DR-TB HIV Coordinator: Supervision

Concept of Supervision

• Supervision is a systematic, ongoing process for increasing the efficiency of health personnel by developing their knowledge, perfecting their skills, improving their attitudes towards their work and increasing their motivation.
• It is one of the most important management functions in an organisation.
• Supervision is also defined as an act of a superior person overseeing the work of the personnel working under him or her. This overseeing means directing, investigating, guiding, helping and advising the subordinates in their performance with the purpose of achieving the established objectives.
• Therefore, it is an extension of training which provides constant observation, monitoring, evaluation and guidance to workers, with the aim of enabling them to perform their activities effectively and efficiently while maintaining the required standards.

Basic Tenets of a Good Supportive Supervisory Process

• Supervision is carried out in direct contact with health personnel.
• It is a two-way communication between supervisors and those being supervised.
• Supervisors are always accountable for the performance of the subordinates under her/his span of control.
• It should not be a fault-finding exercise but a collaborative effort to identify problems and find solutions. Supervisors are to help the workers improve, develop and reinforce knowledge and skills according to their individual learning needs.
• Supportive supervision is provided to health personnel at all levels since they need ongoing support for solving problems and to overcome difficulties.
• Health personnel also need constructive feedback on their performance and continuous encouragement in their work.
• Supportive supervision assists workers to perform in the best possible way to yield the best results in terms of realisation of the organisational goals.

Supportive supervision ensures smooth implementation and continuous programme improvement.

Objectives of Supervision

• To ensure equitable provision of high-quality healthcare services to all sections of society.
• To build capacity of the health staff to implement programme procedures correctly.
• To increase the involvement and commitment of staff at different levels, and to help staff develop their highest potential.
• To plan services cooperatively and to develop coordination to avoid overlapping.
• To develop standards of service and methods of evaluation of personnel and services.
• To assist in problem-solving of the matters concerning personnel, administrative and operational services.
• To provide timely and actionable feedback.
• To assess human resources and their training needs.
• To ensure logistic management as per guidelines.
• To ensure accurate and valid data recording and reporting in Nikshay and other recording systems.
• To interpret policies, objectives and needs of the organisation and to suggest ways and means to improve them.

Resources

• NTEP Training Modules (5-9) for Programme Managers & Medical Officers, 2020.
• Supervision and Monitoring Strategy, RNTCP, 2012.

Assessment

District Drug-resistant TB (DR-TB) HIV coordinator works as the stakeholder at district level to: 

• Coordinate with the diagnostic facility, treatment facility and National TB Elimination Programme (NTEP) field staff of the Peripheral Health Institute (PHI)/ TB Unit (TU)  for the diagnosis, treatment initiation and public health action of DR-TB cases as well as supervision and monitoring of data entry, linkage, logistics of all DR-TB cases in the district
• Coordinate and supervise HIV-TB collaborative activities

Separate checklists are available for each facility/stakeholder. Supervisory activities are conducted using a standard checklist.

Field visits are conducted in the district at least 15 days a month. 

They should visit:

• All TUs every month
• All DMCs every quarter
• All  treatment observation centres in the district once every quarter
• Home visit of DR-TB patient at least  once every quarter

Resources

• Guidelines for Programmatic Management of  Drug-resistant Tuberculosis in India, NTEP, CTD, MoHFW, GoI, 2021.
• TOR and Need Norms of NTEP Contractual Staff, CTD, NTEP, 2021.

Assessment

The District Drug-resistant TB (DR-TB) HIV coordinator ensures treatment initiation, public health actions, logistics, and follow-up of the patient in coordination with the National TB Elimination Programme (NTEP) staff (STS/ STLS), PHI/ treatment centre and DR-TBC/Nodal DR-TBC.

The DR-TB HIV coordinator receives the information about the newly diagnosed DR-TB patient from the lab and coordinates with the field staff/ medical officer of the concerned area. DR-TB HIV coordinator need to coordinate in

• locating the patient, information disclosure about DR-TB status 
• ensure that initial home visit to the patient is done 

• arranging for transportation of the patient to the concerned DDR-TBC for pre-treatment evaluation, and treatment initiation

   

Once the patient reaches the DDR-TBC, 

• District DR-TB HIV coordinator facilitates counselling, pre-treatment evaluation, and fast-tracking of reports for treatment initiation.
• DR-TB HIV coordinator maintains a list of treatment providers and helps in identifying the suitably trained treatment provider for the patient

Once the treatment is initiated and the patient is sent home, they will be regularly followed up over the phone.

DR-TB HIV coordinates with the NTEP field staff of the corresponding PHI/TU to:

• Pay home visits to the patient at least quarterly
• Ensure that the contact tracing of the DR-TB  patient is done, presumptive TB cases are referred for TB diagnosis and TPT is initiated for those eligible
• Ensure that patient receives DBT, nutritional support and linkage to social welfare schemes
• Screening of comorbidity and appropriate management at the health facility.
• Maintain and update the district-level DR-TB treatment cards and information in Ni-kshay
• Monitor the treatment and give feedback and coordinate proactive reach out to patient for follow-up culture, toxicity monitoring 
• Coordinate the information sharing with the difficult-to-treat TB clinic, in case of complicated cases
• They coordinate with DR-TBC for treatment initiation and ADR  management when required and sent the treatment card to be maintained at Nodal DR-TBC
• ensure regular post treatment follow-up for 2 years.

Resources

• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, NTEP, CTD, MoHFW, GoI, 2021.
• TOR and Need Norms of NTEP Contractual Staff, CTD, NTEP, 2021.

Assessment

The district Drug-resistant TB (DR-TB) HIV coordinator coordinates the diagnosis and treatment of DR-TB patients with the diagnostic facility, treatment facility (District DR-TB Centre (DDR-TBC)) and Peripheral Health Institute (PHI).

Their roles in the National TB Elimination Programme (NTEP) in TB diagnostic facilities are the following:

• Coordinate to ensure that Nucleic Acid Amplification Test (NAAT) and first-line Line Probe Assay (LPA) are done/sent for all diagnosed TB cases
• Coordinate with Senior Treatment Supervisor (STS)/ Senior TB Lab Supervisor (STLS) to ensure that for all DR-TB  cases follow-up sputum samples are tested/ sent for testing
• See whether treatment initiation/ necessary actions are taken against the results of all DR-TB cases
• Ensure that diagnosed  TB  cases are referred for HIV testing
• Ensure that  all the data is entered in Ni-kshay and check the accuracy of the data 

At the Integrated Counselling and Treatment Centre (ICTC) ensure that the following activities are done in coordination with ICTC staff and NTEP staff.

• Coordinate to see whether the patient referred from NTEP diagnostic facilities has reached ICTC 
• Screen all the clients attending the ICTC for symptoms of TB
• Ensure that the presumptive TB cases are referred for TB diagnosis
• Check whether the HIV TB line list and HIV TB registers are updated and the data is entered in Ni-kshay
• Ensure that Isoniazid Preventive Therapy (IPT) is started for all eligible People Living with HIV (PLHIV)

Resources

• Guidelines for Programmatic Management of  Drug-resistant Tuberculosis in India, NTEP, CTD, MoHFW, GoI, 2021.
• TOR and Need Norms of NTEP Contractual Staff, CTD, NTEP, 2021.

Assessment

At the treatment centre, the District Drug-resistant TB (DR-TB) HIV coordinator coordinates the counselling, pre-treatment evaluation, treatment initiation and maintains records of the DR-TB patient.

As the patient arrives at the DR-TB centre, the DR-TB HIV coordinator facilitates counselling of the patient, consultation with the DR-TB medical officer, and referral for pre-treatment evaluation. He/ she arranges for  fast-tracking of consultation/ investigations and ensure that treatment is initiated

The District DR TB HIV coordinator

• Coordinate to arrange treatment supporters, train and monitor them
• Coordinate with Peripheral Health Institute (PHI) for treatment continuation and follow-up
• Ensure that the follow-up visit of the patient at the treatment centre is happening on time
• Ensure that PMDT treatment books are updated and the data entry to Ni-kshay is accurate
• Coordinate with Nodal/ DDR-TB Centre to update patient information records/ treatment cards and Ni-kshay data
• Coordinate with Nodal/ DDR-TB Centre for patient referral and Adverse Drug Reaction (ADR) management
• Support updating the patient information template for referral of difficult-to-treat TB cases

Thus, the DR-TB HIV coordinator is responsible for treatment initiation, continuation and follow-up. They can develop a good rapport with the patient and family and function as an effective link between the DR-TB patient and the National TB Elimination Programme (NTEP), which will improve treatment adherence and completion.

DR TB HIV  coordinator  coordinate with the private provider in the treatment and follow up of DR TB  patients diagnosed and wish to  continue their  treatment from private provider. 

•   He/ She  ensures that  the patient is initiated on  DR TB  treatment and the data entry  is done in Ni-kshay. 

•    They coordinate with the private provider for regular follow up and treatment adherence  of patient as well.

   

The DR TB  HIV  coordinator coordinates with the  staff of  peripheral health institution 

• To locate the newly diagnosed DR TB patient and information disclosure
• To mobilise the patient for  treatment initiation 
• To ensure public health actions, contact tracing , TB  screening and TPT  initiation for eligible  cases
•  Coordinate with the pharmacist of PHI  for timely  delivery of the DR  TB  drugs to the patient
•  Ensure and monitor PMDT data completion at Ni- kshay at PHI/ T
• Ensure that PMDT  treatment books are updated at PHI level
• Coordinate with NTEP  staff of PHI for  regular follow up  of the patient

Resources

• Guidelines for Programmatic Management of Drug-resistant TB in India, CTD, MoHFW, GoI, 2021.
• TOR and Need Norms of NTEP Contractual Staff , CTD, NTEP, 2021.

Assessment

The DR-TB HIV coordinator supervises and coordinates the activities related to TB diagnosis and treatment at the ART centre and ICTC

Prepare and maintain a directory of ICTCs, ART Centres /LACs, Community Care Centers and NGOs working in National AIDS  Control Programme  (NACP) in the district and the collaborating NTEP centres

The DR-TB HIV Coordinator visits the ICTC quarterly to:

• Coordinate to check whether the patient referred from NTEP diagnostic facilities has reached ICTC for HIV testing 
• Ensure that all the clients attending the ICTC are symptom screened for TB 
• Ensure that all Presumptive TB cases are referred for TB diagnosis to TB Detection centers (TDCs).
• Inspect records and line list of presumptive TB referral for ICTC and ensure proper maintenance of records

During their monthly visits to the ART center, the DR-TB HIV coordinator does the following:

• Coordinates to check whether the patient referred from NTEP diagnostic facilities has reached the ART centre
• All the clients attending the ART centre are symptom screened for TB
• Ensure that the presumptive TB cases are referred for TB diagnosis
• Ensure a single window mechanism for TB diagnosis and TB treatment initiation in the ART centre
• To see whether the HIV TB line list and HIV TB registers are updated and the data is entered in Ni-kshay
• Ensure that the list of patients on Cotrimoxazole Preventive Therapy (CPT) is entered in Ni-kshay
• To ensure that Isoniazid Preventive Therapy (IPT) is started for all eligible People Living with HIV (PLHIV).

Any deficiencies or issues noted and brought to the notice of the officials of the visiting facility and also to the District TB Officer and District Nodal Officer under NACO for taking corrective actions.

Resources

• Integrated Training Module for HIV/TB Collaborative Activities, CTD & National AIDS Control Organisation, Ministry of Health and Family Welfare, GoI, 2015.
• TOR and Need Norms of NTEP Contractual Staff, CTD, NTEP, 2021.

Assessment

National TB Elimination Programme (NTEP) and National AIDS Control Programme (NACP) conduct regular review meetings on HIV TB collaborative activities at national and state levels.

At National level 

National level review meeting is held jointly by National AIDS Control Organisation (NACO) and Central TB Division (CTD) and representatives from CTD or NACO jointly review the HIV TB activities. 

At State level

The joint review meetings are organised organised in close coordination by State AIDS Prevention and Control Societies (SACS) and State TB Centre (STC).

Joint Review at field level - To strengthen the implementation of collaborative activities at all levels joint field visits are undertaken by: 

• National team (NACO & CTD) - To at least one state per quarter
• State teams (SACS & STC) - Visit at least one district every quarter 

External Programme Review like Joint Monitoring Mission will have TB-HIV as one of the thematic areas.

TB-HIV activities are reviewed during Central Internal Evaluation (CIE) and JSS (Joint Supportive Supervision). The team usually consists of representatives from NACO & CTD. Similarly TB-HIV activities are reviewed at State Internal Evaluation  (SIE) also.

Other Forums for Review Of HIV/TB activities

• National TB HIV Coordination Committee (NTCC)/ National Technical Working Group (NTWG)  on TB HIV collaborative activities consist of representatives from both the programme at the national level and jointly review HIV TB collaborative activities quarterly.
• State TB-HIV Co-ordination Committee (SCC)/ State Technical Working Group (SWG) consist of representatives from both the programme at the state level and jointly review HIV TB collaborative activities quarterly.
• District Coordination Committees (DCC) review activities at the district level. State HIV/TB coordinator or other officers from STC and SACS can attend these meetings to improve the coordination with the districts.
• Monthly HIV/TB coordination meetings of NTEP staff are routinely conducted at the district level. During these meetings, one session should be dedicated to reviewing of HIV/TB activities and all key NACP will attend the session.

Resources

• Integrated Training Module for HIV/TB Collaborative Activities, CTD & National AIDS Control Organisation, Ministry of Health and Family Welfare, GoI, 2015.

Assessment

Performance indicators for TB HIV collaborative activities can be grouped under four headings.

• Indicators for state and district level coordination
• Indicators for Intensified case finding
• Indicators for Isoniazid Preventive Treatment (IPT)
• Indicators for HIV testing of TB patients and HIV care, support and treatment

Indicators for State and District Level Coordination

Indicators for Intensified Case Finding (reported separately for Integrated Counselling and testing Centre (ICTC) and for Antiretroviral Therapy (ART) centres)

Isoniazid Preventive Treatment (IPT)

HIV testing of TB patients and HIV care, support and treatment

Resources

• National Framework for Joint HIV/TB Collaborative Activities, NACO, MoHFW, GoI, 2013.

Assessment

The quarterly report on HIV/TB collaborative activities helps to monitor and assess the performance of HIV-TB collaborative activities.

The report will give an insight to:

• TB and HIV coordinated activities at the district level and state level
• Steps taken to reduce the burden of TB in People Living with HIV (PLHIV) and early Anti-retroviral Therapy (centre) 
• Measures to reduce the burden of HIV in people with presumptive and diagnosed TB

These reports are analysed locally at review meetings and sent to districts, state and national levels for further aggregation, analysis, dissemination and management of the programme.

The analysis will help to identify problems/ opportunities and take necessary actions on them.

HIV/TB activities are implemented with close coordination between two national programmes having different reporting systems. 

HIV/TB recording and reporting involves staff of both programmes.

The following table shows the reporting responsibilities.

The reporting format of the quarterly report on HIV/TB collaborative activities can be found as Annex 6 in the Integrated Training Module for HIV/ TB collaborative activities, 2015. 

Resources

• Integrated Training Module for HIV/TB Collaborative Activities, CTD, NACO, MoHFW, GoI, 2015.

• National Framework for Joint HIV/TB Collaborative Activities, CTD, NACO, MoHFW, GoI, 2013.

Assessment

Ni-kshay HIV status report is available in the comorbidity reports (Figure 1) which are listed under summary reports (patient management) of Ni-kshay.

The reports are available at the TB Unit (TU), District and State levels.

The report gives a summary (Figure 2) of: 

• Total notified cases

• Cases with known HIV status

• Total cases with TB HIV coinfection

• Antiretroviral Therapy (ART) coverage among TB HIV co-infected

• Cotrimoxazole Preventive Therapy (CPT) coverage among TB HIV co-infected

Image

Figure 1: Comorbidity Reports; Source: Ni-kshay Portal

Image

Figure 2: Summary of comorbidity report; Source: Ni-kshay Portal

The summary reports are auto-generated based on the patient information entered in Ni-kshay.

Those who have access to Ni-kshay can see the report at their level of operation.

The information from the report is used to:

• Calculate the NTEP performance indicator 2 - Percentage of TB Notified Patients with Known HIV Status and indicators for HIV TB collaborative activity

• Analyse reports to address the gaps in performance at various levels.

   

   

Resources

• Ni-kshay Knowledge Base Report - Module 10.

Assessment