1. The Three I’s for HIV/TB and Rolling out IPT beyond Pilot -India
Dr. B. B. Rewari
WHO National Consultant
National Programme Officer (ART)
National AIDS Control Organisation
New Delhi, India

2. Content Background about the problem
Status of implementation of 3 I’s in India
Implementation of Intensified Case Finding (ICF) at HIV care settings
Airborne Infection control (AIC)
Isoniazid Preventive Therapy (IPT) –Progress till date

3. Background

4. Declining Trends of HIV Epidemic in India
Female: 38.7% of PLHA; Children: 4.4% of PLHA
Source: HIV Estimations,

5. District-wise Scenario of HIV/AIDS
Category
NACP-III A
156 B 39 C
296 D
118
New Districts 30
Total
609
Category
NACP-III Definition A
> 1% ANC prevalence in any of the sites in the last 3 years B
< 1% ANC prevalence in all the sites during last 3 years with > 5% prevalence in any HRG site (STD/FSW/MSM/IDU) C
< 1% ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG, with known hot spots D
< 1% ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG OR no or poor HIV data with no known hot spots

6. HIV and TB scenario HIV: Concentrated TB: Everywhere, highest burden
0.31% adult prevalence
2.4 million persons
Heterogeneous distribution
NACP (National AIDS Control Programme)-1992
TB: Everywhere, highest burden
About 2.3 m incident TB cases/yr
5% (110,000) HIV-infected with high mortality
RNTCP (Revised National TB Control Programme)
2009 adult HIV
seroprevalence
Overall India has low HIV prevalence, and the HIV epidemic is concentrated to some 6-9 states and few scattered districts in the rest of the country. But in terms of absolute number of cases India ranks no.3 in the world.
India has the highest burden of TB in the world, most of the TB burden is among persons without HIV. Only about 5% of TB cases are HIV infected
HIV may slow down TB control efforts in India
; magnitude variable
Enormous need for improved TB-HIV programme collaboration
Particularly efforts to reduce mortality
(0.25% – 0.39%) in The adult prevalence is 0.26% among women and 0.38% among
The estimated adult HIV prevalence in India was 0.32% (0.26% – 0.41%) in 2008 and 0.31%
men in 2008, and 0.25% among women and 0.36% among men in 2009.
and Maharashtra (0.55%). Besides these states, Goa, Chandigarh, Gujarat, Punjab and Tamil
followed by Andhra Pradesh (0.90%), Mizoram (0.81%), Nagaland (0.78%), Karnataka (0.63%)
Among the states, Manipur has shown the highest estimated adult HIV prevalence of 1.40%,
prevalence of %. All other states/UTs have lower levels of HIV.
while Delhi, Orissa, West Bengal, Chhattisgarh & Puducherry have shown estimated adult HIV
Nadu have shown estimated adult HIV prevalence greater than national prevalence (0.31%),
0.41% in 2000 to 0.31% in 2009, although variations exist across the states. The estimated
incidence (new infections) in India. Adult HIV prevalence at national level has declined from
The HIV estimates highlight an overall reduction in adult HIV prevalence and HIV
number of new annual HIV infections has declined by more than 50% over the past decade.
0.33% in However, the low prevalence states of Chandigarh, Orissa, Kerala, Jharkhand,
a clear declining trend in adult HIV prevalence. HIV has declined notably in Tamil Nadu to reach
All the high prevalence states show
Uttarakhand, Jammu & Kashmir, Arunachal Pradesh and Meghalaya show rising trends in adult
30.4) in Children (<15 yrs) account for 3.5% of all infections, while 83% are the in age
The total number of people living with HIV/AIDS (PLHA) in India is estimated at 24 lakh (19.3 –
HIV prevalence in the last four years.
group years. Of all HIV infections, 39% (9.3 lakh) are among women. The four high
Bengal, Gujarat, Bihar and Uttar Pradesh are estimated to have more than 1 lakh PLHA each
– 2.5 lakh, Tamil Nadu – 1.5 lakh) account for 55% of all HIV infections in the country. West
prevalence states of South India (Andhra Pradesh – 5 lakh, Maharashtra – 4.2 lakh, Karnataka
and together account for another 22% of HIV infections in India. The states of Punjab, Orissa,
number of PLHA due to the large population size.
for another 12% of HIV infections. These states, in spite of low HIV prevalence, have large
Rajasthan & Madhya Pradesh have 50,000 – 1 lakh HIV infections each and together account
This round of estimates has confirmed the clear decline of HIV prevalence among Female Sex
trends in many states.
Users and Men who have Sex with Men are more and more vulnerable to HIV with increasing
Workers at national levels and in most states. However, the evidence shows that Injecting Drug
Using globally accepted methodologies and updated evidence on survival to HIV with and
to AIDS related causes. The trend of annual AIDS deaths is showing a steady decline since the
2009 in India. Wider access to ART has resulted in a decline of the number of people dying due
without treatment, it is estimated that about 1.72 lakh people died of AIDS related causes in
roll out of free ART programme in India in 2004.
One of the key characteristics of this round of estimations is that it allowed for generating
HIV Incidence
estimates of the HIV incidence (number of new HIV infections per year). Analysis of epidemic
50% during the last decade. This is one of the most important evidence on the impact of the
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projections revealed that the number of new annual HIV infections has declined by more than
various interventions under National AIDS Control Programme and scaled-up prevention
While this trend is evident in most states, some low prevalence states have shown a slight
against 2.7 lakh in 2000.
strategies. It is estimated that India had approximately 1.2 lakh new HIV infections in 2009, as
Of the 1.2 lakh estimated new infections in 2009, the six high prevalence states account for only
the programme to focus more on these states with low prevalence, but high vulnerability.
increase in the number of new infections over the past two years, that underscores the need for
Madhya Pradesh and Gujarat account for 41% of new infections.
39% of the cases, while the states of Orissa, Bihar, West Bengal, Uttar Pradesh, Rajasthan,
<0.3%
0.3–0.6%
>0.6%

7. Implementation of 3 I’s

8. Status of implementation of the 3 I’s
Intensified case finding (ICF): implemented at majority of HIV care settings across the country, nearly 12,000
Infection control in HIV care settings
National Airborne Infection Control policy developed by NTP
Basic infection control practices implemented at all ART centres
Isoniazid Preventive Therapy (IPT)
National TB/HIV technical working group accepted global evidence in favor of IPT as a strategy
Operational research to study feasibility and additional value over early ART initiation underway

9. Intensified case finding (ICF)
ICF activity are implemented at Voluntary Counselling and testing centres (VCT centres called ICTC in India) since 2008
ICF at ART centres launched in 2009 and rapidly expanded in 2010
ICF further expanded to the Link-ART centres (a mechanism for decentralized CST) in 2012

10. How ICF works in India ?
Counselor at a VCT centre (or ART centre) actively looks for Tuberculosis symptoms in all clients
Clients (or HIV infected individual at ART centre) having symptom are referred to NTP diagnostic facility
How does ICF work in VCT centres in India.
Simply, counselors are expected to ask all VCT clients about TB symptoms during pre-test and also follow-up counseling sessions.
Counselors are expected to focus on cough for more than 2 weeks. Instead of an algorithm, a list of additional symptoms are provided to prompt referral. These include fever, weight loss, pleuritic chest pain, hemoptyis, and swelling in neck/axillae
Counselors refer clients with symptoms to a microscopy center using the sputum referral form, similarly the ART centre nurse refers HIV infected individuals with cough of any duration for evaluation of TB.

11. How ICF works …cont.
All referrals are enlisted by NACP staff and the list is shared with NTP staff monthly
The NTP staff provide information on
Outcome of the investigations
Status of TB treatment
Monthly TB/HIV reports are generated jointly by NACP and NTP staff and reported in the MIS
Recording is done by a register, kept at the VCT centres, where all referrals are recorded.
This list is passed on to the TB programme monthly, where staff check the microscopy center and TB registers for referral completion, diagnostic outcome, and TB treatment initiation under DOTS. Then each VCT submits a monthly VCT TB-HIV report, the one-pager shown here, jointly to the AIDS and TB programmes. Throughout this process, the HIV status as per programme policies is kept confidential with the VCT counselor. The TB programme staff are not informed of the HIV status of the patients they are reporting on.

12. ICF at VCT centres - Trend
Total ICTC clients reported in ICF reports – Million, and million. About 6% of ICTC clients are identified as TB suspects and referred to TB programme for diagnosis

13. ICF at VCT centre- Tuberculosis detection
Total clients attending VCT
Total TB suspects identified
Total TB cases detected
TB cases notified under the NTP
Contribution by ICF to total TB notification
2010
7,678,746*
484,617
51,412
1,521,438
3.4%
2011
9,774,522
580,689
55,572
1,515,872
3.7%
2012 (Upto April 2012)
3,255,630
196,039
16,861
364,338
3.6%
Total Number of VCT centres in India: 5225
* 22/29 states reported on ICF, while all states reported in 2011

14. ICF in Six HIV high prevalent states -India
Total clients attending VCT
Total TB suspects identified
Total TB cases detected
TB cases notified under NTP
Contribution by ICF to total TB notification
2010
5,086,718
369,918
34,932
409,233 9%
2011
5,6479,97
419,560
36,622
404,423
2012
1,652,398
136,055
11,081
100,410
11%
ICF at VCT centres is established well in the high HIV prevalent states in the country and it contribute upto 10% to the overall TB case notification under the national programme

15. Reporting and performance of ICF at ART centres
About 12,000 TB suspects are identified every month and >2500 TB cases are detected through ICF at ART centres

16. ICF at ART centres Year Total ARTC footfalls (cumulative)
Total TB suspects identified
Total TB cases detected
Total initiated on ATT
2010
1,748,431
56,739
15,911
13,318
2011
3,822,281
111,521
28,435
23,773
2012
(Upto April 2012)
1,820,100
47,185
10,722
8,822
Proportion TB suspects: Between 3% (About 5% in High prevalent states)
Proportion TB suspects found TB: about 23% to 28%
Proportion linked to ATT under national programme: 84%

17. (Air-borne) Infection Control (AIC/IC)

18. OPD and ART waiting area

19. Infection Control
National AIC Guidelines (NAIC) developed and adopted by National TB Programme
Pilot completed (AP, GU, WB)
Recommended Infection control measures included in training module for HIV care staff
Officers at NACP sensitized regarding need of IC
Risk assessments being undertaken by NACO at all ART centers, to be followed with site-specific interventions

20. Infection Control activities implemented at ART centres
Administrative measures
Infection control plan and SOPs
Staff education and training – Included in training module
Identification of staff for AIC activities
Counseling of TB patient regarding cough etiquettes
Triage: Fast-tracking of cough symptomatic through waiting area, consultation, investigation and drug collection
Display of IEC material for cough etiquettes, TB screening etc.
Environmental measures
Promotion of Natural ventilation in waiting area
Appropriate sitting arrangement considering cross-ventilation
Personal protection measures
Provision of surgical masks to symptomatic patients
Facilities for hand wash etc.

21. Recommended arrangement of patients and staff
Optimal arrangement of patients and staff being implemented in all outpatient departments, ART centers, and ICTC

22. Messaging on Cough Etiquette at ART centres22 22

23. Challenges in implementation of AIC
ART centres established in space available within exiting hospital buildings
State government and Hospital authorities not keen for structural modification considering cost implication
Large patient burden in general and ART centres
No provision for the Costly N-95 respirators/masks for staff
NACP is advocating for AIC measures in all newly constructed hospital buildings

24. Isoniazid Preventive Therapy (IPT)

25. Progress till date…
IPT strategy is under consideration at NACP since early 2010
It was deliberated in meetings of the National technical working group for TB/HIV (NTWG)
The NTWG recommended conduct of operational research study at 5 ART centres to study the feasibility
A workshop for development of protocol for operational research on IPT at 5 ART centres was held in April 2010 at NACO
The protocol developed in this workshop a was not executed due to change of guard in both NACP and RNTCP
All Key officers associated with the project were transferred

26. NARI consultation
The issue got a Philip with National level consultation hosted by National AIDS Research Institute of India in January.
leading HIV researchers and experts participated in this consultation and deliberated on need of IPT use in the country perspective.
International experts presented the evidence forming basis of WHO recommendations on IPT and other global experience in use of IPT.
The overall recommendations for National Programme:
The evidence on efficacy of IPT to reduce TB incidence in PLHIV is clear
Trials from India have also demonstrated efficacy of IPT (Pre-ART era)
The fear of increased risk of INH resistance is unfounded

27. Concerns of National Programme managers
Evidence from India on usefulness of IPT from Pre-ART era
Several RCT demonstrated that ART reduces TB incidence by %
India adopted early ART initiation strategy in late 2011 (CD4 less than 350/cumm)
Lack of evidence from India regarding add-on benefit of IPT over early ART initiation
Is IPT feasible to implement in India? 1.5 million in HIV care

28. NTWG decision Concerns were deliberated in NTWG meeting in June 2011
The NTWG recommended to request National Institute for research in Tuberculosis (NIRT) to conduct an IPT efficacy cum operational feasibility study and guide the National Programme
The NIRT developed two separate protocols –Adult and Children and submitted for approval of NACO
NACO approved the protocol in October 2011

29. Proposed IPT study
Study in 15 ART centres across 3 states in South India and 2 states in North
Study design :
A prospective cohort study
Pre-post comparison –to study efficacy of IPT
Implementation in routine programmatic settings with no additional human resources to test feasibility of the strategy
Sample estimate:
Assumption 50% reduction in TB breakdown due to IPT among patients followed up at ART centres
Minimum sample required to estimate TB incidence with 95% confidence and 1% precision is 6000

30. IPT Study…cont.
Inputs in the study include training of staff, introduction of limited records and reports and supervision & monitoring
The funds required for above inputs are proposed through the Model DOTS Project arrangement of NIRT with WHO SEARO
The drugs required (Isoniazid and Vitamin B6) to be mobilized by Central TB division
NIRT obtained approvals of Scientific Advisory Committee and institutional ethics clearance in January-February 2012
Preparations for the study underway
Enrollment pending due to non-receipt of funds

31. IPT Next step NTWG meeting held on 19th July 2012
Progress of study reviewed. Another study proposed by AIIMS on efficacy not approved and PI asked to be part of this feasibility study
Informed that funding is now available from WHO
Data presented on IPT study from Myanmar where CIPT is being implemented
Hope to start study by next month

32. Thank you