XI. Establishment of other referral linkages

1. NGO (TI) – RNTCP Co–ordination
   NGO’S implementing Targeted Interventions Project of National AIDS Control Programme can contribute significantly to the control of HIV and TB in India. NGO’s work with target population like Truckers, Commercial Sex Workers, Migrants, MSM (Men having Sex with Men) that are a high risk group for HIV. Targeted Intervention NGO’s participate in the Revised National TB Control Programme in two ways: – Identification and Referral of suspected TB cases to the RNTCP and Providing DOTS (Directly Observed Treatment Shortcourse) to the TB patients.
2. Community Care Centre – RNTCP Co–ordination
   We have been able to successfully involve one of the Community care centres in RNTCP. This community care centre’ Bel–Air’ is situated at Panchgani in Satara district. It has a Microscopy centre for Sputum examination. It also provides RNTCP for its inpatients as well for its outpatients. HIV positive patients with HIV are also being treated under RNTCP.
3. Drop–in–centre – RNTCP Co–ordination
   Drop–in–centres are another potential are for referral linkages. Two way referral system has been initiated.
4. PPTCT – RNTCP Co–ordination
   Efforts are being made to establish referral linkages between PPTCT and RNTCP diagnostic and treatment centres.
5. ART–DOT centre linkage
   Referral linkages have been established between ART and DMC/DOT centre. Efavirenz based ART regimen have been provided to ART centres for the simultaneous administration of ART and ATT regimens, if need be.

XII. Infection Control Measures
All DTO’s have been provided with book on Standard Operative procedures – Infection Control Measures published by NACO, and the topic was discussed during training. Guidelines for prevention of nosocomial transmission of TB to HIV infected persons have been issued to all the Government hospitals by Directorate of General Health Services. The infection control committee of the hospital ensures safe disposal of hospital waste.

XIII. Sentinel Surveillance of HIV in diagnosed TB patients
The sentinel surveillance would provide point prevalence and identify trends of HIV prevalence amongst TB patients (which will be site specific). This information is of value in designing, implementing and monitoring public health programmes for the prevention and control of tuberculosis.

In the year 2004, sentinel surveillance for HIV in diagnosed TB patients was carried out in the Nashik and Mumbai. 400 new TB patients coming for first follow up examination were tested for HIV using the unlinked anonymous strategy. It was found that 5.75% of the TB patients were found to be HIV sero–positive in Nashik and 11% in Mumbai.

XIV. Monitoring and Supervision
State level

1. Monthly Report of VCTC–RNTCP Co–ordination
   The VCTC’s submit a monthly report on HIV–TB related activities, which are compiled by AIDS Control Society and sent to NACO, CTD and STO. In case reports are not received letters are sent to the VCTC’s. DTO/CTO is also informed. In case of errors in reporting the VCTC’s are immediately informed. Now with monthly counsellors meeting held at state level, any discrepancy in the line–list and monthly report is discussed immediately and corrected.
2. Quarterly Joint Regional Review Meetings
   Quarterly review meetings of VCTC–RNTCP staff have been initiated. These meetings are attended by the District/City TB Officers, Medical Officer Incharge VCTC. Each district’s performance on HIV–TB co–ordination is reviewed meticulously and actions for strengthening the HIV–TB co–ordination is discussed. These meetings have helped us to establish a rapport between the district level programme officers, understand their problems, bring about a sense of accountability into the programme officer and improve the co–ordination.
3. Quarterly Performance Report of VCTC and VCTC–RNTCP Co–ordination
   The performance of each VCTC is reviewed for the activities related to Counselling, HIV testing and VCTC–RNTCP co–ordination. This performance report is prepared for each individual VCTC. Those indicators where the performance is poor is highlighted and a footnote at the end of the table specifies the reason for highlighting and the need for improving.
4. Individual Programme Review
   HIV–TB activities is one of the point for discussion in the Quarterly Review Meeting of DTOs and Monthly Review Meetings of counselors.
5. Supervisory visits by state level officer
   Supervisory visits by either of the state level programme officers to the VCTC–RNTCP Co–ordination sites.
6. State HIV–TB Co–ordination Committee meetings
   At the state level, the state co–ordination committee for TB–HIV under chairmanship of Secretary Health who is the administrative head of public health programme in the state reviews the performance once in 3–6 months.

District Level

1. Cross–Visits by RNTCP and VCTC staff
   At the field level the counsellors started visiting DMC, and the DTO and TB treatment supervisor visited VCTC. This has helped in establishing rapport, understanding each other’s programme and strengthened the co–ordination.
2. Fortnightly/Monthly Meeting
   The DTO in addition conduct fortnightly or monthly review between the VCTC and TB programme staff.
3. District Co–ordination Committee (HIV–TB) meetings
   Every quarter the regional director health, who heads the district co–ordination committee, reviews the performance, which has also contributed in strengthening the co–ordination.

XV. Constraints

1. There was an initial difficulty in establishing rapport, between VCTC and TB programme staff. With the help of joint review meetings, cross–visits to the centres and discussions, the rapport was built up.
2. In spite of the fact that the VCTC–DMC were located in same campus, and the counsellor accompanied the client, there was a drop–out of almost 10%.
3. Incorrect address by the patient probably because of fear of stigmatization has made it difficult to ensure that they are taking treatment.
4. Many clients attending VCTC, come from neighbouring districts, and were referred back to their district for treatment after diagnosis. Their treatment status could not be ascertained.
5. Information on number of TB patients referred from DMC–DOT centre was not collected, and therefore it is not known whether all those referred have accessed VCTC services.

XVI. Conclusion
VCTC is a potential entry point for TB services not only for HIV ser–positives but also sero–negatives. Having successfully established the referral linkage between VCTC–DMC–DOT centre, Referral linkages have been initiated between TB diagnostic and treatment services and Drop–in–centre, Community Care centres, Anti–retroviral treatment centres, NGO’s working with sex workers, truckers, migrants etc, and Prevention of Mother to Child Transmission Projects.

No additional financial burden incurred except for training as the available logistic supports like sputum examination forms for referral, DMC/DOT directory, IEC material and existing recording keeping system were used. Training and repeated discussions with staff is essential for initiating and strengthening the referral mechanism.

Referral Linkage has benefited both the programme. It has been possible to diagnose TB and initiate them on treatment at an early stage. TB patients with high risk behaviour and clinical features suggestive of HIV benefited by counselling and testing facility. Continuous supervision and monitoring by district and state level has strengthened and sustained the co–ordination.