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

Intensified tuberculosis case finding among malnourished children in nutritional rehabilitation centres of Karnataka, India: missed opportunities.

BackgroundSevere acute malnutrition (SAM) is the most serious form of malnutrition affecting children under-five and is associated with many infectious diseases including Tuberculosis (TB). In India, nutritional rehabilitation centres (NRCs) have been recently established for the management of SAM including TB. The National TB Programme (NTP) in India has introduced a revised algorithm for diagnosing paediatric TB. We aimed to examine whether NRCs adhered to these guidelines in diagnosing TB among SAM children.MethodsA cross-sectional study involving review of records of all SAM children identified by health workers during 2012 in six tehsils (sub-districts) with NRCs (population: 1.8 million) of Karnataka, India.ResultsOf 1927 identified SAM children, 1632 (85%) reached NRCs. Of them, 1173 (72%) were evaluated for TB and 19(2%) were diagnosed as TB. Of 1173, diagnostic algorithm was followed in 460 (37%). Among remaining 763 not evaluated as per algorithm, tuberculin skin test alone was conducted in 307 (41%), chest radiography alone in 99 (13%) and no investigations in 337 (45%). The yield of TB was higher among children evaluated as per algorithm (4%) as compared to those who were not (0.3%) (OR: 15.3 [95%CI: 3.5-66.3]). Several operational challenges including non-availability of a full-time paediatrician, non-functioning X-ray machine due to frequent power cuts, use of tuberculin with suboptimal strength and difficulties in adhering to a complex diagnostic algorithm were observed.ConclusionThis study showed that TB screening in NRCs was sub-optimal in Karnataka. Some children did not reach the NRC, while many of those who did were either not or sub-optimally evaluated for TB. This study pointed to a number of operational issues that need to be addressed if this collaborative strategy is to identify more TB cases amongst malnourished children in India

Tuberculosis screening for severe acute malnourished children.

<p>Intensified tuberculosis case finding among Severe Acute Malnourished (SAM) children at Nutritional Rehabilitation Centres (NRCs) of six selected Tehsils (sub-districts) of Karnataka, 2012.</p

Challenges observed in application of NTP diagnostic algorithm in NRCs.

<p>Challenges observed in application of NTP diagnostic algorithm in NRCs.</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 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

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

Modified format of laboratory form for sputum examination, PITC among presumptive TB patients, Karnataka, India, 2012.

<p>Modified format of laboratory form for sputum examination, PITC among presumptive TB patients, Karnataka, India, 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