Launch of Revised Strategy of TB- HIV Cross Referrals Delhi State AIDS Control Society Govt. of Delhi By Dr A.K. Gupta MD (Pediatrics) Additional Project Director

Total population of 1.1 billion 400 million TB infected 2.3 million HIV-infected 0.9 million TB/HIV co-infected 1.8 million new TB cases 4% TB cases HIV-infected HIV-associated TB disease in India

Risk of TB in HIV Patients HIV patients are at an increased risk of: Acquiring latent TB Developing active TB once infected with M. tuberculosis Becoming re-infected with a second strain of TB Relapsing after stopping treatment Source: NACO Lifetime Risk of TB

Diagnosis of Tuberculosis in PLHAs Atypical presentations of TB are more common – Minimal pulmonary disease – Higher proportion of Extra-pulmonary disease Higher proportion of sputum smear negative pulmonary disease (22- 64%) Diagnosis of active disease often delayed

Early and Late Stages of HIV Infection Features Stage of HIV Infection EarlyLate Clinical Presentation Often resembles Post-primary TB (Adult Type) Often resembles primary TB Sputum Smear Result Often positiveOften negative Chest X-ray Appearance Often shows cavities  Atypical presentation, often infiltrates lower lung-field lesions, intra-thoracic lymph nodes & infrequent cavities

The effect of HIV infection on symptoms and signs of TB Symptom/signHIV positive (%) HIV negative (%) Dyspnea Fever Sweats Weight loss Diarrhea Hepatomegaly Splenomegaly Lymphadenopathy Chest 1994;106:1471-6

Sites of involvement and HIV status SiteHIV positive (%) HIV negative (%) Pulmonary Extrapulmonary Both Pleural Pericardial Lymph node J Trop Med Hygiene 1993;96:1-11

Common forms of Extrapulmonary TB among HIV-infected persons Nodal – peripheral nodes - cervical > axillary > inguinal – central nodes - mediastinal > hilar, intra- abdominal Disseminated disease Serosal - pleural, pericardial > ascites Central nervous system - meningitis, tuberculoma Soft tissue abscesses

Effects of HIV on TB One year mortality % (four times than TB in HIV negative with TB) Cause of death is complication other than TB due to accelerated progression of HIV Increased incidence of ADR to ATT Increased emergence of drug resistance

Revised Guidelines for starting ART for HIV TB co-infected patients All HIV infected TB patients need to be started on ART – with CD4 count <350 (in case of pulmonary TB) and – irrespective of CD4 count in case of extrapulmonary TB – within 2 weeks of starting ATT NACO, November 2008

Intensified Case Finding…I Intensified TB case finding at : Integrated Counseling and Testing Center: All clients with symptoms and signs of TB would be referred to the nearest RNTCP diagnostic and treatment facility (DMC ART Center: Screen all patients for the symptoms and signs of TB on a modified diagnostic algorithm including clinical suspicion and other investigations with CXR, USG etc. as required Care and support centers: Implement Intensified TB case finding by symptom screening on a regular basis and prompt referral system

Intensified Case Finding….II Intensified HIV case finding: Screening Tool: for the Health Care Providers to screen all patients for signs and symptoms of HIV and refer them for counseling and testing to the nearest ICTC.

Challenges in ICF Gap in the linkage between DMCs (12,444) and ICTCs (4810) and further linking them for treatment with ART centers (185) and care& support centers; CCCs (195). Different interventions/policies for areas with different HIV prevalence and HIV/TB co-infections Linkage to care, support and treatment since ART centers and the CCCs are not widely distributed Poor referral by the providers & paramedical staff, since HIV and TB, both are stigmatized diseases. Preference for private sector test

Ictc Data- TESTING & COUNSELLING Total no. of Pre-test counselling: Total testing: ( ) Total no of clients found HIV +ve:4946 (1.64% Gen + ANC) Total no. of Post test counselling: (96.16%) Total cross referral: 30065( ) Total co infection:696( )

ICTC to RNTCP & RNTCP to ICTC Cross Referrals Total no. of HIV +ve clients referred from ICTC to RNTCP:1659 Total no of HIV +ve clients reached RNTCP: 1122(67.63%) Detected TB in HIV +ve clients: 59(5.25%) Started DOTS-49, Started ART-31 Total referrals from RNTCP to ICTC:25807 Total no of TB clients found HIV +ve:446 (1.72%) Started DOTS-383, Started ART-200

ART TO RNTCP Total no of HIV +ve clients referred to RNTCP:1034 Detected TB in HIV +ve clients: 191 (18.47%) ATT started: 179 (93.71%) ART initiated- 133 (69.63%) NOTE= 6 out of state clients & 4 dead

ART Registartioin and CD4 Count Total HIV TB Coe infected Clients =696 ATT started: 615/696 (6 out of state clients & 4 dead) ie % started on DOTS ART registration of HIV-TB co-infected clients:605 ( 86.92%) No. of HIV TB co-infected clients tested for CD4 count:547 (90.41%) – No. of clients having CD4 count < 350: 390 (71.29%) – No. of clients having CD4 count >=350: 178 (32.71%) ART started in 349 /605 (57.58%)

Why Revision in Strategy is Required? –Evidence 1.ICTC to RNTCP referrals of HIV Positive cases with symptoms of TB? > 35% HIV positive cases lost to follow up Low Detection of TB- Only 5 % referred cases were diagnosed to have TB Only half of HIV-TB co-infected patients could be put on ART after starting DOTS. 2.ART centre to ICTC referrals of all HIV positive cases – >75% HIV positive cases get registered in HIV care 3.ART centre to RNTCP referral of HIV positive cases with symptoms suggestive of TB > 75% cases reach RNTCP High TB detection rate- > 18% detected with TB Approx. 70% initiated on ART after starting DOTS.

New Referral Forms

No. of DOTS centers supervi sed No. of the patient with HIV-TB Co- infection in last 6 months No. of patients with HIV-TB co- infection initiated on Tb Treatment No. of patients with HIV-TB co-infection initiated on Anti Retroviral Treatment No. of patients with HIV-TB co-infection who may have died Proforma I- Tracking Patients with HIV-TB Co-infection for initiation of Anti Retroviral Treatment after 2 weeks of ATT (to be filled by STS) Name of the District: …………………………………………… Name & Tel No. of District TB Supervisor -………………………….. Date Remarks- Pls send the information every month by10 th bymail-

S.N o. TB No. Name of DOTS centre Name of the patient with HIV-TB Co- infection Residential Address Date of Start of ATT On ART Yes- Y, No.- N If on ART, name of ART centre where getting ART Agree to Instructions of DOTS provider to go to ART Centre Yes-Y, No.-N Proforma II Tracking Patients with HIV-TB Co-infection for initiation of Anti Retroviral Treatment after 2 weeks of ATT (to be provided by STS through DOTS providers) Name of the District: …………………………………………… Name /Contact No. of STS-……………………………… Date- Remarks- Pls send the information by 10 th of every month by mail-

Thank You