AIDSTAR-One | CASE STUDY SERIES                                                                                           ...
AIDSTAR-One | CASE STUDY SERIESKarnataka, HIV testing and counseling services                                       facili...
AIDSTAR-One | CASE STUDY SERIES•	   2007 to 2008: developed the national framework           Samastha’s mission was to red...
AIDSTAR-One | CASE STUDY SERIESKarnataka, and co-chaired by the Project Director     readily available at all centers, wit...
AIDSTAR-One | CASE STUDY SERIESdistrict-level TB officers with the support of the              TB to HIV services, and vic...
AIDSTAR-One | CASE STUDY SERIESfocused on training all health care personnel at the       At the field level, the Engender...
AIDSTAR-One | CASE STUDY SERIES                                                                 TABLE 3. NUMBER OF VARIOUS...
AIDSTAR-One | CASE STUDY SERIESas DOT providers and in information, education,          •	   Stronger linkages were create...
AIDSTAR-One | CASE STUDY SERIESCombined district-level visits: District-levelvisits were conducted regularly by a combined...
AIDSTAR-One | CASE STUDY SERIESThe costs of travel: Since many patients live             Delay in information: Information...
AIDSTAR-One | CASE STUDY SERIESthis nature would need to continue for a few years              HIV testing in all DMCs and...
AIDSTAR-One | CASE STUDY SERIESSufficient time and patience are required for all        ACKNOWLEDGMENTSthese factors to be...
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Aidstar one Case Study: A Positive Partnership

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In Karnataka, India, HIV testing and counseling services have revealed unexpectedly high levels of TB-HIV co-infection. In response, the Samastha Project began supporting the integration of TB and HIV services from 2006 to 2012. Under the Samastha Project, specialized staff training and new collaborations between hospitals, state-level public health agencies, health facilities, and other NGOs have helped to catch and treat TB-HIV co-infection.

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Aidstar one Case Study: A Positive Partnership

  1. 1. AIDSTAR-One | CASE STUDY SERIES November 2012A Positive PartnershipIntegrating HIV and Tuberculosis Services inKarnataka, India C handrappa arrived at Bagalkot District Hospital unable to fully move his legs. The doctors who examined him quickly discovered he was HIV-positive and on antiretroviral therapy (ART). After studying his medical history, conducting a detailed clinical examination, and discussing the findings among themselves, the doctors ordered an X-ray. The Daniel Cothran procedure confirmed their suspicions: Chandrappa (not his real name) had developed tuberculosis (TB) of the spine. He immediately began anti-tuberculosis therapy and recoveredA rural town in Karnataka. rapidly. Given the limitations in health care capabilities in remote parts of India, such as this rural area of Karnataka state, chances are that TB of the spine would not have been diagnosed so promptly. But Chandrappa was fortunate that the hospital has integrated TB and HIV services, enabling staff to develop advanced diagnostic skills and offer the best possible treatment and care to patients co-infected with both diseases. The deadly synergy between HIV and TB is well known. HIV weakens the immune system and makes the body susceptible to such opportunistic infections as TB, while TB infection speeds the progress of HIV-related disease. The higher the number of people living with HIV in a population, the greater the probability that they will contract TB, and the greater the resulting morbidity and mortality, even though TB is a curable disease. In some countries, TB is the greatest killer of people living with HIV.By John Franco Tharakan India, home to more than a billion people, has the second largest population of people living with HIV and the highest TB burden in the world, with an average of 70,000 registered TB patients yearly. In 2009, 258,037 TB patients in India were tested for HIV. Of these, more than 31,058—about 12 percent—were diagnosed with HIV co-infection. InAIDSTAR-OneJohn Snow, Inc. This publication was made possible through the support of the U.S. President’s1616 North Ft. Myer Drive, 16th Floor Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for InternationalArlington, VA 22209 USA Development under contract number GHH-I-00-07-00059-00, AIDS Support andTel.: +1 703-528-7474 Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Stateswww.aidstar-one.com Agency for International Development or the United States Government.
  2. 2. AIDSTAR-One | CASE STUDY SERIESKarnataka, HIV testing and counseling services facilities to ensure a coordinated effort. Patientsfor all newly diagnosed TB patients have revealed such as Chandrappa—whose co-infection mightunexpectedly high levels of TB-HIV co-infection, not have been caught before the Samastha Projectranging from 13 to 56 percent.1 These figures began its work—and thousands of others acrossat both the national and state level show that a India are the beneficiaries.collaborative model to address the TB-HIV nexus isa public health necessity.The integrated TB and HIV services at Bagalkot The National Response toDistrict Hospital are the result of the capacity- Tuberculosis and HIVbuilding and system-strengthening efforts of theSamastha Project (funded by the U.S. President’s The Government of India began its TB programmingEmergency Plan for AIDS Relief through the U.S. in 1962 as the National Tuberculosis Programme.Agency for International Development), which By 1992, the National Tuberculosis Programmefrom 2006 to 2012 supported integration of TB had evolved into the Revised National TB Controland HIV services in Karnataka and other areas Programme (RNTCP). That same year, the RNTCPof India. Clinical and administrative staff at the phased in directly observed treatment short-coursehospital received specialized training to deliver (DOTS) for TB.an integrated package of TB-HIV services, andnew collaborations were launched between the Efforts by the Government of India to integrate HIVhospital and state-level public health agencies, local and TB programming began early in the 2000s:nongovernmental organizations, and other health • 2001: developed a joint action plan for TB-HIV Key interventions implemented by • 2003: piloted cross-referral between integrated counseling and testing centers and designated the national framework for TB-HIV microscopy centers in Maharashtra state, collaboration: followed by implementation in six other states • HIV testing and counseling routinely offered to all TB patients • 2005: developed joint training modules on TB- • Decentralized delivery by RNTCP HIV service promotion of cotrimoxazole prophylactic • 2006: introduced the RNTCP TB-HIV intensified therapy for HIV-infected TB package patients • Referral of all HIV-infected TB • 2006: conducted a 15-district survey of HIV in TB patients patients for ART • Detailed recording and reporting • 2007: piloted cotrimoxazole prophylactic therapy on access to HIV care of HIV- for TB infection, and routine referral of TB infected TB patients. patients for HIV testing in five districts1 Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare. 2010. TB India 2010 Revised National TB Control Programme An-nual Status Report. New Delhi: Ministry of Health and Family Welfare.2 AIDSTAR-One | November 2012
  3. 3. AIDSTAR-One | CASE STUDY SERIES• 2007 to 2008: developed the national framework Samastha’s mission was to reduce the risk of for TB-HIV collaboration, which includes the HIV transmission among vulnerable and at-risk TB-HIV intensified package. populations, while building the capacity of existing health care institutions to provide high-qualityDespite the government’s efforts to address the HIV care, support, and treatment services. A keyproblem of co-infection, given the large number strategy was to hire a full-time TB-HIV specialistof patients affected by HIV and TB, the demand to provide technical assistance to the State AIDSfor services far exceeded availability. Providing Control Society, help strengthen systems andintegrated TB-HIV services proved difficult due to processes, build capacity to increase the uptakethe weak health systems in many states that did of TB services, and improve diagnosis andnot have the capacity to actively search out TB management of TB-HIV co-infection in Karnataka.patients. As a result, many patients slipped throughthe detection net, which negatively affected early Samastha’s prime organization, Karnatakadiagnosis and treatment of co-infected patients. Health Promotion Trust (KHPT), implemented by the University of Manitoba, Canada, workedOther challenges included a lack of expertise and in partnership with international and localskills related to TB-HIV co-infection among health nongovernmental organizations—includingcare providers and a lack of effective coordination EngenderHealth, which also played a leadingbetween different stakeholders involved in the role—and allocated specific tasks to each groupTB-HIV response. The RNTCP urgently needed for a more cohesive and better-managed program.technical support to help it implement initiatives EngenderHealth provided technical assistancefor improved access, high-quality diagnosis, to design care and treatment initiatives, improvetreatment of co-infected patients, better linkages access to services, build capacity, and strengthenamong different stakeholders, increased uptake of systems. Both EngenderHealth and Karnatakaservices, and decreased loss to follow-up. Health Promotion Trust supported improvement of monitoring and evaluation of services. The initiativeThe Samastha Project involved working closely with the Karnataka State AIDS Prevention Society (KSAPS). KSAPS is theWithin this context, the Samastha Project—a main government agency that supports planning,comprehensive HIV prevention, care, and support monitoring, and implementation of the Nationalprogram—launched in October 2006 in Karnataka. AIDS Control Programme Phase III in the state ofIn 2007, the Director General of the National Karnataka.AIDS Control Organisation asked the Executive The State Coordinating Committee and theDirector of Karnataka Health Promotion Trust Technical Working Group, which were primarilyand the Chief of Party of the Samastha Project to responsible for the policy and overview ofsupport integrated TB-HIV activities at the State implementation of the program in Karnataka,AIDS Control Society level. The primary aim of this conducted regular meetings to discuss variouscollaboration was to ensure better coordination issues. These meetings were facilitated by theamong the various health departments at the state TB-HIV specialist appointed through the Samasthalevel to build a more comprehensive and efficient Project and were chaired by the Principal Secretary,health care system. Health and Family Welfare, Government of A Positive Partnership: Integrating HIV and Tuberculosis Services in Karnataka, India 3
  4. 4. AIDSTAR-One | CASE STUDY SERIESKarnataka, and co-chaired by the Project Director readily available at all centers, with systems inof KSAPS. place to ensure their regular supply.The Samastha Project—which ended in March Step 3—Strengthen integration through2012—was ultimately implemented in 12 high- better collaboration: Many innovativeHIV prevalent districts of Karnataka, three urban measures were taken to ensure that healthcenters, and five coastal districts of Andhra care providers working in both the TB and HIVPradesh. programs in Karnataka were on the same page. Samastha facilitated joint monitoring visits atRoll-out in Karnataka the district level by personnel working with the District AIDS Prevention and Control Units and the RNTCP. Similarly, monthly meetings of personnelSamastha took four key steps during the roll-out of working at the community level from the TBthe TB-HIV integration process in Karnataka: and HIV departments were held, which helped track co-infected patients on treatment. DistrictStep 1—Design the service delivery AIDS Prevention and Control Units and districtmodel: The ball was set rolling with a model of supervisors received district-wide feedback onservice delivery largely centered on the TB-HIV the performance of TB-HIV activities in monthlyintensified package. The package had three major reviews.components: intensified case finding, isoniazidprophylaxis, and infection control. The package Step 4—Train health care providers:required service providers to: Samastha conducted training of trainer programs• Routinely offer HIV testing and counseling on the TB-HIV intensified package at the state services to all registered and newly diagnosed level for all program managers of the District AIDS TB patients Prevention and Control Units and for district-level TB officers. Training on the package was then• Procure and distribute cotrimoxazole conducted for medical and paramedical staff at prophylactic therapy to all diagnosed TB the district level. This ensured that all health care patients with HIV infection through the drug personnel at the district level were aware of the distribution system of the RNTCP-DOTS services that were to be provided, which improved program the quality of the services overall. The project also ensured that the TB-HIV intensified package was• Link co-infected patients to the ART centers. implemented by releasing funds at the district level.Step 2—Build human capacity: Vacant Samastha was instrumental in facilitating keypositions in the health system, including lab programs and services related to TB-HIV. Thesetechnicians and integrated counseling and testing included rolling out the TB-HIV intensified packagecenter counselors, were filled with qualified new in allocated districts, planning and coordinatingstaff. The entire team, old and new, underwent activities at the state and district levels, integratinginduction or refresher training on the TB-HIV TB-HIV services at different levels, developing theintensified package. HIV testing kits were made district action plan on TB-HIV coordination, creating a common platform for the district coordination committee, conducting training of trainers for4 AIDSTAR-One | November 2012
  5. 5. AIDSTAR-One | CASE STUDY SERIESdistrict-level TB officers with the support of the TB to HIV services, and vice versa.State TB Cell and Central TB Division, and helpingthe state TB program and KSAPS support linkage Samastha staff in all the project’s districtsworkers to facilitate better TB-HIV linkages. conducted regular follow-up with district-level TB officers and DOTS providers to ensure that patientsSamastha also helped foster an enabling policy diagnosed with TB were routinely screened for HIVenvironment for TB-HIV coordination at the and referred to integrated counseling and testingdistrict level. Previously, the district coordination centers for HIV testing. Additionally, as a resultcommittee’s member secretary had been the of active case finding among people living withprogram manager for the TB program. But with HIV, Samastha was able to detect about 2,000the integration of TB-HIV services, the district new cases of TB annually—about one-third ofprogram officer of the District AIDS Prevention and Karnataka’s TB-HIV co-infection burden.Control Unit, who is primarily responsible for all theactivities in this field, took over the post as program A focus on capacity building throughmanager. This facilitated better integration of TB- training and support: Initially identified as aHIV activities at the field level. critical need to ensure integration, capacity building was addressed at two levels. The first—training andWhat Worked Well support for Samastha staff—was at the program level, while the second was at the field level, as intensified package training efforts were rolled outBecause the intervention model proposed was across Karnataka in a systematic manner.innovative and ambitious, there were initialapprehensions about whether Samastha would Between 2008 and 2010, 425 Samastha partnersucceed. But the dedicated efforts of staff and health staff from both the HIV and TB programsproactive collaboration of different government received training in TB case detection, TB treatmentdepartments led to significant achievements. adherence, referral of TB clients to HIV testing and counseling centers, and management of HIV-Successful integration models: The related diseases in TB-HIV co-infected clients.Samastha Project successfully facilitated Trainees included a wide spectrum of staff: doctors,implementation of different models of TB-HIV nurses, counselors, outreach workers, and peerintegration, including integration of TB-HIV activities educators (see Table 1). This “whole site” approachwith integrated counseling and testing centers anddesignated microscopy centers under thesame roof within both the governmental TABLE 1. SAMASTHA PARTNER STAFF TRAINED, 2008 TO 2010.and nongovernmental sector settings. CATEGORY OF STAFF MALE FEMALE TOTALLocating these services together resultedin an increased uptake of TB-HIV Doctors 36 124 160services, better diagnosis of TB-HIV Professional counselors 21 35 56co-infection, and a decrease in loss to Outreach workers 106 68 174follow-up of patients. Each diagnosticcenter now has a counselor. As a result Health care workers 3 6 9of these efforts, there has been an Peer counselors 15 11 26increase in the number of referrals from Total 181 244 425 A Positive Partnership: Integrating HIV and Tuberculosis Services in Karnataka, India 5
  6. 6. AIDSTAR-One | CASE STUDY SERIESfocused on training all health care personnel at the At the field level, the EngenderHealth TB-HIVservice delivery sites at the same time to ensure specialist under Samastha led the roll-out of trainingthat information provided to all was uniform and across Karnataka and the training of trainersconsistent. Trainees were tested both before and for district program managers of both HIV andafter training; pre- and post-test results show an TB programs, supporting the efforts of the stateincrease in TB-HIV knowledge among trainees. governments. Among the high-prevalence states, Karnataka was the first to complete the trainingIn addition, numerous training workshops on the of trainers for program officers. Because of theTB-HIV package were held for health care workers success of these training efforts, the Nationalat various Samastha service outlets. These training AIDS Control Organisation asked for support tosessions were attended by district-level TB officers, conduct training for its district supervisors in fivemedical officers, counselors, and field-level high-prevalence states: Andhra Pradesh, Tamilworkers. The training model applied participatory, Nadu, Maharashtra, Nagaland, and Manipur. Thislearner-centric, and sustainable training activity was carried out successfully with the help ofmethodologies to build individual and institutional the National Institute for Mental Health and Neurocapacities for high-quality TB-HIV integration. Sciences (NIMHANS) and district-level medicalSupport and training of this nature continues for officers. By May 2009, KSAPS had reached 85newly recruited staff as part of in-service training percent of those targeted to be trained (see Tableand is now leveraged from the state TB-HIV 2).program rather than the Samastha Project.TABLE 2. STATE-LEVEL HEALTH CARE STAFF TRAINED IN KARNATAKA, 2008 TO 2009CATEGORY OF STAFF NUMBER IN PLACE PERCENTAGE TRAINEDDistrict TB officers 25 (5 vacant) 25 (100%)District nodal officers/District 29 29 (100%)program officers/District AIDSPrevention and Control UnitsMedical officer in charge of training 117 (8 vacant) 94 (80%)Medical officer: ART center 67 48 (71%)Medical officer: public health 4,884 2,891 (60%)institutionsDistrict HIV supervisors 29 29 (100%)Senior treatment supervisor 125 121 (97%)Senior TB laboratory supervisor 124 (one vacant) 95 (78%)Senior TB-HIV supervisor 129 111 (73%)Integrated counseling and testing 704 (including ART 604 (85%)center counselors counselors)Pharmacists 2,178 1,047 (48%)6 AIDSTAR-One | November 2012
  7. 7. AIDSTAR-One | CASE STUDY SERIES TABLE 3. NUMBER OF VARIOUS TYPESIn the long term, building capacity and OF CENTERS IN KARNATAKAstrengthening service delivery systems for TB-HIVintegration have led to an increase in uptake of FACILITIES AVAILABLE NUMBERservices. An assessment showed that the training Integrated counseling and 565helped improve knowledge, skills, and practices testing centersamong both TB and HIV health workers, supported Designated microscopy centers 643by easy-to-use job aids. Enhanced indicators Centers with designated 418and monitoring capacity have further facilitated microscopy centers andintegration. integrated counseling and testing centers co-locatedExpanded access to TB-HIV services:The number and type of facilities that offer TB-HIV ART centers 44services increased considerably (see Table 3). Link-ART centers (ART centers 97Samastha helped KSAPS establish DOTS services outside of major urban areas)in many community care centers. This was doneto improve referrals between RNTCP services and workers promoted the use of TB diagnostic servicesintegrated counseling and testing center services, as part of their routine work. They were trained toand establish demonstration sites that integrate identify people with suspected TB infection, referdesignated microscopy centers with DOTS services them to diagnostic and treatment services, followin the community care center setting. While KSAPS up to ensure compliance to treatment and providedeveloped 40 such integrated community care referrals for treatment evaluation at ART centers.centers with DOTS services, Samastha launcheddesignated microscopy at four community care Tuberculosis case finding, diagnosis, and treatmentcenters: Cardinal Gracious Hospital, Belgaum; Holy for people living with HIV expanded as a resultCross, Chamarajanagar; Snehadaan, Bangalore; of integrating TB-HIV services at facilities. Forand Sargur, Mysore. example, Cardinal Gracious Hospital in Belgaum showed an increase of 64 percent in TB diagnosisCo-location of TB-HIV services helped in the timely and treatment of HIV-positive clients after servicesidentification, referral, and treatment of patients. were integrated.The program worked with KSAPS to ensure thatDOTS and designated microscopy center services Effective outreach and follow-up: Thewere made available at 12 community care centers. integrated TB-HIV model has successfully createdThis made it more convenient for patients who were linkages between TB and HIV programming at thereferred from the HIV program to the TB program grassroots level. This has increased the number ofand vice versa to access appropriate services. This diagnosed co-infected patients who are contactedeventually led to better treatment adherence. and then referred to district hospitals for pre- ART registration and CD4 tests. Those eligibleIncreasing TB services for people living for treatment receive ART or anti-tuberculosiswith HIV: Outreach staff of community care therapy, as required. Regular meetings of field-levelcenters and drop-in centers verbally screened staff from both programs and exchange of patientpeople living with HIV for TB symptoms and information ensure that services are complementaryaccompanied them to centres for sputum testing and that patients adhere to treatment. Theand X-ray tests, if needed. Additionally, field-level involvement of PLHIV networks in RNTCP activities A Positive Partnership: Integrating HIV and Tuberculosis Services in Karnataka, India 7
  8. 8. AIDSTAR-One | CASE STUDY SERIESas DOT providers and in information, education, • Stronger linkages were created between theand communication (IEC) and social mobilization ART center and RNTCP services.was strengthened. Overall, the model has fosteredan enabling environment for comprehensive care Reporting and documentation of patients underand support of people living with HIV and those these two programs, with regular exchange ofinfected with TB. information, was regularly carried out for better follow-up. Dedicated technical assistance at thestate level: Having a full-time technical expert Integrating more services in the existingto facilitate coordination between the HIV and heath system through whole site training:TB programs made a very big difference. In this The whole site training approach was integratedcase, the TB-HIV specialist, who had worked with better infection prevention practices to supportin both the government and nongovernmental the integration of TB-HIV services within thesectors, had a unique perspective on how both existing health system. This approach seeks toorganizations worked, which facilitated the smooth meet the learning needs of all the staff at a serviceroll-out of this aspect of the Samastha Project. The delivery site within the context of organizationalspecialist helped the State AIDS Control Society development. Training needs are identified throughimplement the revised national framework for self-assessments and are met through differentTB-HIV collaboration, helped the district-level TB levels of learning. Training takes place at theofficers develop district action plans on TB-HIV service site whenever possible and is supportedcoordination, conducted training of trainers on by post-training facilitative supervision by trainersthe TB-HIV package for district-level TB officers, wherever possible.helped the state TB program and KSAPS supportlink workers, and provided feedback to the DistrictAIDS Prevention and Control Units about the Co-location of services: Samastha stronglyperformance of TB-HIV activities. advocated for co-location of TB-HIV services to increase access to health care for the community. There was a marked rise in the number of patientsA more robust TB-HIV package: The who accessed both HIV and TB services after theyprogram added more components to the prevailing were co-located, since patients had to visit only oneTB-HIV package to make it more effective: center, saving time and transportation money. Co-• HIV testing services were offered to all location also greatly reduced stigma, since a facility persons presumed to have TB, in contrast to that is not seen as exclusively an HIV center is a the previous practice of testing only patients more comfortable place to visit. diagnosed with TB. Intensified case-finding activities: The• Decentralized provision of cotrimoxazole program focused on intensified case finding and a prophylactic therapy from the DOTS center was 10-point TB screening tool for counselors, as they initiated for all TB-HIV patients, with a special are a crucial part of the TB-HIV intensified package. emphasis on ART. Both these documents have been translated into Kannada and Telegu, to facilitate better understanding for staff at various levels.8 AIDSTAR-One | November 2012
  9. 9. AIDSTAR-One | CASE STUDY SERIESCombined district-level visits: District-levelvisits were conducted regularly by a combined Challengesteam consisting of World Health Organization The following are issues observed in implementingconsultants, the district-level TB officers, a state- the integrated TB-HIV model.level TB-HIV consultant (Samastha/KSAPS), andlocal medical regional managers from Samastha Late TB diagnosis: Too few HIV-positiveto review TB-HIV services at the field level. These patients are diagnosed with TB in a timely way,reviews helped ensure better coordination between especially those who are asymptomatic. Thisdifferent levels of services and the implementing matter is further aggravated for patients withnongovernmental organizations for the HIV extrapulmonary TB (where the infection occursprogram. Integrating these combined visits with the outside of the lungs), for which diagnostic facilitiesRNTCP state internal evaluation went a long way in are limited.coordinating and monitoring activities. Insufficient coverage and late start of ART: Of HIV patients diagnosed with TB,Coordinating with other programs: preliminary estimates show that around 99 percentCoordination with National Rural Health Mission- are on cotrimoxazole prophylactic therapy, butdriven antenatal care services to test TB patients only 74 percent are on ART (March 2012). Thefor HIV contributed to increased numbers of TB challenges to increasing ART coverage includepatients knowing their HIV status. In addition, the regulations about minimum CD4 counts and thecotrimoxazole prophylactic therapy kits procured limited availability of centres that can initiateby KSAPS were distributed using the RNTCP drug ART, mostly available only at district hospitalsdistribution mechanism. in Karnataka. A huge number of co-infected patients do not reach the ART center until a veryWell-developed reporting formats: Separate late stage of AIDS. Mechanisms to establishreporting formats for monitoring linkage of TB-HIV early linkages of patients to ART centers need topatients to cotrimoxazole prophylactic therapy and be developed, while logistical and procurementART were developed and rolled out in the state. challenges to achieving complete coverage forThis helped streamline information specific to TB- HIV testing and counseling need to be overcome.HIV integration, identify and follow up with patients With the convergence of TB and HIV services,at the field level, and increase patient adherence nongovernmental organization partners couldand the overall quality of the program. contribute by using their human resources to strengthen linkages from the community to ensure that those on cotrimoxazole prophylactic therapySuccessful advocacy: Samastha successfully are also initiated into ART services.advocated starting ART immediately—whatever theCD4 count—for people living with HIV diagnosed Low levels of referrals: A simulated patientwith TB. One of Samastha’s key tools for this was survey among general practitioners across the statea publication that used Karnataka ART data that showed that few practitioners refer TB suspects orSamastha staff helped collect. patients to RNTCP services because they prefer to treat them as their own private patients even though they know the program exists. Innovative methods to solve this important issue need to be found. A Positive Partnership: Integrating HIV and Tuberculosis Services in Karnataka, India 9
  10. 10. AIDSTAR-One | CASE STUDY SERIESThe costs of travel: Since many patients live Delay in information: Information regardingfar away from the ART centers, costs and time the status of linkages of TB-HIV patients toassociated with travel to the centers continue to cotrimoxazole prophylactic therapy and ART arecontribute to the rise of loss to follow-up cases. recorded in the RNTCP Outcome Report, which often comes too late for corrective actions to beNutrition issues: Lack of appropriate nutrition taken.for co-infected patients on treatment continues tobe a major issue which needs to be addressed. Training issues: Regular turnover among staff at all levels makes it challenging to ensure that allThe following are issues involving nongovernmental are trained.This limits the ability of these centers toorganizations in RNTCP schemes to enhance provide required services in an efficient manner.private-public partnerships. Information, education, andRestrictive regulations: According to the communication tools: There is a dearth ofearlier TB-HIV scheme for non governmental communication tools that focus on TB-HIV co-organizations in RNTCP, a community care center infection. This makes it difficult to sensitize andshould have at least 20 beds to be eligible for raise awareness among people on this importantfunding. Most community care centers under the subject.TB-HIV scheme have 10 beds and were ineligiblefor benefits from this scheme. These guidelines Planning of TB-HIV activities: There ishave been recently amended to enable 10-bedded a need to bring all stakeholders working in HIVcommunity care centers to also be part of this and TB at the district level together at a commonscheme. Uptake has been slow and remuneration planning meeting so that initiatives can be plannederratic at best. collaboratively. This will ensure that all resources meant for activities related to HIV and TB areInsufficient funds for public-private optimally utilized without duplication of resources.partnerships: There is a shortage of funds The district program officer in the District AIDSallocated for nongovernmental organizations/ Prevention and Control Units can take the lead inpublic-private partnership activities. This makes it facilitating such meetings and provide guidance asdifficult for activities proposed to continue smoothly; and when needed.on many occasions, the lack of funds results inactivities being postponed or discontinued.The following are issues and challenges in Recommendationsimplementation of the TB-HIV intensified package. Provide high-quality technicalLocation of testing sites: Not all integrated assistance: To successfully integrate TB-HIVcounseling and testing centers and designated services, strong technical assistance must bemicroscopy centers are co-located, which means available from the start but should also continue forpatients often have to travel to other places to get a few years until adequate integration systems aretested for HIV. Therefore, HIV testing of TB patients in place in the government. The person secondedis delayed and in some cases not done. by Samastha for this project was the cornerstone for most of these integrated activities during the initial phases of the project. Technical assistance of10 AIDSTAR-One | November 2012
  11. 11. AIDSTAR-One | CASE STUDY SERIESthis nature would need to continue for a few years HIV testing in all DMCs and non-DMC peripheraluntil adequate integration systems are in place in health institutions will help in early diagnosis ofthe government. cases.Build the technical capacity of Locate services close to the communitiesimplementing partners: Samastha expended served: Since traveling to community care centersconsiderable effort to build technical capacity for its (which provide both TB and HIV services) requirespartners. This ensured a thorough understanding both time and money, locating these centers closerof what the program entailed and delivery of high- to the community will help improve uptake.quality services. Strengthen TB infection controlUse the whole team approach: Building measures: Ensure that administrative measurescapacity and strengthening service delivery in all co-located DMCs/ICTC and ART facilitiessystems show promising results in increasing the include TB infection control as a key supervisionuptake of TB and HIV services. This is especially responsibility for state- and district-level ARTtrue when capacity building initiatives such as officers.training are conducted across a team of healthworkers and supervisors using the whole team Implement INH Prophylaxis Therapyapproach. (IPT): While awaiting the outcome of feasibility studies for nationwide scale-up, launch IPT withinBuild the capacity of outreach workers: co-located DMCs/ICTC and ART centers in settingsOutreach workers play a critical role in raising with high rates of HIV.community awareness about TB-HIV co-infection.They are also crucial to intensified TB case finding Increase integration and coordination:and in providing DOTS for people living with HIV In India and other countries with a high burdenwho have TB. Thus, their capacity building must be of TB, increasing TB-HIV integration appears toan important focus area. increase the uptake of other HIV services, including HIV testing and counseling, care, and treatment.Improve the quality of co-treatment: Enhanced TB-HIV coordination at the district andART for TB patients should begin while they are state levels strengthens implementation systems,while undergoing baseline evaluation, since four which also benefits other health care services.to six weeks are required for evaluation. Daily TBtreatment for PLHIV is recommended, though it Provide enabling tools to health workers:should be in line with current DOTS practices, Practical tools and reporting forms make it easierinternational standards of TB care, and the soon- for health workers to proactively find TB cases andto-be-developed Indian Standards of TB Care. ART refer them to relevant services.should be guaranteed for all co-infected TB patientsirrespective of CD4 count. Take the time to build strong systems: Good monitoring and evaluation systems areCo-locate TB and HIV services to help important. However, it takes time to build theexpand HIV testing: Co-location decreases understanding and capacity of staff to effectivelybarriers to timely diagnosis of TB and any missed track and follow-up on TB-HIV referrals in the field.opportunities for HIV care and treatment. Providing A Positive Partnership: Integrating HIV and Tuberculosis Services in Karnataka, India 11
  12. 12. AIDSTAR-One | CASE STUDY SERIESSufficient time and patience are required for all ACKNOWLEDGMENTSthese factors to become efficiently operational. The author would like to acknowledge the leaders,Provide timely feedback: Conducting regular staff, and partners of the Samastha Project formonthly review meetings and timely feedback to their support in the development of this case study,each district about the performance of the State especially Dr. Reynold Washington, Chief of Party,AIDS Control Society enables them to address Dr. Vikas Inamdar and Dr Chethana Rangarajuchallenges promptly and also share best practices (TB-HIV specialists), Dr Suresh Shastri (Regionalrapidly. This is key to making the program a Coordinator, ART) and Dr Gajanan Pise (Medicalsuccess. Consultant), the dedicated health care personnel working at the grassroots level, and the manyAdd diagnostic and treatment field workers who gave their time to share theircapabilities: When nongovernmental experiences.organization-managed care and support centershave diagnostic and treatment facilities it helps Thanks are also due to the leaders of theconsiderably in integrating TB control activities with Karnataka State AIDS Prevention Society and StateHIV care programming. Tuberculosis program for their willingness to share their views. Finally, thanks also to USAID/India,Targeted interventions have greater especially Dr. Sangeeta Kaul and Mr. Anand Rudra,impact: Prevention programs for high-risk for assistance, advice, and helpful feedback.populations help tackle intensified TB case findingamong people living with HIV more effectively. g RECOMMENDED CITATION Tharakan, John Franco. 2012. A Positive Partnership: Integrating HIV and Tuberculosis Services in Karnataka, India. Case Study Series. Arlington, VA. USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.12 AIDSTAR-One | November 2012
  13. 13. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at www.AIDSTAR-One.com to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.

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