X. Establishment of VCTC–RNTCP cross–referral system
HIV voluntary counseling and testing has been shown to have a role in both HIV prevention and as an entry point to care. It provides people with an opportunity to learn and accept their HIV status in a confidential environment. VCTC has become an integral part of HIV prevention programs in many countries as it is relatively cost effective intervention in preventing HIV transmission. There is atleast one VCTC in each of the districts. These VCTC are located either in the Civil hospitals or Medical College. One – two Counsellors, one Laboratory Technician, staffs each VCTC. The activities of VCTC are under the supervision of Medical Officer designated as Incharge of VCTC. These VCTC Incharge are either the Pathologist or STD Medical Officer in case of Civil hospital and Microbiologist in Medical College.

Objective of Referral Linkage
The VCTC – DMC/DOT referral linkage was established with the objective of identifying TB suspects amongst VCTC clients and referring them to DMC for the early detection of TB and treatment initiation. Identification was done by the trained VCTC counsellors by asking for symptoms of TB, predominantly cough for more than three weeks. Second objective is to provide counselling and testing facility for TB patients referred by physician or health worker.

The national policy emphasizes on referrals from VCTC to DMC/DOT centres and HIV testing of TB patients is done only among those with symptoms/signs suggestive of HIV infection or history of high risk behaviour.

Process of referral from VCTC to RNTCP
The VCTC counsellors screen all clients at the time of pre–test counselling for symptoms of TB. If client is found to be chest symptomatic, client is referred to DMC for sputum examination by filling in the sputum examination form. Once the patient reaches the DMC, sputum examinations are done as per the protocol.

The patient is then referred to Medical Officer with the sputum results. Medical Officer will decide further management based on the sputum results and treatment is prescribed as per guidelines. Patient is referred to the nearest DOT centre for treatment.

In case of lymphadenitis, the patient is referred directly to the medical officer for diagnosis and treatment.

The counsellor gets feedback about the status on referral either from the patients themselves in few cases and definitely from the TB treatment supervisor.

Process of referral from RNTCP to VCTC
The Medical Officer refers known TB patients with symptoms/signs suggestive of HIV infection or high risk behaviour to the VCTC. At the VCTC the patient receives pre–test counselling, is tested for HIV after taking informed consent and receives the test result with post–test counselling. A few TB patients have come directly seeking VCT services on their own.

The feedback on HIV status is obtained by the physician from the patients themselves.

Issues related to cross–referral
While establishing referral linkage, one major issue was the issue of confidentiality. For TB diagnosis and treatment initiation, name and address is required whereas in the VCTC, the clients are not required to reveal name and address. There was reluctance on the part of VCTC to ask name and address. The VCTC programme officer and staff felt that confidentiality would be breached. But with repeated discussion, they were convinced that since the clients were being referred irrespective of HIV status, there would be no labeling of VCTC referral as HIV positive clients. Also during the referral to RNTCP, the counsellor is not required to mention the HIV status and in most of the cases the counsellor himself is not aware about HIV status of the client as the referrals are done at the time of pre–test counselling. HIV status is not mentioned in any of the RNTCP records like TB Laboratory Register, TB register, TB treatment card etc. As per NACO guidelines HIV status is revealed to client only, and they are encouraged to reveal the HIV status to the treating physician. Once the counsellors were convinced they were able to encourage their own clients about giving name and address. Now majority of clients reveal the name and address and only few of them are still reluctant.

Majority of the VCTCs have a DMC located in the same campus. The clients are mainly referred to DMC in same campus as VCTC, as most clients prefer to visit this DMC itself. Inspite of VCTC and DMC being in same campus, there was high drop–out of referrals initially. The counsellors then started accompanying the client to DMC, which has minimized drop–out.

A few VCTC especially those set up in an NGO facility, corporate sector do not have a DMC in same campus, in which case referral linkages are established to the nearest DMC.

Sometimes the patients travel a long distance to access VCTC, and if client is referred to the DMC situated in same campus as VCTC, the client has to travel once again for accessing DMC services. Therefore the counsellors are provided with directory of DMC, who then identifies and refers them to DMC nearest to their residence.

Reporting Format and System
The reporting format consisting of the line–list of referrals from VCTC to DMC/DOT centre and the monthly report. Considering the time taken for diagnosis, treatment initiation and TB registration, report is prepared after one month gap so that complete information is provided. e.g. Information on referrals in the month of July gets reported in September.

The documentation of referrals is integrated into the existing registers maintained by the VCTC and TB programe.

The line–list of referrals made from VCTC to DMC/DOT centre, is jointly prepared by the VCTC counsellor and the TB treatment supervisor. The first section is prepared by the counsellor and contains information on the name, address, age, sex, date of referral and name of DMC referred to. The first section is filled in by referring to the PID and Counselling Register. After completing the first section, the Senior TB treatment supervisor and counsellor, will jointly complete the second section, containing information on whether person has reported to DMC, sputum result, diagnosis, treatment category and date of starting treatment etc. For completing second section the STS and counsellor refer to the TB Laboratory Register, TB Register and Treatment for Referral Register. The STS of the Tuberculosis Unit, where the VCTC is located will co–ordinate with the Counsellor, and will be also responsible for getting the feedback from his colleagues if the referral has been made to other Tuberculosis Unit. On the basis of the completed line–list, the monthly report is prepared. The monthly report is prepared by each individual VCTC and consists of 4 section. First sections deals with information on new clients attending VCTC, HIV sero–positive amongst them and number of old clients. Second section deals with information on referrals from VCTC to DMC/DOT centre. Third section deals with information on TB patients tested for HIV at VCTC and last section deals with number of VCTC clients receiving information on TB. The monthly report is prepared by the VCTC Counsellor, by referring to the Counselling Register and the completed Line–List. VCTC’s give a copy of the monthly report including the completed line–list to the local District TB Officer. State AIDS control society compiles the information and sends a copy to National AIDS Control Organization, Central TB Division and State TB Office.