launch of revised strategy of tb- hiv cross referrals delhi state aids control society govt. of...
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Launch of Revised Strategy of TB-HIV Cross Referrals
Delhi State AIDS Control SocietyGovt. of Delhi
ByDr A.K. Gupta
MD (Pediatrics)Additional Project Director
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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
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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
10%
60%
0%10%20%30%40%50%60%70%
PPD+/HIV-negative PPD+/HIV+
Source: NACO
Lifetime Risk of TB
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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
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Early and Late Stages of HIV Infection
FeaturesStage of HIV Infection
Early Late
Clinical Presentation
Often resembles Post-primary TB (Adult Type)
Often resembles primary TB
Sputum Smear Result
Often positive Often negative
Chest X-ray Appearance
Often shows cavities
Atypical presentation, often infiltrates lower lung-field lesions, intra-thoracic lymph nodes & infrequent cavities
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The effect of HIV infection on symptoms and signs of TB
Symptom/sign HIV positive (%) HIV negative (%)
DyspneaFeverSweatsWeight lossDiarrheaHepatomegalySplenomegalyLymphadenopathy
9779838923414035
81626483
4211513
Chest 1994;106:1471-6
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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
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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
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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
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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
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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
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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.
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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
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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)
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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
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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
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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%)
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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.
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New Referral Forms
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No. of DOTS centers supervised
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- [email protected]
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S.No.
TB No. Name of DOTS centre
Name of the patient with HIV-TB Co- infection
Residential Address
Date of Start of ATT
On ARTYes- 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
12345678910
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- [email protected]
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Thank You