Treatment Outcome and Mortality at One and Half Year Follow-Up of HIV Infected TB Patients Under TB Control Programme in a District of South India

There is paucity of data from India on the impact of HIV related immunosuppression in response to TB treatment and mortality among HIV infected TB patients. We assessed the TB treatment outcome and mortality in a cohort of HIV infected TB patients treated with intermittent short course chemotherapy under TB control programme in a high HIV prevalent district of south India. [aOR-4.90, CI (1.85–12.96)]. Factors associated with ‘Death’ were non initiation of ART [aOR-2.80, CI (1.15–6.81)] and CPT [aOR-3.46, CI (1.47–8.14)].Despite the treatment success of 75% the high mortality (30%) in the study group is a matter of concern and needs immediate intervention. Non initiation of ART has emerged as a high risk factor for unfavourable treatment outcome and mortality. These findings underscore the importance of expanding and improving delivery of ART services as a priority and reconsideration of the programme guidelines for ART initiation in HIV infected TB patients

Feasibility of Provider-Initiated HIV Testing and Counselling of Tuberculosis Patients Under the TB Control Programme in Two Districts of South India

BACKGROUND:Provider-initiated HIV testing and counselling (PITC) is internationally recommended for tuberculosis (TB) patients, but the feasibility, effectiveness, and impact of this policy on the TB programme in India are unknown. We evaluated PITC of TB patients across two districts in India considered to have generalized HIV epidemics, Tiruchirappalli (population 2.5 million) and Mysore (population 2.8 million). METHODOLOGY/PRINCIPAL FINDINGS:Starting June 2007, healthcare providers in both districts were instructed to ascertain HIV status for all TB patients, and refer those with unknown HIV status to the nearest Integrated Counselling and Testing Centre (ICTC)--often in the same facility--for counselling and voluntary HIV testing. All TB patients registered from June 2007 to March 2008 were followed prospectively. Field investigators assessed PITC practices and abstracted data from routine TB programme records and HIV counselling registers to determine the proportion of TB patients appropriately evaluated for HIV infection. Patient records were traced to determine the efficiency of referral links to HIV care and antiretroviral treatment (ART). Between July 2007 and March 2008, 5299 TB patients were registered in both study districts. Of the 4701 with unknown HIV status at the time of TB treatment initiation, 3368 (72%) were referred to an ICTC, and 3111 (66%) were newly tested for HIV. PITC implementation resulted in the ascertainment of HIV status for 3709/5299 (70%) of TB patients, and detected 200 cases with previously undiagnosed HIV infection. Overall, 468 (8.8%) of all registered TB patients were HIV-infected; 177 (37%) were documented to have also received any ART. CONCLUSIONS:With implementation of PITC in India, HIV status was successfully ascertained for 70% of TB patients. Previously undiagnosed HIV-infection was detected in 6.4% of those TB patients newly tested, enabling referral for life-saving anti-retroviral treatment. ART uptake, however, was poor, suggesting that PITC implementation should include measures to strengthen and support ART referral, evaluation, and initiation

Perceptions of Tuberculosis Patients on Provider-Initiated HIV Testing and Counseling - A Study from South India

Background: The acceptability and feasibility of provider-initiated HIV testing and counseling (PITC) in many settings across Asia with concentrated HIV epidemics is not known. A pilot study of the PITC policy undertaken within the public health care systems in two districts in India offered the opportunity to understand patient's perspectives on the process of referral for HIV testing and linking to HIV treatment and care. Methods: We conducted a cross-sectional study of randomly selected TB patients registered by the TB control program between July and November 2007 in two districts in south India. Trained interviewers met patients shortly after TB diagnosis and administered a structured questionnaire. Patients were assessed regarding their experience with HIV status assessment, referral for counseling and testing, and for HIV-infected patients the counseling itself and subsequent referral for HIV treatment and care. Results: Of the 568 interviewed TB patients, 455 (80%) reported being referred for HIV testing after they presented to the health facility for investigations or treatment for TB. Over half the respondents reported having to travel long distances and incurred financial difficulties in reaching the Integrated Counselling and Testing Centre (ICTC) and two-thirds had to make more than two visits. Only 48% reported having been counseled before the test. Of the 110 HIV-infected patients interviewed, (including 43 with previously-known positive HIV status and 67 detected by PITC), 89 (81%) reported being referred for anti-retroviral treatment (ART); 82 patients reached the ART centre but only 44 had been initiated on ART. Conclusions: This study provides the first evidence from India that routine, provider-initiated voluntary HIV testing of TB patients is acceptable, feasible and can be achieved with very high efficiency under programmatic conditions. While PITC is useful in identifying new HIV-infected patients so that they can be successfully linked to ART, the convenience and proximity of testing centres, quality of HIV counseling, and efficiency of ART services need attention

Interview coverage of the study group.

<p>Interview coverage of the study group.</p

Association of treatment related risk factors with TB treatment outcome and with survival status.

<p>aOR- Adjusted Odds Ratio, CI – Confidence Interval.</p

Univariate analysis of the treatment related factors associated with survival status (N = 281).

<p>OR - Odds Ratio, CI- Confidence interval.</p>*<p>Smear status is given only for those with pulmonary TB. Smear status not available for one patient,</p>**<p>Excludes 16 patients for whom treatment cards were not available (6 in dead and 10 in survived).</p>#<p>For 47 and 26 CD4 counts were not available in dead and survived patients respectively.</p

Treatment outcomes of HIV infected TB patients according to Disease classification N = 281.

<p>( ) Percentage.</p

Socio-demographic profile of HIV infected TB patients interviewed N = 176.

*<p>includes separated (10), widowed (27).</p>**<p>For those employed (105).</p

Disease Classification and CD4 counts in HIV infected TB patients N = 281.

<p>IQR – Inter Quartile Range.</p>*<p>Six smear negative patients had milliary tuberculosis and their median CD4 count was 120. (95–124).</p>**<p>One smear status not available.</p