TB–HIV CO–Ordination, Maharashtra
I. Need for Co–ordination
As the epidemic of HIV is mushrooming it becomes necessary to intensify our efforts in developing strategies for providing supportive services to HIV infected persons. HIV infection has escalated the burden of TB, especially in countries where prevalence of HIV infection and TB infection is high. Though the exact number of HIV–TB co–infected persons is not known, it is estimated that 1/3rd of the 36.1 million PLWHA worldwide at the end of the year 2000 were co–infected with M.Tuberculosis.

HIV infection is the most powerful risk factor for progression from TB infection to disease. An individual with dual infection of HIV–TB has more than 50% lifetime risk of developing TB as compared to 10% in TB infected person without HIV infection. The rate of progression of TB is also 30 times more rapid in an HIV infected person. TB accelerates the progression of HIV by causing a six–seven–fold increase in viral load. It shortens the survival period of an HIV infected individual and is a cause of death for one in three cases of AIDS.

In a developing nation like ours, the burden posed by increasing number of HIV/AIDS and TB cases can overwhelm our available services and budget. It is therefore time for both the AIDS and TB programme to jointly make efforts to deal with the dual epidemic of HIV and TB.

In India, more than 60% of the reported AIDS cases suffered from TB. Though the life of an HIV infected individual appears bleak due to lack of definitive treatment or vaccine, what is encouraging to note is that TB can be cured by treatment with Directly Observed Treatment Short course (DOTS). Treatment with DOTS prolongs and improves the quality of life.

Recognizing this serious threat posed by HIV and TB, the State of Maharashtra has initiated the collaboration of the AIDS and TB Control Programme. Maharashtra is situated in the Western Region of India, with a population of more than one hundred million. It has 35 districts with a population ranging from 1–6 million. Maharashtra has one–tenth of India’s population and Mumbai has one–tenth of Maharashtra’s population.

In Maharashtra, an estimated 1,84,560 new TB cases occur. TB diagnostic services are provided at selected government health facilities called as Designated Microscopy Centres (DMCs) established for every 1,00,000 population. Directly Observed Treatment is provided at DOT centres. The TB treatment success rate in second quarter 2005/04 is 87% and TB case detection is 67% in second quarter 2005. There are 1026 DMCs within the state.

NACO estimates that 0.9% of the adult population is HIV infected. It is estimated that Maharashtra has 1.4 million HIV. Of the 35 districts, 22 districts (63%) have an HIV prevalence of more than 1% among pregnant women. There is atleast one VCTC in each of the districts, and now it is slowly being expanded to sub–district level, with the aim of establishing one VCTC for every 5,00,000 population.

II. Goal and Objectives of Co–ordination
The basic purpose of TB–HIV co–ordination programme initiated in 2001, is to ensure optimal synergy between the two programmes for the prevention and control of both diseases. The overall goal is to reduce TB–related morbidity and mortality in people living with HIV/AIDS while preventing further spread of HIV and TB through collaboration between NACP and RNTCP. The objectives of TB–HIV co–ordination programme is

1. To reduce the TB burden among PLHA by early diagnosis and treatment
2. To reduce the TB related mortality among PLHA’s by early diagnosis and treatment, and
3. To provide counselling and testing facility for those diagnosed TB patients suspected to have HIV infection because of high risk behaviour or diagnosis of other opportunistic infections.

III. Action Plan on TB–HIV Co–ordination Programme
The basic purpose of HIV–TB coordination is to ensure optimal synergy between the two programmes for the prevention and control of both diseases. Key areas include:

1. Commitment to HIV–TB coordination, through sensitization.
2. Service delivery coordination and cross–referral, through training, provision of additional services, and coordination at the local level.
3. Optimal and comprehensive use of the community reach of both programmes through the sensitisation and involvement of NGOs and private practitioners who are involved in both programmes.
4. Infection control to prevent spread of TB in facilities caring for HIV–infected persons, and to prevent spread of HIV through safe injection practices in the RNTCP.
5. Joint efforts at IEC particularly with regard to de–stigmatisation, TB being treatable, HIV being preventable, DOTS prolongs life of HIV infected persons and ensuring confidentiality of HIV– and TB–related information.
6. Monitoring and evaluation at District, State and National level to assess the co–ordination between both these programmes.
7. One of the Key service delivery areas for co–ordination is Co–ordination between Voluntary Counselling Testing Centre and Designated Microscopy Centre/Directly Observed Treatment Centre (VCTC – RNTCP Co–ordination).

Other areas for co–ordination that have been initiated are between NACP services like NGO’s implementing Targeted Interventions, PPTCT, Drop–in–centres and Community Care centres with the RNTCP diagnostic and treatment centre.

IV. Establishment of TB–HIV Co–ordination Programme in Maharashtra

1. Sensitization of Key Policy Makers.
2. State TB officer member of AIDS executive committee and project director member of State TB control society.
3. State HIV–TB Co–ordination Committee.
4. District Co–ordination Committee (HIV–TB).
5. Training of RNTCP and NACP staff, NGO’s and General Health Care Staff.
6. Establishment of referral linkages.
7. Treatment of HIV Sero–positive TB patients.
8. Infection Control Measures.
9. HIV Surveillance in TB patients.
10. Monitoring and Supervision.

V. Sensitization of key policy makers
The first step taken for establishing co–ordination was the sensitization of key policy–makers to address the importance of HIV–TB co–ordination.

Key Policy Makers like Principal Secretary–Public Health, Director General Health Services, Project Director of AIDS Control Societies, Deputy Director (TB and BCG), Programme Officers of AIDS control societies and TB Control Society, Medical Superintendent of TB Hospitals, Representative of NGOs, Municipal Corporation and Medical Superintendent of TB Hospitals participated in a one day discussion on the issue of HIV TB Co–infection and the need for collaboration between the two programmes. This one–day workshop, conducted by MSACS in February 2002 paved the way for smooth implementation and co–ordination of the HIV–TB activities in the State.

In June 2003, a similar sensitization workshop was conducted by MDACS for the Key Health Care Programme Officers of Mumbai Corporation.

Morbidity, mortality and socio–economic consequences of HIV, TB, and the interaction between HIV and TB was discussed. Emphasis was laid on the need for the co–ordination.

VI. State TB officer member of AIDS executive committee and project director member of State TB control society
State TB officer is a member of AIDS executive committee and Project Director of AIDS Control Society is a member of State TB control society.