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Launch of Revised Strategy of TB-HIV Cross Referrals

Launch of Revised Strategy of TB-HIV Cross Referrals. By Dr A.K. Gupta MD (Pediatrics) Additional Project Director. Delhi State AIDS Control Society Govt. of Delhi. 0.9 million TB/HIV co-infected. 400 million TB infected. 2.3 million HIV-infected. 1.8 million new TB cases.

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Launch of Revised Strategy of TB-HIV Cross Referrals

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

  2. 0.9 million TB/HIV co-infected 400 million TB infected 2.3 million HIV-infected 1.8 million new TB cases 4% TB cases HIV-infected HIV-associated TB disease in India Total population of 1.1 billion

  3. 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 Lifetime Risk of TB Source: NACO

  4. 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

  5. Early and Late Stages of HIV Infection

  6. The effect of HIV infection on symptoms and signs of TB Symptom/sign HIV positive (%) HIV negative (%) 81 62 64 83 4 21 15 13 Dyspnea Fever Sweats Weight loss Diarrhea Hepatomegaly Splenomegaly Lymphadenopathy 97 79 83 89 23 41 40 35 Chest 1994;106:1471-6

  7. Sites of involvement and HIV status Site HIV positive (%) HIV negative (%) Pulmonary Extrapulmonary Both Pleural Pericardial Lymph node 40 34 26 31 15 19 72 16 12 19 3 3 J Trop Med Hygiene 1993;96:1-11

  8. 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

  9. Effects of HIV on TB • One year mortality 20-35 % (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

  10. 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

  11. 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

  12. 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.

  13. 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

  14. Ictc Data- TESTING & COUNSELLING • Total no. of Pre-test counselling: 314963 • Total testing: 301290 (166689 + 134601) • Total no of clients found HIV +ve:4946 (1.64% Gen + ANC) • Total no. of Post test counselling:289723 (96.16%) • Total cross referral: 30065(25807 +4258) • Total co infection:696(446+250)

  15. 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

  16. 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

  17. ART Registartioin and CD4 Count • Total HIV TB Coe infected Clients- 59+446+191=696 • ATT started: 615/696 (6 out of state clients & 4 dead) ie 89.79 % 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%)

  18. Why Revision in Strategy is Required? –Evidence 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. ART centre to ICTC referrals of all HIV positive cases – >75% HIV positive cases get registered in HIV care 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.

  19. New Referral Forms

  20. 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 thbymail- delhisacs@gmail.com

  21. 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 10th of every month by mail- delhisacs@gmail.com

  22. Thank You

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