Dialogue around TB and TB-HIV co-infection in India

On 10th May 2011 the new incoming head of India's national TB programme (formally called Revised National TB Control Programme - RNTCP) met the civil society for an open, informal and participatory interaction on a range of TB-related issues. The RNTCP agreed to support and participate in a proposed national consultation on TB and HIV collaborative activities in India. Participants from the civil society raised several key issues.

Dr Ashok Kumar, Deputy Director General, Central TB Division, Ministry of Health and Family Welfare and Dr KS Sachdeva, Chief Medical Officer, RNTCP attended this interface with a range of civil society representatives to have a dialogue on key issues that emerged on TB care and control in India.

Leena Menghaney from MSF Access Campaign said that the HIV positive networks had to struggle a lot to have, and increase, access to antiretroviral therapy (ART) and TB services from DOTS. There were many difficulties in adhering and accessing services. Drug resistant TB poses a big challenge especially for people living with HIV (PLHIV). How can affected communities participate in improving responses to drug resistant TB needs to be understood more, asked Leena.

Loon Gangte from Delhi Network of People living with HIV (DNP+) said: Providing ART and anti-TB treatment (ATT) or DOTS under one roof is not enough because present diagnostic services rarely work for PLHIV. It is very difficult to detect TB in PLHIV. I am a trained DOTS worker, most people remain undetected as sputum and chest x-ray doesn't confirm TB in PLHIV. PLHIV will continue to die of preventable TB if diagnostic services are not improved. Treatment literacy is another point I will like to raise. HIV related treatment literacy has taught PLHIV to take control of their lives. However, most PLHIV don't even know basic information about TB. Due to poor infection control measures in DOTS centres, PLHIV often get infected with TB in such clinics which are ironically supposed to save them from TB! So infection control measures in healthcare settings and communities are most important for PLHIV, said Loon.

Luke Samson from SHARAN/ Indian Harm Reduction Network (IHRN) said: We should be having integrated programmes not vertical – why RNTCP has to go back on nutrition? How are we going to make access more efficient? Collaboration might exist at top level but all health programmes fragment when it comes to community level, said Luke. Dr Sachdeva from RNTCP responded that the RNTCP has nothing against nutrition but there are studies that show: treatment outcome is not influenced by nutritional status. Civil society should come forward and address nutritional needs where required. Dr Sachdeva encouraged local TB programmes to link up with those on nutrition. Anand Grover informed that Right To Food (RTF) bill that is currently in the process in India guarantees nutrition for people living with HIV and those with TB.

Pankaj Anand from International HIV/AIDS Alliance - India, said: Service delivery mismatch is there. Collaboration between NACO and Central TB Division (CTBD) is there but in most states, collaboration between State AIDS Control Societies (SACS) and State TB programmes is not visible or very weak. District TB-HIV committees meet but agenda is not impressive and don’t go beyond snacks or insignificant discussions. How can PLHIV networks be more involved as equal partners in improving these collaborative activities at the ground level?

Leena added: 13,000 sputum microscopy testing centres are there but they don't work for PLHIV because even if PLHIV have TB they test negative for sputum test. PLHIV need drug sensitivity testing (DST) and culture facilities. Also ART centres are not doing TB diagnosis.

Dr Sachdeva from RNTCP responded: We should not write off 13,000 sputum microscopy centres. Also 9% of new TB patients are being diagnosed by NACO. It takes more than 2 years to get one laboratory accredited for culture and DST. Presently we have 27 accredited laboratories for DST and culture. Newer technologies like GENE XPERT are being rolled out too. DOTS Plus will be across the country in 2 years from now and then all PLHIV will have access to these services. 

Mudrika said: I have been working closely on TB at LRS Institute of TB and Respiratory Diseases in New Delhi and TB 'suspects' who don't have confirmed TB diagnosis are being put on anti-TB treatment.

Pradeep asked that PLHIV at times are unable to go to DOTS centres so is there any facility for such people under RNTCP and Dr Sachdeva from RNTCP responded that community volunteers are there for patients who cannot come to DOTS centres. There are many schemes and programmes which encourage people to become community volunteers. 

Another civil society participant asked where are MDR-TB services available as the cost of MDR-TB treatment in private sector is very high at INR 15,000 per month (about USD 380). Dr Sachdeva from RNTCP said that MDR-TB services are available under RNTCP in 15 states, including Delhi. Leena from MSF requested RNTCP to let the civil society know where MDR-TB services are available so that this information can be disseminated widely. Dr Sachdeva from RNTCP further added that the MDR-TB services are free under RNTCP however, diagnosis has to be done through accredited laboratories only.

Kajal Bhardwaj said that there is a need to learn from other programmes on the benefits of treatment counselling and giving information to the patients. Why drugs cannot be given for 1 or 2 months to TB patients? Dr Sachdeva from RNTCP responded tht earlier this model where patients took medicines without medical supervision has failed. We cannot support dilution of DOTS. Kajal responded that she is not asking for diluting DOTS, she is rather suggesting how can community strengthen DOTS and support DOTS.

Joanna from MSF raised a key issue: Irrational use of drugs by private doctors. She also asked on benefiting from generic drug production in India just like AIDS programme has benefited from it. Price of drugs that might go up many times if patent laws come into effect so how does RNTCP plan to respond to such crisis, asked Joanna.

Dr Charles Gilks from UNAIDS India said that the civil society should think not just what RNTCP should be doing but what it should be doing in terms of treatment literacy, adherence and community activism to protect rights of people who develop drug resistance. If we had allowed this to happen in HIV we would have had massive drug resistance epidemic by now. We are putting lot of energy into dealing with the consequences of poor use of good quality drugs, said Dr Gilks.

Anand Grover said that irrational use of medicines is not just limited to TB, even NACO is contemplating regulating private doctors who begin ART with 2nd line regimens. Dr Sachdeva from RNTCP said that they will like to explore legal measures to prevent unscrupulous use of drugs like NACO is contemplating as informed by Anand Grover.

Dr Mira Shiva said that in India 36.6% women have body mass index (BMI) less than 18.5. How can we say that nutrition is not linked to treatment outcome? 

Anandi Yuvaraj said that stigma is a major challenge in TB as well. Dr Sachdeva from RNTCP said that stigma is a major issue especially among women. RNTCP study shows that stigma related to TB was reduced from 37% to 32%. Anandi Yuvaraj asked what were the indicators used to measure stigma reduction?

Dr Charles Gilks raised another key issue: Isoniazid Preventive Therapy (IPT) or Isoniazid Prophylaxis. IPT is so important to prevent people, particularly PLHIV who are at a heightened risk of active TB disease, from developing active TB disease. IPT should only be given to people with latent TB (active TB disease has to be ruled out before IPT provision). Also nutrition is a recognised risk factor for active TB disease and so programme should recognise it too, said Dr Gilks. Blessina Kumar added that there is enough research to show that IPT or isoniazid prophylaxis has saved lives.

Towards the end of this interface of RNTCP with civil society, Dr Ashok Kumar and Dr Sachdeva from RNTCP agreed to support and participate in the proposed national consultation on TB-HIV collaborative activities.

The Stop TB Partnership, International Treatment Preparedness Coalition (ITPC) India and Medicins Sans Frontieres (MSF) Access Campaign had organized this meeting in New Delhi, India.

Bobby Ramakant - CNS

Published in: 
Citizen News Service (CNS), India/Thailand
CNS Stop TB Initiative, India 
Elites TV News, California, USA
AIDS Space.org,    
Health Dev.net 
Microns Tag HIV
AIDS Alliance India, India

1 comment:

  1. "Tuberculosis is the most common HIV-related opportunistic infection in India, and caring for patients with both diseases is a major public health challenge. India has about 1.8 million new cases of tuberculosis annually, accounting for a fifth of new cases in the world — a greater number than in any other country (see pie chart
    Estimated Number of New Tuberculosis Cases, 2004.
    ).1 Patients with latent Mycobacterium tuberculosis infection are at higher risk for progression if they are coinfected with HIV. Patients with HIV infection have a similar bacteriologic response to tuberculosis treatment as those who are not infected but have higher risks of recurrence and death. The influence of tuberculosis coinfection on the progression of HIV disease is controversial.2
    In 2004, about 330,000 people in India died from tuberculosis.1 Two of every five persons — more than 400 million — have latent tuberculosis infection.3 Tuberculosis can be expected to develop in more than half of those who are also infected with HIV. At present, however, only about 5% of new tuberculosis cases in India occur in people with HIV coinfection. The situation differs from that in sub-Saharan Africa, where the incidence of tuberculosis in many countries is higher than in India and as many as 80% of patients with tuberculosis are coinfected with HIV. In Africa, HIV has reversed gains in tuberculosis control that were achieved a quarter-century ago.1,2 Such a reversal is unlikely to occur in India.4"

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