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.

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 cross-referral 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].

and percentages. Quantitative variables were presented as mean and standard deviation (this sentence is to be removed). Chi square test of significance was applied to know the association between variables and p value of less than 0.05 was considered statistically significant.

During the study period of nine months, a total of 9405 clients visited ICTC and underwent HIV counseling and testing. It was observed that majority 3058(32.51%) of the clients were above 50 years of age and majority 4747(50.48%) were female clients as shown in Table 1.

Occupation wise, 2096(44.21%) of female clients were housewives and among males, semiskilled workers constituted the majority 1280 (27.44%) [Table 2].

Of the total 9405 clients visiting ICTC, 68(0.73%) were diagnosed to be HIV positive [Table 3] and among them majority 28(41.17%) belonged to the age group of 35-49 years and HIV seropositivity was observed to be higher 37(54.41%) among males, majority of the HIV sero positives 19(27.94%) were semiskilled workers by occupation, followed by housewives 18 (26.50%) as observed from Table 4.

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].

Table-1: Socio-Demographic characteristics of clients tested at ICTC (N=9405)

Table-2: Gender wise distribution of ICTC clients according to their occupation (N=9405)

*Spouse of HIV positive clients

Table-6: Distribution of HIV status among the TB suspects referred from DMC to ICTC (n= 1322)

Chi square value: 70.55 df =1 p=0.000031

With 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.

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). 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.

Figure-1: Age-wise distribution of cross-referrals from ICTC to DMC (n=470)

The HIV-TB collaborative venture was launched with the primary aim to promote early diagnosis and treatment of HIV in TB patients and of TB in HIV infected individuals. HIV-TB cross-referral and coordination is of utmost importance to improve the outcome and burden of both these infections [3].

An Integrated Counseling and Testing Centre (ICTC) is a place where a person is counseled and tested for HIV either on his own free will or as advised by a medical provider [4].

In our study a total of 9405 clients visited the ICTC during the study period of April 2018 to December 2018, among them majority, 3058(32.51%) of the clients were above 50 years of age this is in contrast to the study by Chauhan N et al [5] where, majority of the study subjects, i.e., 399(79.8%) belonged to age group of 15-49 years. Female clients were 4747(50.48%) whereas in the study by Haider S et al [6], majority was males 79 (68.1%).

Occupation-wise majority 2096(44.21%) of the female clients in our study were housewives and majority 1280 (27.44%) of the male clients were semiskilled workers similar to that of the study by Mishra S et al [7] in which most of the male attendees were semi-skilled(38.61%) workers and most of the females were housewives (72.09%).

The proportion of HIV seropositivity was 68 (0.73%) in our study similar to the study done by Roma C et al [8] where 1.24% of the clients were HIV reactive. However in the study conducted by Mathur A et al [4], 298 (12.35%) were found to be HIV positive.

The HIV seropositivity in our study was observed to be higher than the national values i.e., as per the recently released, India HIV Estimation 2017 report, National adult (15–49 years) HIV prevalence in India is estimated at 0.22% (0.16% – 0.30%) in 2017 [9].

In present study majority 28(41.17%) of the HIV positives belonged to the age group of 35-49 years this is similar to the study by Roma C et al [8] , where maximum sero-reactivity (p< 0.0001) was found in 31- 49years age group (42.59%) and HIV positivity was observed to be higher 37(54.41%) among males similar to the study by Chauhan N et al [5] where, out of the 500 sero-positive cases 316 were males (63.20%).

According to occupation majority of the HIV

similar finding i.e., majority 175(57%) males was observed in the study by Shrivastava S et al [12].

Tuberculosis clinics have been found to form an important portal of entry for HIV diagnosis and treatment as well as to provide an opportunity for counselling, so that new infections can be prevented in the future [3]. In this study, 100% of the TB suspects visiting the DMC were referred to ICTC for HIV testing.

This was because of the strict implementation of intensified TB-HIV collaborative activities under RNTCP. Of the total 1322 referrals from DMC to ICTC 252 (19.06%) were TB positive. Our study revealed that among the total 252 TB positives 121 clients were sputum positive for TB and 9 were sputum negative TB and 122 were extra pulmonary TB.

Among the 8 (3.17%) clients with HIV-TB co-infection 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 extra-pulmonary TB (EPTB). HIV-positive sero status was found in 15(56%) sputum positive TB cases, 8(30%) sputum negative TB cases, 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].

The present study highlights the need for intensive training, motivation and supervision of ICTC counselors in order to ensure proper case detection