Activities

	Quality diagnosis by sputum microscopy.
	3 sputum examinations are done for each chest symptomatic patient for diagnosis purpose. Sputum examinations are done at the upgraded microscopy centre using high quality binocular microscope by trained laboratory technician (LT). Quality Assurance of Sputum Microscopy by Senior TB Laboratory Supervisor (STLS). Diagnostic Algorithm is strictly followed by MOs for sputum negative cases.
	Quality diagnosis by sputum microscopy.
	3 sputum examinations are done for each chest symptomatic patient for diagnosis purpose. Sputum examinations are done at the upgraded microscopy centre using high quality binocular microscope by trained laboratory technician (LT). Quality Assurance of Sputum Microscopy by Senior TB Laboratory Supervisor (STLS). Diagnostic Algorithm is strictly followed by MOs for sputum negative cases.
	Treatment under direct observation
	Un-interrupted supply of good quality drugs in patient wise boxes. Treatment given under direct observation of DOT provider, at the convenient place and time to the patient. Maintenance of records and reports. Recording of every TB patient diagnosed, in the TB Register. Sound and robust record keeping and reporting system. All the districts and corporations are electronically connected and they are submitting their quarterly reports through EPI Centre software to the State and Central TB Division, Delhi.
	Supervision & Monitoring.
	Supervision of overall RNTCP implementation by STS, STLS, MOTUs, DTOs. PHI wise analysis and feedback of the performance from district. TU Wise & District Wise Analysis of Performance from State. Supervisory visits to the districts from State.
	Training of MOs/LTs/Paramedical Staff as an ongoing activity to ensure availability of at least 80% trained staff at any point of time.
	Involvement of Medical Colleges, Big Hospitals, Private Practitioners, Railways, ESIS and NGOs in RNTCP.
	IEC activities at state, district, sub-district & village level.
	Sensitization of village level political leaders/CEOs etc. Cinema slides/cable running message whenever applicable. Patient Meetings etc.
	Activities undertaken by STDC
	Training Training need assessment Co-ordination, supervision and monitoring of all district level trainings in the state Management skill development training of DTO's Supervision & Monitoring Appraisal Internal Evaluation Quality Control

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.

VII. State HIV-TB Co-ordination Committee

Purpose:
It reviews the performance of HIV TB activities in the state, formulate strategies for strengthening HIV TB co-ordination activity, and provide technical guidance for implementation of the activities in the state.
Government Resolution:
The Government Resolution for the establishment of the State Co-ordination Committee is in the process of amendment as per the Revised NACO guidelines.
Members:
Chairman: Addl. Chief Secretary (Public Health)
Vice Chairman: Director General Health Services
Vice Chairman: Executive Health Officer (BMC)
Member Secretary: Addl. Project Director (MSACS)
Member:
Director Medical Education and Research
Project Director (MSACS)
Project Director (MDACS)
Project Director (AVERT Society)
Deputy Director TB-BCG
Director State TB Training and Demonstration Centre, Nagpur
Director (Health), Central Railways
Director ESIS
Deputy Director-VCTC (MSACS)
Deputy Director-VCTC (MDACS)
Deputy Director, Surveillance, MSACS
Member Secretary (MDTCS)
Representative of Armed Forces
Representative of NGO working with NACP --- Network of
Maharashtra Positive People (NMP+)
Representative of NGO working with RNTCP (Interaide)
State HIV-TB Consultant/Co-ordinator
HIV-TB Consultant (WHO)
RNTCP Consultant (WHO)

Terms of Reference:
1. To review the status on training of health care providers in HIV/TB and formulate strategies for ensuring that all the health care providers are trained in HIV/TB
2. To review the co-ordination between Voluntary Counselling and Testing Centre (VCTC) and Revised National TB Control Programme (RNTCP) and formulate strategies for strengthening VCTC and RNTCP Coordination.
3. To review the participation of NGO’s and Private Medical Practitioners implementing NACP / RNTCP in the HIV/TB Co-ordination and formulate strategies for ensuring involvement of NGO’s and Private Medical Practitioner.
4. To ensure and review the participation of Institute providing care and support to HIV/AIDS patients in RNTCP
5. To ensure that appropriate measures are taken to prevent the spread of TB in facilities caring for HIV/AIDS
6. To ensure the prevention of spread of HIV through safe injection practices in RNTCP
7. To ensure confidentiality of HIV status is maintained
8. To take policy decisions for the implementation of HIV/TB activities in the State
9. To ensure co-ordination between (National Aids Control Pogram)NACP and RNTCP at district level
10. To ensure development of effective IEC material and IEC Strategy on HIV / TB
11. To ensure optimum co-ordination in the delivery of DOTS and ART
How often it meets:
Initially the committee used to meet once in six months, now it is scheduled to meets once in three months, as per the revised guidelines of National AIDS Control Organisation(NACO).
VIII. District Co-ordination Committee (HIV-TB)
Purpose:
Ensures the implementation of HIV-TB activities and reviews the performance of HIV-TB activities in the district.

Government Resolution:
The Government Resolution for the establishment of the District Co-ordination Committee is in the process of amendment as per the Revised NACO guidelines.
Members:
Chairman: Collector
Co-Chairman: CEO
Vice-Chairman: Civil Surgeon
Member Secretary: District TB Officer
Member:
City TB Officer
MO-Incharge VCTC
HOD-Obstetrics and Gynaecology Dept of the hospital providing
PPTCT Services (MO-Incharge of PPTCT)
Dean Medical Colleges (if any)
Medical Officer Incharge of ART Delivery site
MO-STD
District Health Officer
District Publicity Officer
Representative of NGO working with NACP --- NGO’s attached to
VCTC for outreach activities or NGO working with PLHA or
a Targeted Intervention NGO
Representative of NGO working with RNTCP

Terms of References:
1. To ensure and review the co-ordination between VCTC and RNTCP.
2. To ensure and review the participation of NGO’s and Private Practitioner implementing NACP/RNTCP in the HIV–TB co-ordination.
3. To ensure and review the participation of Institutes providing care and support to HIV/AIDS patient in RNTCP
4. To ensure that appropriate measures are taken to prevent the spread of TB in facilities caring for HIV-AIDS.
5. To ensure that prevention of spread of HIV through safe injection practices in RNTCP.
6. To ensure Confidentiality of HIV related information.
7. To develop strategies for strengthening the HIV-TB co-ordination.

How often it meets:
Meetings are held every quarter.
IX. Training of RNTCP and NACP staff; NGO’s and General Health Care Staff
One of the pre-requisites for effective implementation of cross-referral system, is to train the staff directly involved in the programme i.e. Counsellors, Medical Officer VCTC, District TB Officer, Medical Officer-TB Control, TB treatment supervisor, TB Laboratory Supervisor and the Lab Technician of the DMC.
The objective of training NACP staff in RNTCP is to enable them to understand and be able to apply principles of diagnosis, treatment, monitoring, and reporting under RNTCP. Similarly the RNTCP staff if trained in HIV/AIDS will be able to understand and apply principles of HIV prevention and AIDS control, and specific concerns about diagnosis of TB in HIV-infected persons, about TB treatment in HIV-infected persons, and about the need for confidentiality. Further both the staff should be aware about the specific infection control measures to be taken for preventing the spread of TB and HIV infection.
One training was not sufficient, repeated discussion at individual programme reviews, joint review meetings were done. Supervisory visits helped to identify centre specific problems and resolve the issues.

Training of NACP staff
The NACP staff trained includes the Nodal Officers for HIV/AIDS, Medical Officers Incharge of VCTC and VCTC Counsellors.
A two days training programme coupled with a field visit to Microscopy and DOT centre for District Nodal Officer and MO-VCTC. For Counsellors either one day training was taken or integrated into their basic induction training.

The training programmes for all the NACP staff started with the discussion on the need for HIV-TB Collaboration, Principles of RNTCP, Diagnosis and Treatment of TB. For the DNO’s and MO-VCTC, this was followed by lectures on Special issues in the diagnosis and treatment of HIV-TB patient, Infection Control Measures for TB and HIV, Anti-retroviral and anti-tuberculosis treatment.
Initially when we did the training for the first time we took the participants for a field visit to Microscopy Centre and DOT Centre, but later on realised that we should take them to a VCTC also. Thus in the subsequent training programmes the participants were taken to VCTC also. Also three years back when we did the trainings, there were no operational guidelines for VCTC-RNTCP co-ordination, but as we became clearer on how to co-ordinate, this session was included in the training programme. The MO-VCTC were explained in detail about the reporting format and also given a feedback on the reports received from their VCTC.
For the VCTC Counsellors, initially we took training only on aspects related to TB and explained them about reporting format. As we started implementing the programme we realised plenty of errors in reporting and understanding of the Counsellors and also with the field experience we realised the need to modify the training content. Initially we had done a separate one day training programme for Counsellors and subsequently the session on TB was integrated into their induction training curriculum. Now apart from the basic information on TB, we teach the counsellors how to fill the sputum requisition slip, Operationalisation of VCTC-RNTCP Co-ordination, documentation –record keeping, monthly report.
We also had undertaken a pilot project for developing the monitoring system for VCTC-RTNCP Surveillance system. During this pilot project we had 2 days training for Counsellors and STS, who came for the training simultaneously. The initial part i.e. 1 and1/2 days modular training was done separately and for the second half day the Counsellors and STS were brought together for discussing the operationalisation of VCTC-RNTCP Co-ordination. This greatly facilitated in establishing the co-ordination.

Training of RNTCP staff
The RNTCP staff trained includes the District TB Officers, MO-DTC, MO-TC and STS. Though STLS are not required to be trained as per action plan, we had trained the STLS too.
A two days training programme coupled with a field visit to VCTC for Medical Officers. The training programmes for all the RNTCP staff started with the discussion on the need for HIV-TB Collaboration, Epidemiology of HIV/AIDS, HIV Counselling and Testing Centre. For the DTO’s, MO-DTC and MO-TC, this was followed by discussion on Special issues in the diagnosis and treatment of HIV-TB patient and Infection Control Measures for TB and HIV.
The training for DTO’s was taken for 2 days in the lecture form coupled with a field visit to VCTC. For the MO-DTC/MO-TU and STS/STLS, training was 2 days of modular training along with refresher training on TB. The Medical Officers were taken for a visit to VCTC. For the STS/STLS a module –‘VCTC-RNTCP Co-ordination’ was jointly prepared by Maharashtra State TB Control Society and State AIDS Control Society. Facilitators Guide was prepared. For the Medical Officers, the training module on HIV/AIDS prepared by NACO was converted into module by adding exercises at the end of chapter. Chapters on Operationalisation of VCTC-RNTCP Co-ordination, Anti-TB and ART and Role of MO-TU were added. A Facilitator guide and supplementary training material was prepared by the State TB Society and AIDS Control Society.

Training of General Health Care staff
Training of General Health Care Staff is an ongoing activity. In Mumbai some training programmes for Medical Officers and paramedical staff of Public Health Department have been conducted. Since most of the Medical Officers and paramedical staff were already trained on HIV-TB only relevant aspects have been included. In rest of the Maharashtra, through the training on Clinical Management of HIV-AIDS; where a chapter on RNTCP has been added, Medical Officers are being trained. Similarly now in Mumbai, all trainings on HIV/AIDS for Medical Officers, Resident Doctors etc include discussion on TB.

Training of NGO’s
A one day joint sensitisation programme for both RNTCP and NACP NGO’s. In addition separate training programme for NGOs of TI was conducted at a later stage.

Training Material
· Training module on HIV-TB for District Nodal Officers and MO I/c VCTC’s –NACO publication
· Training module on HIV-AIDS for Medical Officers -CTD publication
· Treatment guidelines for TB in HIV infected –NACO/CTD publication
· Standard Operative Procedures - Infection Control Measures - NACO publication
· TB-HIV: A guide for Health worker - CTD publication
· HIV-TB: A guide for Counsellors - NACO publication
· The HIV-TB Co-infection- Programme Coordination guidelines for clinicians and standard operating procedures. - NACO/CTD publication.
· VCTC-RNTCP Operational Guidelines - Maharashtra State TB Society in collaboration with Maharashtra State AIDS Control Society and Mumbai District AIDS Control Society.
· Training Module for RNTCP Health Worker on HIV-TB, VCTC-RNTCP Co-ordination- Maharashtra State TB Society in collaboration with Maharashtra State AIDS Control Society

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.
XI. Establishment of other referral linkages
a. 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.
b. 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.
c. Drop-in-centre – RNTCP Co-ordination
Drop-in-centres are another potential are for referral linkages. Two way referral system has been initiated.
d. PPTCT – RNTCP Co-ordination
Efforts are being made to establish referral linkages between PPTCT and RNTCP diagnostic and treatment centres.
e. 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.