Training Manual on Intensified A TB/HIVPackage for NACP & RNTCP Programme Managers at State and District level
Item
- Title
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Training Manual on Intensified
A TB/HIVPackage
for NACP & RNTCP Programme Managers
at State and District level - extracted text
-
4M
A
Training Manual on Intensified
TB/HIV Package
for NACP & RNTCP Programme Managers
at State and District level
/
Central TB Division and National AIDS Control Organization
Ministry of Health and Family Welfare
Government of India
New Delhi
DOTSsure cure for TB.
June 2008
( '
Intensified TB/HIV package
Training Manual for NACP & RNTCP Programme Managers
and Supervisors at State and District level
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Index
1.
Preface
2
2.
Acknowledgements
3
3.
Introduction
4
4.
Routine offer of HIV testing to all TB patients
5
5.
Cotrimoxazole Prophylaxis Therapy (CPT)
8
6.
Anti - retroviral therapy (ART) for HIV infected TB patients
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7.
Intensified TB Case Finding at ART Centres
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8.
Monitoring and supervision
18
9.
Monitoring indicators
27
10.
Annexures
30
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Preface
It
It is
is estimated
estimated that
that 2.5
2.5 million
million people
peopL are infected with HIV in India and considering
estimated 40% of the Indian population is infected with Mycobacterium tuberculosis, an
estimated 1 million persons are co-infected with Mycobacterium tuberculosis & HIV. HIV
is the most powerful risk factor for the progression of 1B infection to PB disease. Active
TB disease is the commonest opportunistic infection amongst HIV-infectedjndividuals
and is also the leading cause <of death in PLHA (People living with HIV/AIDS). This is
further substantiated by the fact that an HIV positive person has 50-60% lifetime risk of
developing TB disease as compared to an HIV negative person who has a lifetime risk of
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10% of developing the TB disease.
HIV survey amongst the TB patients jointly conducted by CTD & NACO has shown 1%
to 13% HIV amongst TB patients. This diverse data shows us that different strategies need
to be employed within the country to reach out to PLHAs and addresses their needs for
early diagnosis, treatment and care & support. The need of the hour is to establish an
intensified package of services for TB-HIV for high HIV prevalence areas and a basic
package for the rest of the country'.
TB can be easily cured through the DOTS strategy provided through RNTCP; there is still
no cure for HIV. With ART being provided free through NACP, HIV is now a chronic
manageable illness.
The basic purpose of HIV-TB collaborative activity is to ensure synergy between the two
programmes for the prevention and control of both diseases. National Framework for
joint TB/HIV collaborative activities has been laid down by both the programmes and the
collaborative activities have yielded very promising results over the last few years. In order
to further strengthen the collaborative activities training of staff is very crucial. To
streamline training, both the programmes have come up with joint modules which address
the training needs of various categories of staff. It is envisaged, diat standardized modular
training shall be imparted to all the Programme and general health staff in the country.
The modules cover the relevant aspects of both the diseases comprehensively, and will be a
valuable guide for the different category of health service provider towards discharging
their duties optimally. We hope this module would be useful for further strengthening the
TB/HIV collaborative activities in the country.
';r
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(Dr. Jotna Sokhey)
Addl. DG & APD (NACO)
(Dr. L. S. Chauhan)
Deputy Director General (TB)
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Acknowledgements
This training material has been prepared jointly by Central TB Division, DGHS 8c
National AIDS Control Organization tor the training of programme managers under the
guidance of Dr Jotna Sokhey, Addl DG, NACO and Dr LS Chauhan, DDG (TB) CTD,
DGHS by a writing group comprising of Dr. A. K. Khera, Dr. Devesh Gupta, Dr. Neeraj
Raizada, Dr. Rahul Thakur and Dr. Puneet Dewan.
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INTRODUCTION:
Active TB disease is the most common opportunistic infection amongst HIV infected individuals.
From the public health point of view, the best way to prevent TB is to provide prompt effective
diagnosis & treatment to people with infectious TB. This interrupts the chain of transmission. For
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HIV-infected patients who have TB, they will benefit from HIV-related care and treatment. Basic
TB/HIV collaborative interventions are necessary across the country. These include the establishment
of coordination mechanisms at all levels, service delivery coordination and cross referrals,
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involvement of NGOs in TB/HIV activities, and implementation of airborne infection control
measures in HIV care settings.
Surveillance has shown that where HIV seroprevalence is high, HIV infection among TB patients is
also common. Because of this association, in areas where HIV seroprevalence is high and HIV
testing services are widely available, it is important that patients with tuberculosis have the
opportunity to know their HIV status. An Intensified TB/HIV Package of Services has been
established for high HIV prevalence areas. This package would facilitate early detection of HIV
infection in IB patients and promote early access to HIV care and treatment, and is expected to
reduce death and disease among HI V-infected TB patients.
HIV counselling and testing and care and treatment services including management of OIs,
Cotrimoxazole Prophylaxis and access to ARI is rapidly expanding and widely available under the
National AIDS Control Programme. Management of TB is provided through widely acclaimed DOTS
strategy under RN TCP which now provides emphasis amongst H1V/TB patients for management of
TB and early linkage to care & support services.
The expanded scope of a new approach to TB control in populations with high HIV prevalence
comprises of up scaled interventions against TB and HIV. Interventions include intensified case
finding at high HIV settings like ART centers, Community Care Centers (CCCs), NGO led Targeted
Intervention sites (Tls). This would help in early diagnosis of HIV/TB patients and provision of care
& support including DOTS treatment for TB, CPT prophylaxis and ART. Counsellors and clinicians
at HIV care settings regularly interact with persons living with HIV and thus are in the key position
to refer to the nearest RNTCP services when indicated. Therefore, the crucial service delivery sites of
NACP i.e. ICTCs, ART centres, Community Care Centres, and Targeted Intervention sites should be
effectively involved for implementation of the up scaled activities.
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ROUTINE OFFER OF HIV TESTING TO ALL TB PATIENTS
Rationale
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HIV counselling and testing is now widely available under the National AIDS Control Programme,
for persons who are HIV-infected, care and treatment services are also widely available, and access to
treatment for HIV infection is rapidly expanding. Surveillance has shown that where HIV
seroprevalence is high, HIV infection among TB patients is common. Because of this association, it is
important that patients with tuberculosis have the opportunity to know their HIV status. This will
allow appropriate prevention, care, and treatment for patients and their families.
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HIV testing of TB patients
Central TB Division (CTD) & the National /\1DS Control Organization (NACO) have adopted the
policy of routinely offering voluntary HIV counselling and‘testing to all TB patients as part of
an intensified TB/H1V package of services for states with the highest HIV burden. This policy will
facilitate early detection of HIV infection in TB patients, and lead to early access' to HIV care and
treatment. These interventions are expected to reduce death and disease among HIV-infected TB
patients.
In these states, providers will routinely offer of voluntary’ counselling and testing for all TB patients,
except those with an already known HIV status. “Known” HIV status means those patients with a
history/ of positive HIV test from an ICTC or those with a negative HIV test from ICTC within the
past 6 months. HIV test results from ICTCs are preferred because there HIV testing uses reliable
laboratory kits, is conducted using a multiple-test algorithm to reduce false results, and is properly
accompanied by counselling.
TB patients with unknown HIV status are to be referred to the nearest and most-convenient ICTC.
The referral may be made any time after TB diagnosis, during or after initiation on TB treatment
(preferably at the earliest). Treating physicians and paramedical workers should explain the need and
importance for patients to be confident about their HIV status, and also that HIV testing is
Voluntary’ and ‘not mandatory’. This offer should be made at least once during the course of TB
treatment.
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If the patient accepts the advice for VCT, then the patient is referred to the nearest ICTC using the
standard “Integrated Counselling and Testing Centre referral form” (Annex 2). The counsellor
during the counselling session should spend adequate time with the TB patient to explain the
importance of sharing their HIV rest result with the treating physician, for better care. To facilitate the
process of routine referral of TB patients a one-page tool (Annex 1) reminding providers about the
need to determine the HIV status ofTB patients should be widely disseminated to all PHIs, and used
during medical officer, nursing, and paramedical staff trainings.
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______________________________________ KEY POINTS_______________________
> All TB patients should have the chance to know their HIV status.
Quality-assured HIV counselling and testing is available widely at ICTCs.
> All TB patients should be routinely offered voluntary HIV counselling and testing.
All HIV-infected TB patients should be provided CPT and promptly referred for ART.
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What should programme officers know?
> Providers and paramedical staff will require training and monitoring to implement new policy and records.
> HIV status and CPT/ART will be recorded on TB treatment cards, TB registers, and for the cohort will be
reported on quarterly reports.
> CPT will be provided locally to HIV-infected TB patients at PHI level, facilitated by RNTCP
The recording of HIV status and updating of CPT and ART information on treatment cards must be
included in routine monitoring and supervision activities.
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What should providers and paramedical staff do?
> Refer patients to nearest ICTC.
> Who need NOT be referred to an ICTC?
o Patients who report being HIV-positive, with results from an ICTC.
o Prior HIV test result negative from an ICTC in past 6 months.
> Use the referral form to facilitate feedback.
> Document HIV status on treatment card.
> Patient history alone is adequate to record HIV status.
> Prescribe CPT and ensure prompt referral to ART centre.
> Follow up with patient to ensure CPT and ART being taken.
> Document CPT and ART on original TB treatment cards only
Communication of HIV test result to treating physician: ‘Shared CONFIDENTIALITY’
ICTC Counsellors will counsel patients to share their HIV result with the referring physician. In
addition, unless patients object counsellors should directly and confidentially share HIV test results
with the referring or treating physician, to ensure optimal care & case management. Knowledge of
HIV status will enable providers to:
•
•
•
•
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Provide the correct anti-TB treatment and correctly manage other illnesses.
Counselling to reduce risk to current and future partners
Linkage to social support services
Initiate Cotrimoxazole Preventive Therapy (CPT).
Prompt referral for anti-retroviral treatment.
The mechanisms for sharing the HIV status of referred TB patient, by the counsellor with the
treating physician are as under:
1. Through the client: The Counsellor counsels the client to share the HIV test result, completes
the referral form, and sends the form via the client to the referring physician. Also while referring
a known HIV-infected clients suspected of having TB to RNTCP, the counsellors asks client to
share his/her HIV test report with the treating physician.
2. By the counsellor: When the physician referring the TB patient for HIV testing which is
physically located in the same premises as the
ICTC or in very close proximity, after advising
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the patient the ICTC Counsellor can personally share the HIV result with the concerned Medical
Officer.
3. By the counsellor —telephonically: The counsellor can, alter advising the client, communicate
the HIV test result to the treating physician telephonically, using the telephone of the facility
where the ICTC is located.
In case the TB patient raises his/her objection to the direct communication of the HIV test result
from the ICTC to the medical officer, his objection should be honoured and the HIV test result
should not be communicated directly by the counsellor to the referring physician. Treating physician
shall record the HIV status of the TB patient on the original TB treatment card in the provided space,
along with date of testing. Th HIV status shall not be recorded on the duplicate treatment card, held
by community DOT provider
It is the responsibility of the PHI staff to maintain the confidentiality of the HIV status of the TB
patients with in the health system.
Recording of HIV status on PHI-held TB treatment Cards
Treating physician shall record the HIV status of the TB patient on the original TB treatment card
in the provided space, along with date of testing (Figure). The HIV status should not be recorded on
the duplicate treatment card, held by community DOT provider.
Figure: Back of TB treatment card, and space for recording HIV status and additional treatment
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If HIV status of the patient is known, tick the appropriate box (‘Pos’ or ‘Neg’) and record the
date of test. For patients who decline HIV testing, tick ‘Unknown’
Patients should not be required to show proof of HIV test results for recording on treatment
cards, but documentation of positive HIV test results from an ICTC is required by NACP
ART centres.
If the HIV status is ascertained during the course of TB treatment, the latest information
should be updated on the card.
If HIV status of the patient remains unknown at the end of rhe treatment, tick the appropriate
box (‘unknown’), at the time of declaring treatment outcome for the patient.
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COTRIMOXAZOLE PROPHYLAXIS THERAPY (CPT)
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Co-trimoxazole is a fixed dose combination of sulfamethoxazole and trimethoprim, it is a broad
spectrum antibiotic that targets a range of gram-positive and gram-negative organisms, fungi, and
protozoa. Co-trimoxazole can also be given routinely for the 'prevention of opportunistic infections in
HIV-infected persons; this strategy is called Cotrimoxazole prophylaxis th'erajSy:
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Why provide CPT?
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Reduces morbidity and mortality of HIV-infected patients
All HIV-infected TB patients registered under RNTCP arc eligible for CPT, irrespective of
their CD4 counts.
Eligibility
All adults (> 14 years old) who are HIV-infected with tuberculosis disease on RNTCP treatment are
to be prescribed CPT. Patients who report being HIV-infected should have their HIV status
confirmed at an ICTC if not yet done. CPT can be prescribed at any point during TB treatment,
whenever HIV-infection is determined. Pregnant patients are also eligible, regardless of foetus
gestational age. Patients with a history of a serious drug allergy to sulpha drugs or known glucose-6
phosphate dehydrogenase (G6PD) deficiency should be excluded.
Prescribing CPT
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No baseline laboratory investigations are required to initiate CPT
Dose for prophylaxis for adults (> 14 years old) and > 30 kg body weight): 960 mg (800 mg
sulfamethoxazole + 160 mg trimethoprim) daily.
Daily (self-administered), one tablet per day
Taken alongside anti-tuberculosis treatment (ATT) and /\RT
CPT is provided to patients in monthly packets.
CPT is self-administered by the patient on a daily basis, and not under direct observation.
Duration of treatment
Co-trimoxazole is to be given for the entire duration of TB treatment. After TB treatment, CPT
should be continued from the patients’ ART centre.
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Treatment interruptions
Patients who do not take CPT do not get the prophylactic benefits. If patients are noted to have
interrupted CPT, counselling by the health staff (including medical officer) is recommended to
promote adherence at the next available opportunity. There is no “Default’ in CPI; the treatment is
voluntary. Patients who have interrupted CPI may choose to re-start and continue later.
Children
HIV-infected children are recommended to be provided lifelong CPT. Paediatric formulations of
cotrimoxazole are available at ART centres. Paediatric HIV patients are to be immediately referred to
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the most convenient ART centre for CPT and ART evaluation and initiation.
Clinical and laboratory monitoring of patients on CPT
No baseline laboratory investigations arc required to initiate CPI. Drug-related side effects to
Cotrimoxazole are uncommon and usually occur within first 2 weeks of starting treatment. W hen
initiating treatment, patients should be asked to report side effects as soon as they are recognized.
Clinical monitoring should be carried out regularly, at least once every three months. During clinical
monitoring visits, adherence should be encouraged. No specific laboratory monitoring is required
among children or adults receiving CPT. Although Cotrimoxazole can induce haemolytic anaemia in
patients with G6PD deficiency, routine testing for G6PD deficiency is not indicated.
Side effects
Major side effects are uncommon, but may occasionally occur. Anaemia, allergic reactions, skin rashes
and yellowing of skin/eye are the major side effects for which the patients need to consult the treating
physician. Loss of appetite, joint pains, nausea and vomiting arc other minor side effects. Severe
adverse reactions to Cotrimoxazole are rare, bur include exfoliative dermatitis, erythema multiforme
(Stevens Johnson Syndrome), severe anaemia, and pancytopenia. Because patients are usualh taking
other medications with similar side effects (e.g. isoniazid, pyrazinamide, efavirenz), care must be taken
during clinical evaluation. Patients with serious side effects should be referred to a higher level centre,
for evaluation and treatment by a physician comfortable with desensitization.
Discontinuing Cotrimoxazole prophylaxis
Serious side effects should lead to prompt discontinuation and referral for care, ()thcr\visc.
discontinuation of CPT would be decided upon by the ART centre, depending on the immune
recover}' due to z\RT.
Mechanisms for CPT delivery to HIV-infccted TB patients
CPT delivery sites:
a. At all the ART Centres, and
b. At all PHIs in the districts having a Medical officer and an institutional DOF centre,
supervised by RNTCP in coordination with NACP.
The treating physician should:
Initiate him/her on CPT from the institutional DOT centre, while also assessing the
a.
relevant history of adverse reaction to sulpha drugs.
The treating physician prescribes CP 1 by ticking the relevant cell on the TB patient
b.
identity card (Page 23).
Records the prescription of CPT on the TB treatment card (PH I-held, original treatment
card) (Page 7).
d. Asks these clients to report to the PHI in case of any adverse drug reaction
on the importance of regular follow-up examination and advice the
e. Counsels the patient
client to come for monthly examination to monitor the progress of treatment.
c.
f.
Bor children and very low-weight adults (<30 kg), because alternate formulations of CPT
are not provided under this decentralized mechanism, CPT for these patients is to be
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managed by ART centres.
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At the PHI, institutional DOT provider (pharmacist/ health worker) should:
a.
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Provide a monthly supply of CPT on seeing the TB identity card.
b. Record the date of delivery of CPT on the space provided on TB treatment card
c.
Ask the client to come on a monthly basis to collect the monthly supply of CPT.
d. Encourage the patient to meet the MO for clinical evaluation, at time of these monthly
visits to the PHI.
HIV-infected TB patients getting TB treatment from community DOT provider would get his
monthly CPT supply from institutional DOT centre and continue getting TB treatment from
community DOT provider. Records of HIV status, CPT delivery and ART are not be updated on
the duplicate TB treatment card kept with the community DOT provider.
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All HIV-infected TB patients initiated on CPT should be provided counselling on adherence to
CPT by the ICTC counsellor at the time of each contact. The clients would also be encouraged to
come for monthly/ regular clinical examination by the treating physician to evaluate progress of
HIV disease & TB treatment.
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STS during their each monthly visit to each PHI should:
1. Collect data on HIV test result of the TB patient, initiation on CPT, referral for ART, and
initiation on ART from each TB treatment card and update the same in TB register (Page 2223)
2. This information shall be reported in the district RNTCP quarterly case finding and results of
treatment RNTCP reports (Page 23-24).
Transition of CPT for HIV-infected TB patients
During TB treatment - CPT should be made available to the patient at the PHI for the duration of
TB treatment, or till the time the patient takes CPT from the ART centre. Feedback from the
ART centre regarding initiation of CPT is essential to ensure a smooth transition.
In case the HIV-infected TB patient is already on CPT before the initiation of TB treatment, CPT
can be continued from that source.
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After TB treatment — After the completion of TB treatment the HIV-infected client is to continue
CPT from ART Centre. Also if the HIV-infected TB patient is initiated on ART during TB
treatment, he is to continue CPT along with ART from the ART Centre.
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Summary' of mechanism for providing CPT for 1 IlV-infected TB patients
7’
HIVr-infecred TB patient
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Treating physician;
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Prescribes CPT
Checks CPT box on patient 'IT ID card
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Pharmacist:
Provides monthly pouch of CPT
Records date of deliver on PHl-held original TB treatment card
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Monthly follow-up
IB patient returns monthly for CPT refill; Pharmacist re tills & records date on card
If ART initiated, then CPT is to be provided by ART centre instead
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After TB treatment completion.:
Patient to be referred again to ART centre for CPT and ARI re-evaluation
CPI’ should continue from ART centre
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Monthly recording and drug indent
Pharmacists indents CPT using monthly PHI report on CPT
STS updates TB register from TB treatment cards
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CPT Drug supply management
Management of drug supply of cotrimoxazole (CTX) is challenging due to the irregular duration of
treatment. Patients may start CPT late, may transition to CPT from ART centre at any time during TB
treatment, may die or default from TB treatment, may interrupt CPT, or may even require more than
6 months in the case of Cat II patient or extensions of TB treatment. Therefore the system for CTX
supply management is similar to RNTCP prolongation pouches.
Cotrimoxazole (CTX) for provision of CPT to HIV-infected TB patients are to be procured by the
State AIDS control societies and supplied in monthly packs containing contain 30 tablets of
Cotrimoxazole 960 mg (800 mg sulfamethoxazole + 160 mg trimethoprim) to the ART Centre and
District TB officer.
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At the time of initiation of CPT availability in a district:
o All PHls should be supplied with 10 CPT monthly pouches, to account for patients
immediately eligible for CP I and to have a CPT buffer supply.
All TU’s should maintain a stock of one quarter’s requirement, which should be a
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number pouches of equal to
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[6*(5% of the number of TB patients registered the previous quarter)].
AB Districts should maintain a stock of one quarter’s requirement, which should be
a number pouches of equal to [6*(5°/o of the number of TB patients registered the
previous quarter)].
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The CPT should be stored in the Pharmacy of die PHI; the Pharmacist is to maintain a
record of stock in the regular PHI Stock Register.
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On a regular monthly basis, PH Is should obtain CPT pouches from the concerned TU
based on their actual requirements, considering the number of CPT pouches consumed,
and the number HIV-infected TB patients detected. Regular re-supply of CPT pouches are
requested from the TU headquarters using the monthly PHI CPT Indent (Annex 4).
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TU will supply CPT monthly pouches to the PHI on the basis of the number of pouches
requested.
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The stock and requirement of the TU for CPT monthly pouches should be reported by
the TU to the district level in Quarterly TU CPT Report (Annex 5).
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The District TB cell based on these requests, supplies CPT monthly pouches to TU.
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On a quarterly basis, the District TB Cell is to indent supply requirement of CPT monthly
pouches from the District AIDS prevention and Control Unit (DAPCU) (or SACS if
DAPCU not estabUshed) by the ‘Quarterly District CPT Report’ (Annex 6).
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In addition, emergency indent can also be made in case of urgent requirements.
Summary of mechanism for providing CPT for HIV-infected TB patients
DAPCU*
A
ART Centre (for drug storage)
Quarterly indent
Quarterly supply
DTC
Quarterly indent
Quarterly supply
TU
Monthly indent
Monthly Supply
v
Medical Officer - MO (PHI) (dispensed at PHI DOT Centre)
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Monthly Supply
CPT to HIV-infected TB patient
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ANTI-RETROVIRAL THERAPY (ART) FOR HIV-INFECTED TB
PATIENTS
Anti-retroviral drugs act by blocking the action of enzymes that are important for replication and
functioning of HIV. The drugs must be used in standardized combinations (usually three drugs
together). Anti-retroviral therapy (ART) results in reductions in morbidity and mortality’ in HIVinfected people. For ART to remain effective, extremely good adherence is required. Intensive
counselling, support, and monitoring are required.
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ART eligibility criteria for HIV-infected TB patients
All HIV-infected TB patients are in HIV clinical stage 3 or 4 (Pulmonary TB-Stage 3 & Extrapulmonary' TB-Stage 4). NACO recommends (March, 2007) that ART be given to:
• All patients with extrapulmonary TB (stage 4) and
• AU those with pubnonary TB (stage 3) unless CD4 count is > 350 cells/mm3.
Most HIV-infected TB patients will be eligible for ART. The decision of the ART Centre Medical
Officer for r\RT initiation should be based on NACP ART guidelines. In general, ART should be
initiated for eligible HIV-infected TB patients as soon as possible as per NACP ART guidebnes.
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Linking HIV-infected TB patient with ART Centres
Smear-positive TB patients should be asked to attend the ART centre only after completing at least 2
weeks of intensive phase anti-TB treatment (i.e. 6 doses), and to carefuUy ‘cover your cough’ with a
cloth. This is to reduce the risk of TB transmission of TB to other persons seeking care in the same
place.
HIV-infected TB patients not already on ART should be referred using the standard ART Centre
referral form” (Annex 3). The referral to ART centre should also be recorded on the TB treatment
card. TB treatment is the priority, and should not be interrupted by ART referral. However, prompt
referral and evaluation for ART are also very important. For those patients already on ART, prompt
referral is also important so that their ART drugs can be adjusted to account for their TB treatment.
While referring the HIV-infected TB patient to ART centre, the client must be counselled by the
treating/referring physician and the ICTC counsellor on:
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The importance and free availability of ART
The locations of ART centres
The need to take the ICTC HIV test report to the ART centre for confirmation of HIV status
Procedure of pre-/XRT evaluation including CD4 testing
The days on which the CD4 testing is available at the respective AR f centre.
Process at ART Centre
1. In view of advanced clinical stage of HIV disease, HIV-infected TB patients are to be evaluated
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for ART on priority. HIV-infected TB patients should be prioritized for CD4 testing.
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2. The ART Centre staffs are to record patients’ TB number and name of referring unit in the pre
ART register (along with ‘entry point code’) and ART- register.
3. If the HIV-infected TB patient is initiated on ART, they would also continue their CPT from the
ART Centre.
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4. The ART Centre staffs are expected to provide feedback to the referring physician.
Mechanism for feedback from ART centres to the referring physician:
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1. Feedback is to be provided by the ART centre MO on the referral form sent from TB treating
physician.
2. The patient is to be counselled by the ART centre staff to share the ART patient booklet and
treatment history with the TB treating physician
3.
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An ART Centre staff should attend the district level monthly RNTCP meeting for better
coordination.
4. The ART centre staffs are to on a monthly basis compile a list (Annex 7) of those ART clients
who were on RNTCP TB treatment during that month, including TB number, and share the same
with the DTO. For patients from other districts, that list should be forwarded to the respective
DTO of the neighbouring district. This information can be directly updated onto TB registers.
The initiation on ART should be recorded on the original TB treatment card with the date of ART
initiation and ART registration number. If the HIV-infected TB patient is nor been initiated on ART
after their initial referral, s/he should be again referred to the ART centre after completion of TB
treatment for ART re-evaluation, and for continuation of CPT.
Reporting by the ART Centre
A section is to be added in the regular ART centre reporting formats on the number of TB patients
received from RNTCP, of this number on pre- ART care, and number on ART & CPT.
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INTENSIFIED TB CASE FINDING AT ART CENTRES
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HIV-infected persons attending ART centres for pre-ART registration have a high prevalence of
TB disease. The incidence of TB disease among ART clients is also very high. While ART reduces
the risk of TB disease, this risk is still remains many times higher than the general population.
Hence intensified TB case finding at ART centres is very important for early suspicion and
diagnosis of TB. The ART guidelines describe that all patients coming to centre should be
screened for opportunistic infections specially TB before start of ART. 1 he ART. centres MO
should have a very high index of suspicion for TB and ensure that TB disease in clients attending
ART centre is not missed. This provisional guidance is intended to define the rnuumum Standard
for TB disease screening among clients attending ART centra. This guidance is expected to
evolve, as ongoing and planned operational research will clarify the optimum screening and
diagnostic procedures for TB.
WHAT to do:
,
z
..
Counsellors & Other Para-medical staff of ART Centre: Screen ail patients (even if no
complaint), for the following signs and symptoms:
Symptoms
■ Cough (of 2 week duration and/or of any duration with a history of contact with a sputum
smear positive pulmonary TB patient)
■ Cough with blood in sputum, any duration
■ Fever
‘
■ Unexplained weight loss, excessive fatigue/night sweats/ loss of appetite
■ Pleuritic chest pain (increasing on cough/deep breathing)
■ Swelling in the neck, arm-pits, groin, abdomen, joints, etc.
If symptoms are suspicious for TB disease are present.
• ART Centre health staff to refer patient to ART MO for clinical evaluation
• ART Centre medical officer to refer patient on the same day for:
1. Sputum microscopy to the institutional Designated Microscopy Centre
2. Chest X-Ray, if indicated as per NACO ART guidelines
3. For additional investigations as clinically indicated in ART guidelines
)
WHEN to do it:
At all patient encounters at the ART centre
• Pre-ART registration & follow-up visits
•
•
ART initiation
Monthly visits to ART centre &. ART medical follow up (6 monthly)
•
Unscheduled follow-up visits
TB diagnosis and treatment:
• TB Diagnosis to be clone based on RN TCP diagnostic algorithm
• In case the client has three negative sputum smear examination results, but has abnormal
CXR, diagnosis of TB disease should be decided in clinical consultation between ART MO &
RNTCP MO.
15
5
•
•
•
l
................
AD patients diagnosed with TB disease should
be initiatedI on RNTCP DOTS as quickly as
possible and be referred for treatment to a DOTS centre near their place of residence.
Once client is initiated on TB treatment, feedback to be provided to ART Centre.
For clients not initiated on ART so far, once the TB treatment is started, ART should be
considered as per NACP guidelines.
Recording:
• Referral to RNTCP: Use standard RNTCP sputum referral slips, indicating patient is from
ART centre
• At RNTCP DMC: In the RNTCP Lab register, ART Centre is to be recorded as the referring
centre
• Initiation on DOTS: As per RNTCP referral for treatment mechanism, by DMC staff
• At ART Centre: TB diagnosis & initiation on DOTS to be recorded on ART treatment cards
& registers, per NACO guidelines
I
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16
INTENSIFIED TB CASE FINDING AT ART CENTRES:
Quick verbal TB symptom
screening at each
encounter
---------------- ——►------------------------ ——
Any of the below:
•
Symptoms not
present
•
•
•
•
Routine Care
•
('ough of 2 weeks &/or H/O contact
with TB patient
Haemoptysis
Fever
l.xcessivc fatigue/night sweats/ loss
of appetite /wt loss
Pleuritic chest pain (increasing on
c< )ugh/clccp breathing)
Swelling in the neck, arm-pits, groin,
abdomen, joints, etc
-,
r ~
Evaluation by ART MO
Referral for sputum
examination using
sputum referral form
(directly or via OPD)
Other investigation as
per symptoms (for extra
pulmonary TB)
I
Determination of
diagnosis; feedback to
ART MO
17
JiMi'
Wflb'. •
MONITORING AND SUPERVISION
Roles and Responsibilities
ROLE OF PHARMACIST/ INSTITUTIONAL DOT PROVIDER
1. Check the TB identity card for CPT prescription.
2. Provide monthly supply of CPT to the HIV-infected TB patients, who have been prescribed CPT by the
attending MO and record the date of delivering on the TB treatment card.
3. Indent (from MO-TC) and maintain stock of Cotrimoxazolc for the HIV-infected TB patients prescribed
CPT for the entire duration of their TB treatment.
4. Encourage the HIV-infected TB patients, during their monthly visit to PHI for collecting CPT, to meet
the Medical Officer for routine examination.
5. Ensure confidentiality of HIV status of the TB patients remains confidential with in the health system.
6. Encourage patients on CPT to continue their CPT from an ART centre after TB treatment is finished.
ROLE OF COUNSELLORS
1. Screen clients for TB symptoms, and refer TB suspects to the DMC, recording referrals on the TB
suspect line list.
2. Record referral from RNTCP in the counselling register.
3. Record the HIV test result on the referral form and send it back to referring physician through the TB
patient.
4. Communicate the HIV test result of TB patients referred for VCT, to the referring/ treating physician
unless the patient has requested that the HIV test results not be shared.
5. Emphasis, while counselling clients, on the importance of sharing HIV test result with the referring/
treating physician
6. Counsel HIV-infected clients on the importance of CPT, including adherence.
7. Provide information to ICTC clients having TB disease or suspected of having TB on availability of
decentralized CPT through the RNTCP.
8. HIV-infected clients on the importance of ART and CPT, including adherence and their free availability
under the programme.
9. Counsel the clients being referred to ART centre, on the process of ART evaluation and the importance
of completing the necessary steps to determine the need for ART.
F
ROLE OF STS
1.
2.
3.
4.
5.
Update TB registers during monthly visits to PHls with information on HIV status, and (for HIV infected
TB patients) provision on CPT and ART from the original TB treatment card.
Coordinate with MO-PHls and pharmacist and facilitate the availability of CPT at the PHIs.
Ensure HIV status of the TB patients remains confidential with in the health system.
Supply cotrimoxazolc to requesting PHI’s on an as-needed basis.
Coordinate with ART centre staff during monthly meeting to ascertain ART provision to HIV-infected
TB patients.
18
J
i
ROLE OF MEDICAL OFFICER
1. Assess HIV status of TB patients, and refer all with unknown HIV status to the nearest ICTC for
voluntary HIV counselling and testing. Use the referral form.
2. Prescribe CPT to all known HIV-infected TB patients without contraindications. Counsel HIV-infected
TB patients, prescribed CPT on possible side effects of Cotrimoxazole.
3. Refer HIV-infected TB patients to the nearest ART Centre, preferably after two weeks of IB treatment.
Use the ART referral form.
4. Monitor the updation of information on CPT and ART deliver}' to HIV-infected TB patients on the TB
treatment card.
5. At the end of TB treatment refer all HIV-infected TB patients not already taking ART again to the ART
Centre for continuation of CPT and for re-evaluation ot eligibility for AR I. Use ARI referral form.
6. Ensure HIV status of the TB patients remains confidential with in the health system.
ROLE OF MO-TCS
1.
2.
3.
4.
5.
6.
.7.
Provide support to DTOs and DNOs in training ot MOs, STS, Counsellors and Pharmacists on
intensified TB/HIV package.
Sensitize medical officers in the implementation ot routine referral ot IB patients for HIV testing, CPI
provision, and ART referral, and the correct updation of TB records.
Coordinate with ail the PHls and ensure the availability of CPT ar PHI having HIV-infected 1 B patients.
Indent Cotnmoxazole in a timely manner from the DT(.) and maintain adequate supply at 1 L level.
Facilitate the training of field staff in coordination with DTO.
Supervise field staff and sensitize them regarding responsibilities.
Ensure HIV status of the TB patients remains confidential with in the health system.
ROLE OF DAPCU OFFICER
L In coordination with DTOs, organize training for MOs-TCs, MOs, STS, Counsellors, AR I centre staff
and Pharmacist on intensified TB/HIV package.
2. Overall supervision and ensuring smooth implementation ot intensified TB/HIV package, as pci National
framework of joint TB/HIV collaborative activities.
3. Ensure adequate ICTC human resource management and supply of test kits and consumables.
4. Supervise ICTC counsellor’s provision of confidential feedback of HIV test results for TB patients to
referring providers.
5. Ensure seamless supply of Cotrimoxazole to rhe DTO.
6. Ensure rhe availability of referrals forms for referral of all FB patients for VC 1 and referral of co infected
patients to ART centre.
Ensure
that ART centre staffs join the RNTCP monthly meeting.
7.
Ensure
that ART centre staffs have prepared rhe /XRT-TB notification list of AR 1 clients on treatment
8.
with RNTCP and the same is sent to concerned RNTCP officials.
9. Monitor the effectiveness of intensified TB case finding at ART and Care and Support and Link centres.
10. Coordinate with ICTC counsellors and SACS, and ensure the compli ance of counsellors.
11. Coordinate with DTO and facilitate in resolving the issues emerging in the field.
19
I
I
■ : ■• '•I
V
ROLE OF DTOS
f
In coordination with DTOs, organize training for MOs-TCs, MOs, STS, Counsellors, ART Centre staff
and Pharmacist on intensified TB/HIV package.
2. Overall supervision and ensuring smooth implementation of intensified TB/HIV package as per National
framework of joint TB/HIV collaborative activities.
Review
the ascertainment of HIV status by medical officers, and the recording of HIV status on TB
3.
treatment cards.
4. Ensure that HIV status is recorded only on PH I-held original treatment cards, and not on duplicate
treatment cards held by community DOT providers, and that HIV status remains confidential within the
health system.
5. Monitor STS recording of HIV status, CPT, and ART1 from TB treatment cards onto TB registers.
6. Supervise the recording of ART provision to HIV-infected TB patients from ART-TB notification list.
7. Transmit information to neighbouring districts in the state for ART-TB notifications for TB patients from
other districts.
8. Indenting Cotrimoxazole from DNOs and supply the same to the TUs
9. Collect information on the delivery of CPT from all the STSs on a monthly basis & compile a
consolidated quarterly report on the same in a prescribed format.
10. Report promptly any shortcoming/ issues emerging in the field to STC & CTD.
1 1. Ensuring in coordination with DNOs, the availability of referrals forms for referral of all TB patients for
VCT and referral of co infected patients to ART centre.
1.
I
F
ROLE OF ART CENTRE
Evaluate HIV-infected TB patients for ART on priority, including prioritization for CD4 testing.
Record patients’ TB number and name of referring unit in the pre-ART register (in the column ‘entry
point code’, along with the appropriate code for RNTCP) and the ART- register.
3. Ensure CPT is provided to all HIV-infected TB patients for the duration of TB treatment from either
the PHI or from ART centre.
4. Continue CPT after the end of TB treatment from ART centre as per NACP OI guidelines.
5. Provide feedback on CPT continuation and ART initiation to the referring physician, using the same
ART centre referral form if received and available.
1.
ROLE OF STATE TB CELL AND STDC
Organize training of trainers for DTOs and DNOs in coordination with SACS on intensified
TB/HIV package.
2. In coordination with DTOs, organize training for MOs-TCs, MOs, STS, Counsellors, ART centre
staff and Pharmacist on intensified TB/HIV package.
3. Overall supervision and ensuring smooth implementation of intensified TB/HIV package, as per
National framework of joint TB/HIV collaborative activities.
1.
ROLE OF SACS
Organize training of trainers tor DTOs and DNOs in coordination with State IB Cell on intensified
TB/HIV package.
2. In coordination with DNOs, organize training for MOs-TCs, MOs, STS, Counsellors, ART centre
staff and Pharmacist on intensified TB/HIV package
TB/HIV
of intensified
implementation
3. Overall supervision and ensuring smooth
I.
2f.)
i
package, as per National framework of joint TB/HIV collaborative activities
4. Ensure optimal availability of HIV test kits, Cotrimoxazole (in monthly packs), and referrals forms
(for referral of all TB patients for VCT and referral of co infected patients to ART centre).
i
J
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21
T
■ ■■'.".‘Tn------------------
L '
■
.. IT--i< •■■r- ’
■?r
•s?
1 ■ ’-■x
:••'• '
'•■?■'S'c'
Recording: Key points to remember
I
i
Original TB treatment card
Information on the TB treatment card, on HIV status, CRT delivery and ART referral and
treatment of the TB patient is to be kept confidential within health system on the original TB
treatment card. This should not be disclosed to the community DOT provider.
i.
___
Additional Treatments
HIV status^JSUnknown DPos ONeg
2.
CRT delivered on (date^t)
(2)
(date) _w
(3)
(4}
(5)
referred to ART centre
3.
Initiated on ART: (ZlNo
O'
{date}
1. HIV Status:
HIV testing is a voluntary procedure and not mandatory. Patients not willing for HIV
testing or sharing their HIV test result should not be forced to take the test or disclose this
information.
If HIV status of the patient is known, tick the appropriate box ('Ros' or 'Neg') and record
ii.
the date of test.
Patients already on HIV care should not be required to show proof of HIV test result
iii.
If the HIV status is ascertained during the course of TB treatment, the latest information
iv.
should be updated on the card.
V.
If HIV status of the patient remains unknown at the end of the treatment, tick the
appropriate box ('unknown'), at the time of declaring treatment outcome for the patient.
1
2. CRT (Cotrimoxazole preventive therapy) delivery
All known HIV-infected TB patients are to be provided access to CRT.
i.
ii.
If CRT provided from the PHI, record dates of each monthly delivery in the space
provided.
iii.
In case the TB patient is already on CRT before the initiation of TB treatment, record
most recent date of CRT pickup.
3. Referral and initiation on ART
1. All known HIV-infected TB patients are to be referred for ART to the nearest ART Centre.
For referred clients record the date of referral.
2. If patient Initiated on ART, tick the "yes" box, and the date of initiation of ART should be
entered on the treatment card.
3. In case the TB patient is already on ART before the initiation of TB treatment, tick yes,
and record approximate date of initiation.
>
X
*X X
22
in
MS 85
t
■
TB Identity card
Tuberculosis Identity Card
Back_______
Front
Follow up sputum examination
Revised National
Tuberculosis Control Programme
IDENTITY CARD
Name of Patient:
___________
Date
Time point
Lab
Mo,
Result
Preveatment
Complete address:
End of IP/4xter>ded IP
TU district name
2 months in C P
Ph
Er-o of w«atment
10 No.
Sex: MC FC Age:
Appointment dates
PH!:.
CP
IP
Disease
Classification
Pulmonary
Sxtra-pu n-onar?
H
!i
Site:
J
Treatment
Started on
1; Date Month Year
,
Treatment outcome with date:
Signature and stamp of MO with date:
Type of Patient
• Mew
• Relapse
• Treatment after oe'au'-t
• Failure
• Transfer In
• Other-Spec r*y____
11 Category of
j Treatment
|i
Z Category I
Category II
Z Category III
REMEMBER
1
CRT
I
Keep your card safely
, ou car be cired f you take treatment
as advised.
i ou may infect your near and dear if
you do ro: fake you' medicnes as
adv'sed
A. CRT:
i
.
If the patient is HIV-infected, and not already being provided CPT from any other source,
MO (PHI) is to prescribe CPT by ticking in the section on CPT
.
Institutional DOT provider on seeing the ticked box provides monthly supply of CPT and
records the same on Original treatment card.
!
i
r
23
/
!TB Register
Left side of the TB register
Name
Dale of
Regis
No.
tranon
Nrnnt (ui hill)
fM/F)
of
Coinpiat* Adcliat* At
Sax
TB
•M*
Data of
Staltuig
PHI
T»l«q>liona N timbal
NSP
(S-P ytl
NSN
■________
NEP
Now
Othart
Ticannant ND1/ND2)
Tvp»*
Put*
Status* |
Lab
No
■nwnr
(PZN/Uf
| HXV stama
KN' •■ami m reported before ot dtuuij TP ireltinent.
P-PcsiWe. N'-Nepurit. C-vtdJtwttn
£Z
.Male
(P/EV>
DMC
Name
N»w R.»Jan-«. Tiui'ftnHl tn. r*thxr»- TAD. Dthwi
Cat 11
Others
TAD
FvnuU
Class
• Tvp» of Patiaut (u»» compl»<« woich)
Relapee j Failure
VC
HIV \
Pt♦ • 11»annent ipsiiinniwxam
Cateporv
(!/tl,Tli
Summaty fot Ceee Piudiiig (DOTS C aeet Only |
eat_____________ y‘‘
Quartet
Revised National Tuberculosis Control Progratnnie - IB Rcgiatgr
Right side of the TB register
Reused N.itiona] Tuberculosis Control Programme - TB Regisfer Qujujej _CT
Vtsi.
H
Trearment Outcotp^^l Tf HlV-pooriy
End o< TreanHem EMani
2 Months in C P. Exam
End of 1 F / Extended I.F.
DMC |
Lab |
Name
No
Smt «i
I ixilSM.'MMAKV
■Juretl
Dace
Dat«
DMC
Lab
Name
No
Smrji
D»:r
DMC
Lab
N ame
No
Smear
Ouiconie
5
CFT
I. n.a»tr
ART
Htn»r>is
I'
_______ NM’
N-f' ;M |l j
IHrJ
I ><-<»oK
I Ml-'-l
Il .wleler ■ »ul |
£.
E
*» Tieattnem Outcome - u»« complera words
Cured. Compkted usutaMat. Died. Defaulted Frilure ci
Tcuttfrued out
; AddinonaJ neamrents if patient HB’-poaittve
F
Reqantei otw’ fdi patwatw koowa to be HlX'-petrerr
prontkrl o- u>y loutee daunt TB ■.teautsem eiitet "Y >j>d
approxunite d-stt If see provided witwvt eatet N’
L '.HI'
24
A
A: HIV status:
•
HIV Status (as provided in the original TB treatment card) should be recorded in the space
provided at the time of registration. Record 'P' for HIV-positive; 'N' for HIV-negative; 'U' for
unknown.
• At the time of the case finding report preparation, all 'blank' entries in the HIV Status column in
the TB register should be counted as 'Unknown' for the purposes of reporting.
• If the HIV status is later ascertained and updated on the treatment card during the course of TB
treatment, the same should be updated in the TB register.
• By the time of Results of Treatment quarterly report preparation, ALL TB treatment cards should
have an entry for HIV status (P, N, or U). Similarly, the TB register should reflect the entry on the
TB treatment cards. If the HIV status information on the TB treatment card for whatever reason
remains blank, that is to be recorded as 'Unknown' in the TB register.
I
B: CRT and ART delivery:
• The section is to be filled up for all TB patients known to be HIV-infected and should be left
blank for others.
• CPT and ART information should be recorded on the register at the same time of treatment
outcome recording i.e. within a month of TB treatment completion.
• Record CPT started as 'yes', with the date, if at least one month of CPT delivery is recorded in
the original treatment card.
• Record ART started as 'yes' if recorded as 'yes' in the original TB treatment card. Record the
documented approximate date of ART initiation from the original TB treatment card.
• For patients who were already taking CPT or ART at the time of TB diagnosis, the dates for
CPT and/or ART initiation would be expected to be earlier than the date of initiation of TB
treatment.
|
Reporting in RNTCP case finding report: Key points to remember
Block 3: TB/HIV Collaboration
J
Of all Registered TB cases no. known
to be tested for HIV before or during
the TB treatment
(»)
Of (a),
No. known to be HIV infected
(b)
1
The purpose of this block 3 is to provide information on the process of ascertainment of HIV
status of TB patients:
In cell 'a', enter the sum of all TB patients registered in this quarter, with their HIV status
recorded as either positive (P) or negative (N) in the TB register. Do not include those
patients with HIV status recorded as (U) unknown, or those patients with no information
available regarding HIV status.
•
In cell 'b', enter the sum of all TB patients registered in this quarter, with their HIV status
recorded as positive (P) in the TB register.
It is to be noted that the number of patients known to be HIV-infected may be less than the
number that will ultimately be reported in the Results of Treatment quarterly report, as it is
expected that some patients will undergo HIV testing during the course of treatment after the
case finding report is prepared.
•
J
25
Reporting in RNTCP treatment outcome report: Key points to remember
1. Treatment outcomes of HIV positive TB patients:
Type of TB
case
Total No.
known to
be HIV
infected
Treatment outcomes
Cure
Treatment
completed
Died
Treatment
failure
Default
Transfer
out
NSP
All TB cases
a. In this section TB treatment outcomes of HIV-infected TB patients are to be reported
b. In the first column 'Total No known to be HIV-infected', enter the sum of all TB patients
registered in the relevant quarter, whose HIV status was recorded as positive (P) in the TB
register, for 'NSP' only in the first row, and for 'All TB cases' (including NSP) in the second
row.
c. Record the treatment outcomes of the known HIV-infected TB patients as indicated.
I-
Note:
d. This number of known HIV-infected TB cases may be greater than reported in block 3 of case
finding reported for this quarter, as more TB patients will have been identified as HIV positive
during the course of treatment subsequent to the time of submission of the quarterly CF
report.
e. However, all efforts should be made to gradually decrease this difference and
ensure that an increasing proportion of TB patients get their HIV status ascertained
as early as possible after TB diagnosis
i
2. Provision of CRT & ART to HIV-infected TB patients
i-
Total no of TB
patients known to
be HIV infected
No.
given
CPT*
No.
given
ART*
s Dwuif TB trajmaot
Enter
the
sum
of
HIV-infected
TB
patients
that had 'yes' recorded in the CRT started
a)
of the TB register and record in the space provided.
column
b) Enter the sum of HIV-infected TB patients that had 'yes' recorded in the ART started column
of the TB register and record in the space provided.
i
I:
I
26
i
i
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i \
MONITORING INDICATORS
1. Case finding report
Indicator 1: Proportion of TB patients with known HIV status (before or after TB
treatment) (%)
In the states implementing intensified TB/HIV package, voluntary HIV testing should be
offered to all TB patients and all TB patients should be counselled to get their HIV status
ascertained
Optimal: Majority of TB patients with known HIV status
i.
I
|
Low proportion/ declining trend in proportion of TB patients with known HIV
status
Possible
actions:
lie auuiHia:
.
whether VCT is being offered at all PHIs to TB patients using standard referral
z Check
(
/
Check whether the information related to TB/HIV is being updated on the original TB
treatment cards
Check if all ICTC counsellors are providing feedback on HIV test to the referring
physician.
Re-sensitize all MOs on the policy of offering of VCT to all TB patients and timely
recording of HIV status on the TB treatment card in the routine district level meetings
z
of MOs conducted by CDHO/ DHS.
Address the issue of ICTC feedback to referring physician by discussing the same with
District nodal officer for AIDS and ICTC counsellors
• Sensitize State TB Cell on the issue.
Nurses and pharmacists should be sensitized on routine referral and the recording
process.
ii.
Very high proportion or dramatic unexplainable rise in proportion of TB patients
with known HIV status
Possible actions:
Ensure that while all TB patients are offered HIV testing, the process remains
voluntary and no TB patient is forced to undergo HIV testing
• Conduct random TB patient interviews;
• Ask all field staff elicit information on the issue from TB patients and check if
there was any coercion for getting HIV tested.
In case of any instances of coercion:
•
Reassure the TB patient;
•
urgently discuss and clarify the policy with the concerned officials
{
I
2. Results of treatment report
Indicator 2: Difference between number of TB patients known to be HIV infected
reported in Results of Treatment report and Case Finding report (for the same cohort)
Optimal: Declining trend over successive quarters
Explanation:
The basic purpose of the intensified TB/HIV package is to 'promptly' identify, all HIV
infected TB patients and provide them access to HIV care.
. The difference between the number of patients knowing their HIV status at the end of TB
treatment and at the time of compilation of case finding report indicates delay in
ascertainment of HIV status of TB patients leauing to delayed opportunity to access HIV
.
27
I
•
•
•
'I
•i'
I.
b
It
J:
r
-j.
I.
care. This may result in increased morbidity and mortality.
As HIV testing is a voluntary procedure, some TB patients might not to get them selves
tested for HIV. Some TB patients may choose to get them selves HIV tested beyond the
first quarter of TB treatment.
Also, there may be some delay on account of delay in communication of HIV test result
from ICTC and also delay in its recording on the original TB treatment card.
Efforts should be made to decrease the difference between the two figures over
the successive quarters.
Possible actions:
Check whether VCT is being offered at all PHIs to TB patients using standard referral
form as soon as possible after TB diagnosis, preferable during the first few weeks of TB
treatment
>/ Check if the TB patients being offered HIV testing are explained the importance early
determination of HIV status and sharing the same with medical officer
Check whether the information related to TB/HIV is being updated on the original TB
treatment cards.
Check if all ICTC counsellors are providing feedback to the referring physician.
Re-sensitize all MOs on the policy of offering of VCT to all TB patients and timely
recording of HIV status on the TB treatment card in the routine district level meetings
of MOs conducted by CDHO/ DHS.
Address the issue of ICTC feedback to referring physician by discussing the same with
District nodal officer for AIDS and ICTC counsellors- sensitize State TB Cell on the
issue.
Nurses and pharmacists should be sensitized on routine referral and the recording
process.
3. TB Register & TB treatment cards
I. Indicator 3: Proportion of HIV infected TB patients given CPT
II. Indicator 4: Proportion of HIV infected TB patients given ART
Optimal: All HIV infected TB patients given CRT, and majority given ART
Explanation:
• The basic purpose of the intensified TB/HIV package is to promptly identify all HIV
infected TB patients and provide them access to HIV care.
• All known HIV infected TB patients should be initiated on CPT and referred for ART as soon
as possible preferably within the first month of TB or ascertainment of HIV status- which
ever is earlier. Delay in initiating them on HIV care is known to lead poor TB treatment
outcomes.
• All HIV infected TB patient are likely to have low CD4 count (<350) and be eligible for
ART. However, a sub-group of these patients (~20%) might have higher CD4 count and
might not be eligible for ART.
• Data on HIV infected TB patients being initiated on CPT and ART is reported in the RNTCP
results of treatment report. However, this should be monitored at the district and sub
district levels on a monthly basis from the TB registers and TB treatment cards and all
known HIV infected TB patients not initiated on CPT and not referred for ART should be
promptly initiated on CPT and referred for ART.
Possible actions to ensure all known HIV infected TB patients are initiated on CPT:
Check whether adequate supply of Cotrimoxazole is available at all TUs and PHIs
z Identify the PHIs not providing CPT and:
Check if CPT delivery is being recorded on the treatment cards
Check if patients are collecting the monthly supply of Cotrimoxazole from the PHI
Check if concerned MOs and Pharmacist have been trained; identify and address issues
at the PHI; Re-sensitize PHI staff
z During interaction with TB patients not collecting monthly supply of CPT, counsel the
clients on the utility of CPT
28
•■
•.Mmp.WK■‘•■■“r-WS-'■ -•'■■•'
/
-»-S* -1.-.W.-—.MJ— -
...........
Re-sensitize all MOs during the routine district level meetings of MOs conducted by
CDHO/ DHS
Possible actions to ensure all known HIV infected TB patients referred for ART and
all eligible are initiated on ART:
J Check if adequate supply of ART referral forms is available at all PHIs; Also check if
these forms are being utilized during referrals
J Check if ART Centre MOs are providing feedback to the referring physician on the
outcome of the referral
Identify the PHIs having HIV infected TB patient not referred/ initiated on ART; identify
and address the issues related to referrals with PHI staff
In case of clients being referred to ART Centre, but not started on ART; collect patient
details and discuss with ART Centre staff to check if patient reached ART Centre and
was evaluated for ART; conduct random patient interviews to identify issues, if any.
>/ Re-sensitize PHI staff and ART Centre staff.
Re-sensitize all MOs during the routine district level meetings of MOs conducted by
CDHO/ DHS
7 Ensure ART centre staff participating in monthly meetings. STS to check HIV/TB
register at ART centres during RNTCP monthly meetings, or at the ART centre if
necessary.
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Annex 1
GUIDANCE TOOL ON ROUTINE REFERRAL OF TB PATIENTS
FOR VOLUNTARY HIV COUNSELING AND TESTING
The periodic HIV survey in TB patients for the year 2006-07 has demonstrated high HIV prevalence in
TB patients within settings having high HIV seroprevalence. Given the increasing availability of
decentralized services for VCT & HIV care in high HIV prevalence areas, Central TB Division (CTD) &
the National AIDS Control Organization (NACO) have adopted the policy of routinely offering voluntary
HIV counselling and testing to all TB patients in select States with high prevalence of HIV (listed below).
The policy is expected to facilitate early detection of HIV infection in TO patients and pave way for their
early access to HIV care and treatment. These interventions may reduce morbidity & mortality among
HIV-infected TB patients.
WHOM TO ADVISE TO ATTEND ICTC
• All TB patients, ‘except’ those with a history of positive HIV test from an ICTC, or those with a
negative HIV test from ICTC within the past 6 months.
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WHEN TO ADVISE VOLUNTARY COUNSELLING AND TESTING FOR HIV
• Any time during, or after initiation on TB treatment (preferably at the earliest).
• The client should be explained the need and importance of counselling and testing for MIV, and also
that HIV testing is ‘voluntarily’ and ‘not mandatory’.
• The offer should be made at least once during the course of TB treatment.
HOW TO REFER TO ICTC
• Referral can be done by medical officers with necessary support from paramedical staff of the
health facility.
• Ask TB patients if they have ever had an HIV test, if yes, when and where, and what was the result.
• If HIV status is unknown, advise the TB patient to get an HIV test done at an ICTC and also explain
that HIV testing is ‘voluntarily’ and ‘not mandatory’
• If the patient accepts the advice, & fulfils the above criteria, refer the patient to nearest ICTC.
ROLE OF ICTC COUNSELLOR
TB patients referred for HIV testing, on reaching ICTC are to be offered voluntary counselling and
testing for HIV. The ICTC counsellor is to counsel these clients on HIV & TB (using 10 point
counselling tool), and explain the clients the importance of sharing their HIV test result with the treating
physician, for better care. All TB patients diagnosed with HIV infection are to be referred by the ICTC
counsellor to the nearest ART Centre for ART evaluation and treatment of other opportunistic infections.
ROLE OF ART CENTRE STAFF
/All HIV-infected TB patients referred to ART Centre are to be:
1. Promptly evaluated for ART, on priority
2. If found eligible for ART initiated as early as possible
3. Promptly initiated on monthly CPT course and provide treatment for other Opportunistic Infections
4. Counselled to share the information of ART evaluation & initiation on ART with rhe TB treating
physician
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Annex 2.
Integrated Counselling and Testing Centre referral form
Referral to Integrated Counselling and Testing Centre
i
Dear Counsellor,
The patient with the following details is being referred for VCT to your centre:
Nt/we_______________
____ ii^e/ sex
TB Number (if available)
Kindly do the needful and provide me feedback on the same, in a confidential manner.
Referring Provider
Name:
Contact Phone #:
Date of referral:
Name of the PHI:
Feedback by the Counsellor to referring provider
(To befilled in duplicate by the counsellor. One copy for patient, the other for referring MO)
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TEST RESULT FROM ICTC
HIV positive
HIV negative
Indeterminate
Opted out
PID Number
Date of conducting test
Additional communication to the referring physician
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Signature of MO ICTC/counsellor
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ANNEX 3.
ART CENTER REFERRAL FORM
REFERRAL TO ART CENTER
(7 o befilled m duplicate by PHI MO. One copyforpatient, onefor record)
ART Centre (location, address):
Dear Doctor,
I am referring
Age,
Sex,
who
is a diagnosed HIV-infected patient to your ART centre for further
evaluation.
(If applicable: Type of TB Case
& TB number
Referring Doctor:
Contact Phone
Name & signature:
Date:
Name & address of the PHk
District:
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TU Name:
Details regarding ART
(to befilled by the APfY medical officer and sent to the referring PHI through the
patient)
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Pre-ART Registration Number:
Patient Started On Art
Yes / No
ART Reg No:.
If No, reason:
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Patient started on CPT - Yes / No
If No, reason:
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Additional, information:
Date
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Annex 4
Monthly PHI report on CPT for HIV-infected TB patients
(To be added to the monthly PHI report)
Unit of
Measureme
nt
ITEM
Stock on
first day of
month
(a)
Stock
received
during
the
month
(b)
Consump i Closing stock
on last day of
tion
the month (d)
during
the
d=(a+b-c)
month i
Quantity
Requested
(e)
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1
Ld±J
1
Monthly
pouch (30
tablets)
Cotrimoxazole
monthly pouch
(960 mg Double
Strength tablets)
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Annex 5
i
— ' reportt on CPT for HIV-infected TB patients
Quarterly TU
(To be sent to district as a separate sheet)
ITEM
i
Cotrimoxazole
monthly pouch
(960 mg Double
Strength tablets)
Unit of
Measureme
nt
Stock on
first day of
quarter
(a)
Stock
received
during
the
quarter
Consump
tion
during
the
quarter
(b)
(c)
Closing stock
on last day of
the quarter (d)
Quantity
Requested
(e)
d=(a+b-c)
I
Monthly
pouch (30
tablets)
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Annex 6
Quarterly DTC reportt on CPT for HIV-infected TB patients
(To be sent to ’DAPCU/SACS as a separate sheet)
ITEM
Unit of
Measureme
nt
Stock on
first day of
quarter
(a)
Cotrimoxazole
monthly pouch
(960 mg Double
Strength tablets)
Closing stock
1I on last day of
the quarter (d)
Cfnrlr
Stock
COHSlimp II
received
during
the
quarter
during
the
quarter
(b)
(C)
Monthly
pouch (30
tablets)
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tion
d=(a+b-c)
Quantity
Requested
(e)
I.
Annex 7
HIV / TB Referral Register at ART Center
Date of
referral
Name
!— Address
I
i Name of the
District
referred
from
TB Unit
(TU) name
& TB No.
Baseline
Pre
ART | CD4
No.
Date of
starting
of ART
ART I
No.
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