HIV Testing among Patients with Presumptive Tuberculosis: How Do We Implement in a Routine Programmatic Setting? Results of a Large Operational Research from India.

BACKGROUND: In March 2012, World Health Organization recommended that HIV testing should be offered to all patients with presumptive TB (previously called TB suspects). How this is best implemented and monitored in routine health care settings in India was not known. An operational research was conducted in Karnataka State (South India, population 64 million, accounts for 10% of India's HIV burden), to test processes and learn results and challenges of screening presumptive TB patients for HIV within routine health care settings. METHODS: In this cross-sectional study conducted between January-March 2012, all presumptive TB patients attending public sector sputum microscopy centres state-wide were offered HIV testing by the laboratory technician, and referred to the nearest public sector HIV counselling and testing services, usually within the same facility. The HIV status of the patients was recorded in the routine TB laboratory form and TB laboratory register. The laboratory register was compiled to obtain the number of presumptive TB patients whose HIV status was ascertained, and the number found HIV positive. Aggregate data on reasons for non-testing were compiled at district level. RESULTS: Overall, 115,308 patients with presumptive TB were examined for sputum smear microscopy at 645 microscopy centres state-wide. Of these, HIV status was ascertained for 62,847(55%) among whom 7,559(12%) were HIV-positive, and of these, 3,034(40%) were newly diagnosed. Reasons for non-testing were reported for 37,700(72%) of the 52,461 patients without HIV testing; non-availability of testing services at site of sputum collection was cited by health staff in 54% of respondents. Only 4% of patients opted out of HIV testing. CONCLUSION: Offering HIV testing routinely to presumptive TB patients detected large numbers of previously-undetected instances of HIV infection. Several operational challenges were noted which provide useful lessons for improving uptake of HIV testing in this important group

To start or to complete? – Challenges in implementing tuberculosis preventive therapy among people living with HIV: a mixed-methods study from Karnataka, India

Background: Isoniazid preventive therapy (IPT) has been shown to reduce the risk of tuberculosis (TB) among people living with HIV (PLHIV). In 2017, India began a nationwide roll-out of IPT, but there is a lack of evidence on the implementation and the challenges. Objectives: Among PLHIV newly initiated on antiretroviral therapy (ART) from January 2017 to June 2018, to: (i) assess the proportion who started and completed IPT and (ii) explore reasons for non-initiation and non-completion from health-care providers’ and patients’ perspectives. Methods: An explanatory mixed-methods study was conducted in two selected districts of Karnataka, South India. A quantitative phase (cohort analysis of routinely collected program data) was followed by a qualitative phase involving thematic analysis of in-depth interviews with providers (n = 22) and patients (n = 8). Results: Of the 4020 included PLHIV, 3780 (94%) were eligible for IPT, of whom, 1496 (40%, 95% CI: 38%-41%) were initiated on IPT. Among those initiated, 423 (28.3%) were still on IPT at the time of analysis. Among 1073 patients with declared IPT outcomes 870 (81%, 95% CI: 79%-83%) had completed the six-month course of IPT. The main reason for IPT non-initiation and non-completion was frequent drug stock-outs. This required health-care providers to restrict IPT initiation in selected patient subgroups and earmark six-monthly courses for each patient to ensure that, once started, treatment was not interrupted. The other reasons for non-completion were adverse drug effects and loss to follow-up. Conclusion: The combined picture of ‘low IPT initiation and high completion’ seen in our study mirrors findings from other countries. Drug stock-out was the key challenge, which obliged health-care providers to prioritize ‘IPT completion’ over ‘IPT initiation’. There is an urgent need to improve the procurement and supply chain management of isoniazid

Antiretroviral therapy (ART) eligibility in newly diagnosed HIV among patients with presumptive TB, Karnataka state, India, January-March 2012.

<p>Antiretroviral therapy (ART) eligibility in newly diagnosed HIV among patients with presumptive TB, Karnataka state, India, January-March 2012.</p

Operational procedures in provider-initiated HIV counselling and testing among patients with presumptive TB in Karnataka state, India, January-March 2012.

<p>Operational procedures in provider-initiated HIV counselling and testing among patients with presumptive TB in Karnataka state, India, January-March 2012.</p

Modified format of laboratory register, PITC among presumptive TB patients, Karnataka, India, 2012.

<p>Modified format of laboratory register, PITC among presumptive TB patients, Karnataka, India, 2012.</p

Ascertainment of HIV status among patients with presumptive TB, district-wise, in Karnataka state, India, January-March 2012.

<p>Ascertainment of HIV status among patients with presumptive TB, district-wise, in Karnataka state, India, January-March 2012.</p

Increase in workload at HIV testing centres due to strategy of ‘routine HIV testing of presumptive TB patients’, Karnataka state, India, January-March 2012.

<p>Increase in workload at HIV testing centres due to strategy of ‘routine HIV testing of presumptive TB patients’, Karnataka state, India, January-March 2012.</p

Ascertainment of HIV status and HIV positivity among patients with presumptive TB in Karnataka state, India, January-March 2012.

<p>Ascertainment of HIV status and HIV positivity among patients with presumptive TB in Karnataka state, India, January-March 2012.</p

Ascertainment of HIV status and HIV positivity among patients with presumptive TB, district-wise, in Karnataka state, India, January-March 2012.

<p>Ascertainment of HIV status and HIV positivity among patients with presumptive TB, district-wise, in Karnataka state, India, January-March 2012.</p