Tuberculosis management practices by private practitioners in Andhra Pradesh, India.

SETTING: Private medical practitioners in Visakhapatnam district, Andhra Pradesh, India. OBJECTIVES: To evaluate self-reported TB diagnostic and treatment practices amongst private medical practitioners against benchmark practices articulated in the International Standards of Tuberculosis Care (ISTC), and factors associated with compliance with ISTC. DESIGN: Cross- sectional survey using semi-structured interviews. RESULTS: Of 296 randomly selected private practitioners, 201 (68%) were assessed for compliance to ISTC diagnostic and treatment standards in TB management. Only 11 (6%) followed a combination of 6 diagnostic standards together and only 1 followed a combination of all seven treatment standards together. There were 28 (14%) private practitioners who complied with a combination of three core ISTC (cough for tuberculosis suspects, sputum smear examination and use of standardized treatment). Higher ISTC compliance was associated with caring for more than 20 TB patients annually, prior sensitization to TB control guidelines, and practice of alternate systems of medicine. CONCLUSION: Few private practitioners in Visakhapatnam, India reported TB diagnostic and treatment practices that met ISTC. Better engagement of the private sector is urgently required to improve TB management practices and to prevent diagnostic delay and drug resistance

What are the reasons for poor uptake of HIV testing among patients with TB in an Eastern India District?

BACKGROUND: National policy in India recommends HIV testing of all patients with TB. In West Bengal state, only 28% of patients with TB were tested for HIV between April-June, 2010. We conducted a cross-sectional survey to understand patient, provider and health system related factors associated with low uptake of HIV testing among patients with TB. METHODS: We reviewed TB and HIV program records to assess the HIV testing status of patients registered for anti-TB treatment from July-September 2010 in South-24-Parganas district, West Bengal, assessed availability of HIV testing kits and interviewed a random sample of patients with TB and providers. RESULTS: Among 1633 patients with TB with unknown HIV status at the time of diagnosis, 435 (26%) were tested for HIV within the intensive phase of TB treatment. Patients diagnosed with and treated for TB at facilities with co-located HIV testing services were more likely to get tested for HIV than at facilities without [RR = 1.27, (95% CI 1.20-3.35)]. Among 169 patients interviewed, 67 reported they were referred for HIV testing, among whom 47 were tested. During interviews, providers attributed the low proportion of patients with TB being referred and tested for HIV to inadequate knowledge among providers about the national policy, belief that patients will not test for HIV even if they are referred, shortage of HIV testing kits, and inadequate supervision by both programs. DISCUSSION: In West Bengal, poor uptake of HIV testing among patients with TB was associated with absence of HIV testing services at sites providing TB care services and to poor referral practices among providers. Comprehensive strategies to change providers' beliefs and practices, decentralization of HIV testing to all TB care centers, and improved HIV test kit supply chain management may increase the proportion of patients with TB who are tested for HIV

Box 2- Decision aid for analysis.

<p>This is a decision aid for the purpose of analysis of data; the type of question asked in the questionnaire, subject of the question and the responses which should be considered as compliant against each diagnostic and treatment standard are summarized.</p

Private Practitioners adhering to ISTC^* diagnostic practices in Visakhapatnam, Andhra Pradesh.

<p><b>*(International Standards of TB Care).</b></p><p><b>TB = tuberculosis;</b></p><p><b>*Response to what antibiotic was used as trial antibiotic. 85 (53%) used non-fluoroquinolones.</b></p><p><b>**5 approaches included history, clinical examination, Tuberculin skin testing, bacteriological evaluation or relevant investigations to diagnose e.g. cervical lymph node TB.</b></p

Factors associated with failure to be tested for HIV among patients with TB who reported being referred for HIV testing after TB diagnosis was made in South 24 Parganas District, West Bengal State, India – July–September, 2010.

*<p>IP = Intensive phase of TB treatment.</p

Demographic and clinical characteristics of patients with TB (n = 1,633) registered for treatment from July – September, 2010 in South 24 Parganas District, West Bengal State, India.

<p>ICTC = Integrated Counseling and Testing Centre (HIV testing centers),</p>**<p>only for those who got HIV tested during the intensive phase.</p

Characteristics of private practitioners in relation to compliance with 3 selected core ISTC^* in Visakhapatnam, AP.

<p><b>*(International Standards of TB Care).</b></p><p><b>Core ISTC Standards: Standard 1 = Using 2–3 weeks cough for identification of Pulmonary TB suspects; Standard 2 = Using sputum smear microscopy examination; and Standard 6 = Treatment with the standard 6-month regimen; TB = Tuberculosis; AYUSH = Ayurveda, Unani, Siddha, Homeopathy; RNTCP = Revised National TB Control Programme; RR = Relative Risk has been calculated for standard 1+2+8; CI = Confidence Interval.</b></p

Perception of Providers on barriers to HIV testing for people with TB in South 24 Parganas District, West Bengal, India.

*<p>ICTC = Integrated Counseling and Testing Centre (HIV testing centers).</p

Private Practitioners adhering to ISTC^* treatment practices in Visakhapatnam, Andhra Pradesh.

<p><b>*(International Standards of TB Care). H = INH, R = Rifampicin, Z = Pyrazinamide, E = Ethambutol, FDC = Fixed Drug Combinations, DOT- Directly observed treatment; TB = Tuberculosis; DR TB = Drug resistant TB.</b></p

Box 1- Diagnostic and treatment standards in International Standards of Tuberculosis Care.

<p>The principles of diagnostic and treatment standards in the International Standards of TB Care with their rationale and references are summarized.</p