DR-TB HIV Coordinator: TB and HIV Collaborative Activities

TB-HIV collaborative activities between the Revised National Tuberculosis Control Programme (RNTCP) and National AIDS Control Programme (NACP) started initially in the year 2001, in the six states with a high prevalence of HIV/AIDS, i.e., Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu. The collaborative activities were extended to 8 additional states in 2004.

NACP and RNTCP developed the “National framework of joint TB/HIV collaborative activities” in 2007 which was revised in February 2008 to redefine the scope of TB/HIV collaborative activities being implemented in the country.

The 2009 revision of the National framework:

• Establishes uniform activities at Antiretroviral Therapy (ART) centres and Integrated Counselling and Testing Centres (ICTCs) nationwide for intensified TB case finding and reporting
• Strengthens joint monitoring and evaluation with specified national TB/HIV programme indicators and performance targets.

The overall purpose of the National framework is to articulate the policy for strengthening TB/HIV collaborative activities between the National TB Elimination Programme (NTEP) and NACP, resulting in the reduction of the TB and HIV burden in India.

Objectives

• To strengthen the mechanisms for coordination between NTEP and NACP at the national, state and district levels
• To decrease morbidity and mortality due to tuberculosis among persons living with HIV/AIDS
• To decrease the impact of HIV on tuberculosis patients and provide access to HIV-related care and support to HIV- infected TB patients

For smooth coordination mechanisms at the national, state and district levels, the National Technical Working Group (NTWG) is constituted at the national level comprising key officials from NACO and Central TB Division (CTD) dealing with TB/HIV collaborative activities;  State Coordination Committees (SCC) at the state level chaired by the Principal Health Secretary ; State Working Group (SWG) composed of key officials from State AIDS Prevention and Control Society (SACS) and State TB Cell; and district level coordination committees are established.

Resources

• National Framework For Joint HIV/TB Collaborative Activities, NACO, CTD, MoHFW, GoI, 2009.

Assessment

 TB-HIV collaborative activities are the first among the TB comorbidities-specific interventions started in India and globally. In India, structured and systematic TB and HIV collaborative efforts were started in 2001. 

The scope of work for collaboration between the National AIDS Control Programme (NACP) and the National TB Elimination Programme (NTEP) includes:

1. Establish/ strengthen NACP-NTEP coordination mechanisms at the national, state and district levels

2. Scaling up of intensified TB/HIV package of services across the country

3. Joint monitoring and evaluation including standardised reporting shared between the two programmes

 4. Training of the programme and field staff on TB/HIV

 5. TB and HIV service delivery coordination by:

• Offering HIV testing to TB patients
• Intensified TB case finding at Integrated Counselling and Testing Centres (ICTCs), Antiretroviral Therapy (ART) and Community Care Centres
• Linking of HIV-infected TB patients to NACP for HIV care and support (including ART) and to NTEP for TB treatment
• Provision of Cotrimoxazole Prophylactic Treatment (CPT) for HIV-infected TB patients

6. Implementation of feasible and effective infection control measures

7. Involvement of Non-government Organisations (NGOs)/ Community Based Organisations (CBOs) and affected communities working with NACP and NTEP for all activities on TB/HIV collaboration

8. Operational research to improve the implementation and impact of TB/HIV collaborative activities

Intensified efforts are required for addressing the TB Burden among PLHIV. The three “I” s to reduce the burden of TB among PLHIV include:

• ICF: Intensified (TB) Case Finding at ICTC, ART centres and Link ART Centres (LAC)
• IC-AIC: Air-borne Infection Control measures for prevention of TB transmission in HIV care settings
• IPT: Implementation of Isoniazid Preventive Treatment for all PLHIV (on ART + Pre-ART

Resources

• National Framework for Joint HIV/TB Collaborative Activities, NACO, CTD, MoHFW, GoI, 2009.
• Training Modules (1-4) for Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

Assessment

There is a well-structured system of National AIDS Control Programme (NACP) and National TB Elimination Programme (NTEP) coordination at the national, state and district levels which includes the following:

1. National Level

• National Technical Working Group (NTWG): At the national level, a technical working group comprising key officials from NACO and Central TB Division (CTD), dealing with TB/HIV collaborative activities and experts from World Health Organisation (WHO), is in place. The purpose of the TWG, which meets at least quarterly, is to review, optimise and plan for future TB/HIV coordination activities.

2. State Level

• State Coordination Committees (SCC): To ensure smooth implementation and regular review of TB/HIV collaborative activities, SCCs chaired by the Principal Health Secretary are established at the state level. These coordination committee meetings are organised by the State AIDS Control Society (SACS) on a biannual basis.
• State Working Group (SWG): At the state level, SWG is composed of key officials from SACS and State TB Cell (State TB Officer, second Medical Officer, if present), along with other officials dealing with TB/HIV collaborative activities and consultants involved in HIV/TB collaborative activities. The SWG is organised by SACS at least once in a quarter to review and streamline the collaborative activities.

3. District Level

• District Coordination Committees (DCCs): To ensure smooth implementation and regular review of TB/HIV collaborative activities, coordination committees are established at the district level. These coordination committees meet on a quarterly basis. DCCs are organised by District AIDS Prevention Control Unit (DAPCU) Nodal Officers or District TB Officers (DTOs) (in districts where there is no DAPCU).
• Monthly meeting at the District level: A monthly meeting of the DTO and the District Nodal Officer (DNO) is held with the participation of key staff from both programmes. Monthly key staff meetings for NTEP are already being conducted at the district level. It is envisaged that during these monthly key staff meetings, additional sessions be organised for TB/HIV which should be attended by the key district staff of NACP. In these monthly meetings, a review of the ongoing TB/HIV collaborative activities and discussion on key issues emerging from the field is done.

4. Annual Review of TB/HIV Collaborative Activities at National and State Level

• NTEP conducts regular programme reviews at the national and state levels. It is planned that at one of these reviews at the national level, an annual review of the TB/HIV collaborative activities is held with the participation of State Programme Managers of both programmes. The annual review is held in close coordination between NACO and CTD. Similar annual reviews are also held at the state level.

5.  Dedicated Positions Sanctioned to Facilitate Coordination and Successful Implementation of TB/HIV Collaborative Activities

• Full-time regular government officer would be in charge of TB/HIV collaborative activities in the programmes at the national and state level in NACP and NTEP
• National consultants for TB/HIV (NACP & NTEP)
• Technical Officers at SACS for basic services (including TB/HIV) are available across the country (1-2 per state)
• State TB/HIV Coordinators
• District level DR-TB HIV Coordinator

Resources

• National Framework for Joint HIV/TB Collaborative Activities, NACO, CTD, MoHFW, GoI, 2009.

Assessment

National AIDS Control Organisation (NACO) provides leadership to HIV/AIDS Control Programme in India, implementing one National Plan within one monitoring system. State AIDS Prevention and Control Societies (SACS) implement the NACO programme at the state level, but have functional independence to upscale and innovate.

SACS Structure

SACS are autonomous and decentralised. Each SACS has a governing body, its highest policy-making structure, headed either by the minister in charge of health or the chief secretary. 

It has onboard representatives from key government departments, civil society, trade and industry, the private health sector and  People Living with HIV/AIDS (PLHA) networks, who meet twice a year. 

It approves new policy initiatives, annual plans and budget, appoints statutory auditors and accepts the annual audit report. For better financial and operational efficiency, administrative and financial powers are vested in the Executive Committee and the Programme Director.

Functions of SACS 

•      Medical and public health service
•      Communication and social sector services
•      Administration, planning, coordination, monitoring and evaluation, finance and procurement.

With the setting up of the District AIDS Prevention and Control Unit (DAPCU) under the National AIDS Control Programme-III (NACP-III), there will be an increased emphasis on improving coordination functions at the state level in supporting the programme implementation at the district level.

The specific roles of SACS with respect to TB and HIV collaborative activities are:

1.       SACS ensures smooth implementation and regular review of TB/HIV collaborative activities, chaired by the Principal Health Secretary by organising coordination committee meetings twice on a biannual basis.
2.       The State Working Group (SWG) is organised by SACS at least once in a quarter to review and streamline the TB/HIV collaborative activities.
3.         In order to strengthen the field-level collaborative activities, joint field visits are undertaken by the SACS & State TB Centre (STC) to at least one district every quarter.
4.       The SACS is also a part of an annual review of the TB/HIV collaborative activities organized by the state in coordination with SACs.
5.       Trainings on TB/HIV are an integral part of NACP and National TB Elimination Programme (NTEP) activities. Budgets for the training of staff are borne by SACS for their programme personnel.
6.       The supply of Cotrimoxazole Preventive Therapy (CPT) is procured and packaged into monthly pouches by SACS and the local distribution is carried out by NTEP in coordination with NACP.

Resources

• SACS, National AIDS Control Organisation.

Assessment

 Programme management under NACP was decentralised to the district level in the form of District AIDS Prevention and Control Units (DAPCU).

Constitution of DAPCU

The DAPCU team consists of District AIDS Control Officer (DACO), District Integrated Counselling and Testing Centre (ICTC) Supervisor (DIS), the Monitoring & Evaluation Assistant (M&E Assistant) and Accounts Assistant. DAPCU staff reports to the DACO and functions as a unit at the district level.

The key functions of DAPCU are:

1. Through active engagement of the district administration mobilise response from allied line departments and private sector in mainstreaming the programme.
2. Initiates evidence-based district-specific initiatives by leveraging local resources.
3. Facilitates linking vulnerable populations with various social entitlement and welfare schemes under the mechanism of the DAPCU-led single window approach.
4. Mentor facility staff in efficient delivery of services, conducts impact monitoring through regular supervisory visits to HIV facilities, monthly review meetings and management and use of multiple databases (Strategic Information Management System (SIMS)/ Mother and Child Tracking System (MCTS)/ Pregnancy, Child Tracking and Health Services (PCTS) management).
5. Coordinate among NACP as well as NHM facilities and functionaries in strengthening referrals and linkages.
6. Address supply chain management issues through inter and intra-district transfers and liquidation of advances.
7. Other activities entrusted by SACS such as setting up of Facilitated Integrated Counselling and Treatment Centres (FICTCs) in both Government and PPP mode, facilitating Migrant Health Camps, and Mid-media campaigns under the Information, Education, and Communication (IEC) programme, and preparation of district epidemiological profiles are also part of their functions.

Operations related to TB services:

1.       The DAPCU convenes a joint review meeting of all NACP facilities which includes National TB Elimination Programme (NTEP) facilities in the district to review:

•      Ensure 100% reporting from all NACP facilities in the district. 
•      Review and validate monthly reports (SIMS) submitted by the facilities. 
•      Review of facility performance
•      Review of referrals and linkages between facilities. 
•      Review status on benefits of social benefit schemes to PLHIV and HRG.

2.   DACO and/or DPM from DAPCU are expected to participate in the DHS meetings, facilitate HIV TB coordination meetings and convene such forums and meetings as per requirements of SACS and district priorities.

3.    Ensure HIV testing for all TB notified cases in the district in coordination with NTEP.

4.    To ensure that all symptomatic clients are referred to NTEP and all TB-positive cases are referred to ICTCs for HIV testing.

Resources

• Operational Guidelines District AIDS Prevention and Control Units (DAPCU), 2012.

Assessment

National AIDs Control Programme (NACP) has established partnerships with bonafide registered entities, which include non-governmental organisations (NGOs), community-based organisations, federations of self-help groups (SHGs), registered medical practitioners (allopathic/ AYUSH), hospitals, nursing homes, clinics, health professional bodies and organisations. The three primary models for establishing a ‘Facility-ICTC’ in the private sector under a Public Private Partnership Integrated Counselling and Testing Centre (PPP-ICTC) are: 

1. Provide training to medical/para-medical staff on national guidelines and protocols with no support for commodities

2. Provide training to medical/para-medical staff on national guidelines and protocols with support for commodities such as HIV diagnostic test kits, prevention of parent to child transmission of HIV (PPTCT) drugs, counselling tools, information, education and communication (IEC) as per requirement 

3. Provide sensitisation to medical/ para-medical staff on national guidelines with no training to medical/ para-medical staff and no support on commodities

The Guidance Document on Partnerships Revised National Tuberculosis Control Programme mentions providing services in the private sector for linking TB-HIV coordination services. This includes collaborating and designing the appropriate model of referral linkage and testing services at private hospitals and clinics based on National TB Elimination Programme (NTEP) and NACO guidelines. This may include

• Establishing HIV testing facilities at the private hospital
• Facilitating patient testing, preferably at a free testing centre, such as F-ICTC/ICTC or NACO-empanelled HIV testing centres
• Establishing effective linkages between the patient and the nearest ICTC for confirmatory test
• Update HIV status of TB patients in Ni-kshay
• Providing HIV testing services through the Patient Provider Support Agency (PPSA)

Resources

•       National HIV Counselling and Testing Services (HCTS) Guidelines, NACO, GoI, 2016.

•       Guidance Document on Partnerships - Revised National Tuberculosis Control Programme, CTD, MoHFW, GoI, 2019.

  Assessment

PLHA network is a network of People Living with Human Immuno-deficiency Virus (HIV)/ Acquired Immuno-Deficiency Syndrome (AIDS) [PLHA] created for PLHA, by PLHA.  The goal of the PLHA network is to sensitise the communities on HIV and AIDS, improve access of communities to HIV prevention and PLHA to treatment and care; and support services.

Advocacy to PLHA networks

Objective

Data suggests that people with HIV often have either latent TB infection or TB disease. Hence the objective is to utilize the PLHA network under the (NTEP) which is available at national, state and also at some of the districts is an appropriate step for advocacy towards catering to TB -HIV patients.

Opportunities for advocacy to PLHA networks under NTEP

Under the TB programme PLHA network can be utilized for advocacy in following areas:

• Social mobilization to raise awareness and increase TB testing among the PLHA and contacts.

• Information, Education and Communication (IEC) activities on initiation of appropriate TB treatment services for the PLHA along with uptake of Anti Retro-viral Therapy (ART).

• Advocacy to improve coverage of TB preventive treatment in the eligible PLHA and their children.

• Promotion of TB literacy for the PLHA and focus on de-stigmatization and social inclusion measures.

Importance of advocacy to PLHA networks: 

The National AIDS Control Programme (NACP) has benefitted extensively by the role played by the PLHA network in community mobilization, increasing access to services, addressing stigma and discrimination issues in the field of HIV.  Further, many PLHA are also members of other key population groups who encounter the challenges affecting TB care. Since PLHA networks are available at the district levels utilizing them in the field of TB through TB Forum meetings, HIV Co-ordination meetings etc., for advocacy to the district administrators as well as for the community level meetings should be an important consideration for the NTEP towards the goal of ending TB.

Resources

 NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS: 2017-25 ELIMINATION BY 2025, MoHFW, India

Training Modules (5-9) for Programme Managers & Medical Officers, WHO, NTEP, CTD, MoHFW, GoI, 2020.

Assessment

Content

In order to reduce coverage gaps and improve access to HIV prevention, treatment, care and support, the National HIV Counselling Testing Services (HCTS) guidelines, 2016 recommends the routine HIV testing for all presumptive and diagnosed TB cases and partners of known HIV-positive TB patients.

 The process flow for the testing of presumptive TB cases and patients is as follows:

Image

  Resources

• Training Modules (1-4) for Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

Assessment

Tuberculosis Health Action Learning Initiative (THALI) initiative was started in 2016, with the support of the United States Agency for International Development (USAID) as a four-year patient-centric family focused TB prevention and care initiative to facilitate quality TB services to vulnerable populations. THALI was implemented by the Karnataka Health Promotion Trust (KHPT) in Karnataka in collaboration with the National Tuberculosis Elimination Programme (NTEP).

The project focused on behaviour change, primarily among communities of the urban poor. The population with co-morbidities such as HIV-AIDS, diabetes and undernutrition were prioritized under THALI. KHPT piloted this project from June 2019-July 2020 in four high-burden HIV districts in the intervention states. In Karnataka, it was launched in Belgaum and Bagalkot.

Best practices that can be learned from this initiative are:

1. Integrating TB-HIV activities by capacitating providers and officials, and advocacy.     
2. Raising awareness about direct benefit transfer (DBT) and how to acquire it. 
3. Supporting patient support groups (PSGs) to help patients overcome unpleasant side-effects and stigma, follow healthy nutritional practices and adhere to treatment with a goal to improve TB treatment experiences within government TB facilities.      
4. Capacity building of TB champions.     
5. Partnering with the care and support centres (CSC) teams to conduct awareness-raising meetings for people living with HIV (PLHIV) at the anti-retroviral (ART) centres, and advocate with the district health officer (DHO), district TB officer (DTO) and state TB office to increase isoniazid preventive therapy (IPT) supply. 

While there is still a lot to be done to address the remaining gaps consistently and cohesively, the intervention has been successful in helping the stakeholders recognize the value of an integrated approach and understand the problems better. Among other high-risk groups (HRGs), THALI has made a start with data (there is no screening data from the past) and other activities. THALI has demonstrated pathways through a collaborative approach involving the NTEP and PLHIV networks that, if sustained, will enable the success of future efforts.

Resources

 Tuberculosis Health Action Learning Initiative (THALI) - Best Practices and Lessons in TB-HIV Integration from Bagalkot, USAID, KHPT, 2020.

Assessment