Study of cross-referrals between Integrated Counselling & Testing Centre and RNTCP-Designated Microscopy Centre at a tertiary care hospital in Bengaluru, Karnataka

present study was designed to assess the socio-demographic profile of the clients visiting ICTC and to assess the pattern of cross referrals between ICTC and RNTCP Designated Microscopy


Introduction
India has the world's highest burden of tuberculosis (TB) and third largest number of people living with HIV in the world; it also ranks third in the world for HIV-associated TB.India's national AIDS control programme (NACP) and the revised national TB control programme (RNTCP), were established in 1992 and 1993, respectively.This study was conducted to assess the pattern of cross-referrals between ICTC and DMC in order to find areas for improvement for better case finding and reporting of HIV-TB co-infection which is essential for effective management and better prognosis of these cases.As far as HIV testing of spouses of seropositive ICTC clients was concerned, there were 14 discordant couples.Among the 9 concordant couples HIV seropositivity was observed to be higher 5 (55.56%) among female spouses of male HIV positive clients as compared to male spouses 4 (44.44%) of female HIV positive clients [Table 5].It was observed that among that 252 TB patients referred from DMC to ICTC, 8(3.17%) patients were found to be HIV positive (i.e., HIV-TB co-infection).

Materials and Methods
Among the TB negative suspects referred to ICTC 3(0.28%) were found to be HIV seropositive [Table 6].
This association between HIV status and TB Status was found to be statistically significant (p= 0.000031).Among the 8 patients who were both HIV and TB positive, 7 were sputum positive TB and 1 was extra pulmonary TB.   housewives.Housewives maintain the pool of infections [10].
In this study, majority 14 (60.86%) were discordant couples.Among the 9 (39.14%)concordant couples HIV seropositivity was observed to be higher 5 (55.56%) among female spouses of male HIV positive clients as compared to male spouses 4 (44.44%) of female HIV positive clients.
However this difference was not found to be statistically significant (p=0.47).This is similar to the findings of the study by Roma C et al [8] where 44.90% were concordant couples and 55.10% were discordant couples.
In Among the 8 (3.17%) clients with HIV-TB coinfection 7 were sputum positive TB and 1 was extra pulmonary TB while in the study by Shrivastava S et al [12]264 confirmed cases of TB were referred to ICTC for their HIV status.There were 33 extrapulmonary TB (EPTB).HIV-positive sero status was found in 15(56%) sputum positive TB cases, 8(30%) sputum negative TB and 4(15%) of EPTB cases.
The proportion of HIV positivity among TB confirmed cases in our study was 3.14%.Similar finding was observed in the study by Gupta A K et al [13] where total number of TB clients found HIV positive was 446(1.72%).Whereas in the study by Shrivastava S et al [12]and Giri P et al [14]the proportion of TB-HIV co-infection was 10% and 17% respectively.
(Please remove "This study highlights") ICTCs and TB clinics play a significant role of in diagnosing TB or HIV among the patients who have been collaterally referred.It also emphasizes the need for further strengthening the partnership between RNTCP and NACP to extend and expand diagnostic services to both cadres of patients [12].
Although, significant efforts are being made at the national level, it is essential to make efforts at the micro level to achieve system of cross-referrals with sustainable results [15].

Conclusion
The present study highlights the need for intensive training, motivation and of ICTC counselors in order to ensure proper case detection And cross referrals.Regular scheduled interaction, feedback and documentation by the health workers of both ICTC and DMC is imperative for successful implementation TB-HIV collaborative activities.
Both programmes have been instrumental in impacting the burdens of HIV and TB in India.To address the burden of HIV-associated TB, collaborative TB/HIV activities have been implemented by NACP and RNTCP since 2001[1].Implementation of TB/HIV collaborative activities in India started in 2001 with six high HIV prevalence states.Early collaborative activities included joint training of TB and HIV programme staff and crossreferral of patients.The cross-referral included intensified case-finding (ICF) at HIV testing and counselling (HTC) centres and referral to RNTCP Designated Microscopy Centres (DMCs), as well as referral of TB patients at high risk of HIV for HTC [1].HIV-associated TB is fatal if not treated.Early detection and prompt treatment is critical to minimize mortality.Early detection requires effective implementation of provider-initiated HIV testing and counselling in TB patients and intensified TB case finding among PLHIV.In India these activities are executed by two separate and strong vertical national programmes: RNTCP and NACP.Close collaboration between the two programmes is necessary to ensure 100% detection and ART for all HIV-positive TB patients [1].RNTCP is facilitating provision of HIV testing services through TB microscopy centres (DMCs) using existing human resources.These efforts aim to optimize utilization of existing resources and make the interventions sustainable [1].For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for Revised National Tuberculosis Control Programme (RNTCP) and conducting operational research relevant to RNTCP [2].
Chi square value: 70.55 df =1 p=0.000031With regard to the cross referrals from DMC to ICTC, there were a total of 1322 referrals, of which 252 (19.06%) were TB positive.Of these 252 TB positives, 121 were sputum positive for TB, 9 were sputum negative TB and 122 were extra pulmonary TB.

Figure 4
Figure 4 shows the proportion of TB positives 252 (19.06%) and TB negative 1070 (80.94%) patients among the total TB suspects (1322) visiting the DMC.It also depicts the proportion of HIV negatives 244(96.83%)and HIV positives 8 (3.17%) among the TB positive patients.The figure also reveals that TB-HIV co-infection in this study is 8 (3.17%).

period. Method of data collection: The study subjects
Study setting: Integrated Counselling and Testing Centre (ICTC) and RNTCP-Designated Microscopy Centre (DMC) at Raja Rajeswari Medical College and Hospital (RRMCH), Bengaluru Study design: Descriptive study Study period: Nine months (April 2018 to December 2018) Study subjects: All the clients visiting ICTC and all the TB suspects visiting RNTCP-DMC at RRMCH during the study period.Exclusion criteria: Pregnant women visiting ICTC during the study

Table - 5: Distribution of spouse of HIV positive clients according to their HIV test result (n=23) (Please note this table had row percentages previously now it is changed to column percentages) Srividya V. et al: Study of cross-referrals between Integrated Public Health Review -International Journal of Public Health Research 2019;6(1) Variab le HIV Status Total no. of clients tested at ICTC HIV
Negative No.

et al: Study of cross-referrals between Integrated Public Health Review -International Journal of Public Health Research 2019;6(1)
the present study, Out of the total 9405 clients [10]rity 251 (53.41%) of the cross referrals from ICTC to DMC were above 50 years of age whereas in the study by Shrivastava S et al[12]majority 190(62%) were from 20 to 40 year age group[10].In this study, males were the majority 294 (62.55%) among cross-referrals from ICTC to DMC Srividya V.