.
2.       The State Working Group (SWG) is organised by SACS at least once in a quarter to review and streamline the TB/HIV collaborative activities.
3.         In order to strengthen the field-level collaborative activities, joint field visits are undertaken by the SACS & State TB Centre (STC) to at least one district every quarter.
4.       The SACS is also a part of an annual review of the TB/HIV collaborative activities organized by the state in coordination with SACs.
5.       Trainings on TB/HIV are an integral part of NACP and National TB Elimination Programme (NTEP) activities. Budgets for the training of staff are borne by SACS for their programme personnel.
6.       The supply of Cotrimoxazole Preventive Therapy (CPT) is procured and packaged into monthly pouches by SACS and the local distribution is carried out by NTEP in coordination with NACP.

Resources

• SACS, National AIDS Control Organisation.

Assessment

 Programme management under NACP was decentralised to the district level in the form of District AIDS Prevention and Control Units (DAPCU).

Constitution of DAPCU

The DAPCU team consists of District AIDS Control Officer (DACO), District Integrated Counselling and Testing Centre (ICTC) Supervisor (DIS), the Monitoring & Evaluation Assistant (M&E Assistant) and Accounts Assistant. DAPCU staff reports to the DACO and functions as a unit at the district level.

The key functions of DAPCU are:

1. Through active engagement of the district administration mobilise response from allied line departments and private sector in mainstreaming the programme.
2. Initiates evidence-based district-specific initiatives by leveraging local resources.
3. Facilitates linking vulnerable populations with various social entitlement and welfare schemes under the mechanism of the DAPCU-led single window approach.
4. Mentor facility staff in efficient delivery of services, conducts impact monitoring through regular supervisory visits to HIV facilities, monthly review meetings and management and use of multiple databases (Strategic Information Management System (SIMS)/ Mother and Child Tracking System (MCTS)/ Pregnancy, Child Tracking and Health Services (PCTS) management).
5. Coordinate among NACP as well as NHM facilities and functionaries in strengthening referrals and linkages.
6. Address supply chain management issues through inter and intra-district transfers and liquidation of advances.
7. Other activities entrusted by SACS such as setting up of Facilitated Integrated Counselling and Treatment Centres (FICTCs) in both Government and PPP mode, facilitating Migrant Health Camps, and Mid-media campaigns under the Information, Education, and Communication (IEC) programme, and preparation of district epidemiological profiles are also part of their functions.

Operations related to TB services:

1.       The DAPCU convenes a joint review meeting of all NACP facilities which includes National TB Elimination Programme (NTEP) facilities in the district to review:

•      Ensure 100% reporting from all NACP facilities in the district. 
•      Review and validate monthly reports (SIMS) submitted by the facilities. 
•      Review of facility performance
•      Review of referrals and linkages between facilities. 
•      Review status on benefits of social benefit schemes to PLHIV and HRG.

2.   DACO and/or DPM from DAPCU are expected to participate in the DHS meetings, facilitate HIV TB coordination meetings and convene such forums and meetings as per requirements of SACS and district priorities.

3.    Ensure HIV testing for all TB notified cases in the district in coordination with NTEP.

4.    To ensure that all symptomatic clients are referred to NTEP and all TB-positive cases are referred to ICTCs for HIV testing.

Resources

• Operational Guidelines District AIDS Prevention and Control Units (DAPCU), 2012.

Assessment

National AIDs Control Programme (NACP) has established partnerships with bonafide registered entities, which include non-governmental organisations (NGOs), community-based organisations, federations of self-help groups (SHGs), registered medical practitioners (allopathic/ AYUSH), hospitals, nursing homes, clinics, health professional bodies and organisations. The three primary models for establishing a ‘Facility-ICTC’ in the private sector under a Public Private Partnership Integrated Counselling and Testing Centre (PPP-ICTC) are: 

1. Provide training to medical/para-medical staff on national guidelines and protocols with no support for commodities

2. Provide training to medical/para-medical staff on national guidelines and protocols with support for commodities such as HIV diagnostic test kits, prevention of parent to child transmission of HIV (PPTCT) drugs, counselling tools, information, education and communication (IEC) as per requirement 

3. Provide sensitisation to medical/ para-medical staff on national guidelines with no training to medical/ para-medical staff and no support on commodities

The Guidance Document on Partnerships Revised National Tuberculosis Control Programme mentions providing services in the private sector for linking TB-HIV coordination services. This includes collaborating and designing the appropriate model of referral linkage and testing services at private hospitals and clinics based on National TB Elimination Programme (NTEP) and NACO guidelines. This may include

• Establishing HIV testing facilities at the private hospital
• Facilitating patient testing, preferably at a free testing centre, such as F-ICTC/ICTC or NACO-empanelled HIV testing centres
• Establishing effective linkages between the patient and the nearest ICTC for confirmatory test
• Update HIV status of TB patients in Ni-kshay
• Providing HIV testing services through the Patient Provider Support Agency (PPSA)

Resources

•       National HIV Counselling and Testing Services (HCTS) Guidelines, NACO, GoI, 2016.

•       Guidance Document on Partnerships - Revised National Tuberculosis Control Programme, CTD, MoHFW, GoI, 2019.

  Assessment

PLHA network is a network of People Living with Human Immuno-deficiency Virus (HIV)/ Acquired Immuno-Deficiency Syndrome (AIDS) [PLHA] created for PLHA, by PLHA.  The goal of the PLHA network is to sensitise the communities on HIV and AIDS, improve access of communities to HIV prevention and PLHA to treatment and care; and support services.

Advocacy to PLHA networks

Objective

Data suggests that people with HIV often have either latent TB infection or TB disease. Hence the objective is to utilize the PLHA network under the (NTEP) which is available at national, state and also at some of the districts is an appropriate step for advocacy towards catering to TB -HIV patients.

Opportunities for advocacy to PLHA networks under NTEP

Under the TB programme PLHA network can be utilized for advocacy in following areas:

• Social mobilization to raise awareness and increase TB testing among the PLHA and contacts.

• Information, Education and Communication (IEC) activities on initiation of appropriate TB treatment services for the PLHA along with uptake of Anti Retro-viral Therapy (ART).

• Advocacy to improve coverage of TB preventive treatment in the eligible PLHA and their children.

• Promotion of TB literacy for the PLHA and focus on de-stigmatization and social inclusion measures.

Importance of advocacy to PLHA networks: 

The National AIDS Control Programme (NACP) has benefitted extensively by the role played by the PLHA network in community mobilization, increasing access to services, addressing stigma and discrimination issues in the field of HIV.  Further, many PLHA are also members of other key population groups who encounter the challenges affecting TB care. Since PLHA networks are available at the district levels utilizing them in the field of TB through TB Forum meetings, HIV Co-ordination meetings etc., for advocacy to the district administrators as well as for the community level meetings should be an important consideration for the NTEP towards the goal of ending TB.

Resources

 NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS: 2017-25 ELIMINATION BY 2025, MoHFW, India

Training Modules (5-9) for Programme Managers & Medical Officers, WHO, NTEP, CTD, MoHFW, GoI, 2020.

Assessment

Content

In order to reduce coverage gaps and improve access to HIV prevention, treatment, care and support, the National HIV Counselling Testing Services (HCTS) guidelines, 2016 recommends the routine HIV testing for all presumptive and diagnosed TB cases and partners of known HIV-positive TB patients.

 The process flow for the testing of presumptive TB cases and patients is as follows:

Image

  Resources

• Training Modules (1-4) for Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

Assessment

Tuberculosis Health Action Learning Initiative (THALI) initiative was started in 2016, with the support of the United States Agency for International Development (USAID) as a four-year patient-centric family focused TB prevention and care initiative to facilitate quality TB services to vulnerable populations. THALI was implemented by the Karnataka Health Promotion Trust (KHPT) in Karnataka in collaboration with the National Tuberculosis Elimination Programme (NTEP).

The project focused on behaviour change, primarily among communities of the urban poor. The population with co-morbidities such as HIV-AIDS, diabetes and undernutrition were prioritized under THALI. KHPT piloted this project from June 2019-July 2020 in four high-burden HIV districts in the intervention states. In Karnataka, it was launched in Belgaum and Bagalkot.

Best practices that can be learned from this initiative are:

1. Integrating TB-HIV activities by capacitating providers and officials, and advocacy.     
2. Raising awareness about direct benefit transfer (DBT) and how to acquire it. 
3. Supporting patient support groups (PSGs) to help patients overcome unpleasant side-effects and stigma, follow healthy nutritional practices and adhere to treatment with a goal to improve TB treatment experiences within government TB facilities.      
4. Capacity building of TB champions.     
5. Partnering with the care and support centres (CSC) teams to conduct awareness-raising meetings for people living with HIV (PLHIV) at the anti-retroviral (ART) centres, and advocate with the district health officer (DHO), district TB officer (DTO) and state TB office to increase isoniazid preventive therapy (IPT) supply. 

While there is still a lot to be done to address the remaining gaps consistently and cohesively, the intervention has been successful in helping the stakeholders recognize the value of an integrated approach and understand the problems better. Among other high-risk groups (HRGs), THALI has made a start with data (there is no screening data from the past) and other activities. THALI has demonstrated pathways through a collaborative approach involving the NTEP and PLHIV networks that, if sustained, will enable the success of future efforts.

Resources

 Tuberculosis Health Action Learning Initiative (THALI) - Best Practices and Lessons in TB-HIV Integration from Bagalkot, USAID, KHPT, 2020.

Assessment

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. 

Image

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. 

Image

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

Mycobacterium tuberculosis is transmitted in airborne particles called droplet nuclei that are expelled when a person with pulmonary TB coughs, sneezes, shouts, or sings. People nearby may breathe in these bacteria and become infected. 

Airborne infection control is essential to prevent the spread of TB within a health facility and other settings.

Hierarchy of Controls to Reduce Risk of Transmission of TB (see the Figure)

Figure: Hierarchy of controls to reduce risk of transmission of TB

Environmental factors that influence transmission of M. tuberculosis are elaborated in the table below.

Resources

1. Guidelines on Airborne Infection Control in Healthcare and Other Settings.
2. Tuberculosis Infection Control.

With a high burden of TB patients in close proximity to large numbers of vulnerable patients frequently visiting the ART centre, there is an increased risk of TB transmission. Factors like overcrowding, inadequate natural ventilation and re-circulating air-conditioners add to this risk.

ART centres are required to initiate the following measures aimed at reducing the exposure of HIV-infected patients to M. tuberculosis:

1. Infection control activities

• All the team members of ART centre shall be trained in universal workplace precautions, waste segregation and disposal and Airborne Infection Control (AIC) practices, with special reference to tuberculosis.
• Conduct TB risk assessment in collaboration with National TB Elimination Programme (NTEP) and National AIDS Control Organisation (NACO).
• Develop a written TB infection control plan by the Hospital infection control committee and ART nodal officer. This may be incorporated into the facility infection control plan.
• Hospital infection control committee and ART nodal officer should be assigned the responsibility for TB infection control at ART centres.
• Display proper IEC material on cough and hand hygiene practices in the hospital, hospital waiting area, ART centre, and particularly the waiting area of the ART centre. Notice to be put up that patients with cough shall be seen on a priority.
• Make surgical masks, tissues, and appropriate no-touch disposal receptacles available.

2. ART centres with specific location and design

• ART centres should be located at a distance from chest clinics, Direct Microscopy Centres (DMCs), or DOT Centres, with no shared waiting areas.
• There should be a well-ventilated waiting & seating area. Open outdoor roofed additional waiting areas are encouraged.
• There should be a separate, well-ventilated waiting area for respiratory symptomatic wherever possible (particularly in busier ART centres).
• Adhere to ventilation standards for airborne infection control (>15 air exchanges per hour [ACH] throughout). Where natural ventilation is of concern, augmenting ventilation through the well-planned use of exhaust fans may be considered. Installation should be properly designed and maintained, and electrical power must be consistently available.
• Any cooling/ heating systems should be implemented in a way that adheres to ventilation standards (>15 ACH). Use of re-circulating (split) air conditioners should be avoided.

3. Screening of clients for respiratory symptoms

• Care coordinators or nurses should screen all clients arriving at the ART centre as early as possible for respiratory symptoms. Patients with respiratory symptoms should be educated on cough hygiene, kept in a separate, well-ventilated waiting area if possible, and fast-tracked through their visit.
• Educate people with respiratory symptoms on cough hygiene.
• Educate Healthcare Workers (HCWs), patients, family members, and visitors on the importance of cough etiquette to help prevent the transmission of airborne infections (both TB and respiratory viruses). Instruct patients about covering their mouth and nose with a tissue when coughing and dispose of used tissue in waste containers.
• Provide a disposable surgical mask to coughing patients.

4. Fast-tracking of known pulmonary TB patients and persons with respiratory symptoms

• Fast-tracking of patients with respiratory symptoms is critical in reducing the time the patient is in the facility to reduce possible contamination of air and spread of disease.
• Care coordinator or nurse of the ART centre shall facilitate the fast-tracking of patients with respiratory symptoms. These patients will be helped by the nurse to get them counselled by the counsellors, examined by the doctors and provided with the drugs quickly, without making them wait in the regular queue.
• Presumptive TB shall be referred to the DMC/ DOTS centre for their sputum smear examination as a part of Intensified Case Finding (ICF). This will facilitate early recognition and identification of possible pulmonary TB patients.
• A signboard display of the fast-tracking policy within the ART centre should be visible to avoid confusion among waiting patients.

References

• Operational Guidelines for ART Services, NACO, 2012.
• Tuberculosis and HIV, Global HIV Programme, WHO. 

Assessment

The objective of Co-trimoxazole Preventive Therapy (CPT) is to reduce morbidity and mortality among People Living with HIV (PLHIV) from opportunistic infections.

CPT is effective in preventing a range of bacterial fungal and protozoal opportunistic infections in PLHIV including Pneumocystis Pneumonia (PCP) caused by the fungus Pneumocystis jirovecii, toxoplasmosis, bacterial pneumonias, nocardiasis and isosporiasis. Hence, CPT is a standard component of HIV care.

Co-trimoxazole is a combination of two drugs – Sulfamethoxazole (SMX) and Trimethoprim (TMP). A single-strength tablet contains 400 mg SMX and 80 mg TMP

There are two types of CPT prophylaxis:

1. Primary prophylaxis - Aims to avoid the first occurrence of infection

2. Secondary prophylaxis - Aims to avoid the recurrence of infection after successful treatment 

Dispensation of CPT: The Medical Officer at the ART Centre assesses the patient and prescribes CPT. The tablets are dispensed by the pharmacist at the ART centre.

References

• National Guidelines for HIV Care and Treatment, NACO, MOH, GoI, 2021.

• Paediatric ART Guidelines, NACO, 2013.

• Operational Guidelines for ART Services, NACO, 2012.

Assessment

Isoniazid Preventive Therapy (IPT) administration in People Living with HIV (PLHIV) prevents the incidence and relapse of TB and is a key public health intervention for TB prevention in PLHIV. Concomitant administration of Anti-retroviral Therapy (ART) and IPT, restores TB-specific immunity and prolongs the beneficial effect of IPT.

Combined use of IPT with ART is recommended for all Children Living with HIV (CLHIV)/ PLHIV regardless of:

• Degree of immunosuppression

• Previous treatment for TB  

• Pregnancy

ART should not be delayed while starting or completing a course of IPT. If there is any doubt about the TB status of a patient, IPT should be delayed.

PLHIV/ CLHIV are offered IPT by the treat-only policy, i.e., tests for TB infections, like Tuberculin Skin Test (TST) or Interferon Gamma Release Assay (IGRA) are not warranted. However, active TB disease must be ruled out before starting IPT.

Ruling Out Active TB

• In adults and adolescents living with HIV: Screen for active TB with a clinical algorithm, for the four symptoms (current cough, night sweats, fever, weight loss). (4S symptom negative, i.e., 4S -ve) identifies PLHIV with a very low probability of having TB disease and who can be reliably initiated on IPT. 

• In CLHIV (more than 12 months of age): Screen for current cough, fever, poor weight gain and history of contact with a TB case. When negative (4S -ve), they are unlikely to have active TB. A chest X-ray may be useful.

• Infants aged <12 months living with HIV who are in contact with a person with TB should undergo clinical evaluation. Those who are unlikely to have active TB should receive TB Preventive Treatment (TPT).

Contraindications to IPT

• Signs and symptoms of peripheral neuropathy such as persistent tingling, numbness and burning sensation in the limbs
• Regular and heavy alcohol consumption
• Active hepatitis
• Concurrent use of other hepatotoxic medications
• Contact with a Multidrug-resistant TB (MDR-TB) case
• PLHIV who have completed DR-TB treatment

IPT Work-up: The patient should be examined for signs of liver disease (jaundice, tenderness in the right upper quadrant of the abdomen) and neuropathy. Wherever available, routine Liver Function Tests (LFTs)/ Alanine Aminotransferase (ALT) should be performed, but a lack of LFTs/ALT results should not delay the initiation of IPT in asymptomatic patients. 

Dosage in Adults and Adolescents: Isoniazid 300 mg + Pyridoxine 50 mg (Vitamin B6) per day x 6 months

Non-availability of pyridoxine should not be a reason to withhold TPT. Alternatively, the multivitamin/ B-complex formulations with the requisite prophylactic dose of pyridoxine may be given.

IPT Initiation and Follow-up

•      All 4S -ve patients should be assessed by the Senior Medical Officer (SMO)/ MO to determine eligibility for IPT. IPT should be considered for both on-ART and pre-ART patients and initiated if not contraindicated. IPT drugs must be provided monthly (30 days) to all eligible patients.
•      In case a patient becomes 4S +ve during the IPT course, he/she should be investigated for TB and if found positive, IPT should be stopped, and appropriate anti-TB treatment should be initiated.

References

• National Guidelines for HIV Care and Treatment, NACO, MoH, GoI, 2021.

• Guidelines for Programmatic Management of Tuberculosis Preventive Treatment in India, WHO, MoHFW, GoI, 2021.

Assessment