India's battle against the tuberculosis-HIV dual epidemic

[Guest guest]

The Lancet Journal of Infectious Diseases, February 2004

India's battle against the tuberculosis-HIV dual epidemic

Patralekha Chatterjee

The morning rush at the government-run DOTS (directly observed

treatment, short course) centre at Madangir, a low-income

neighbourhood in Delhi, India's capital city, is an indicator of the

challenges confronting India's tuberculosis-control programme.

In a room barely 2·5 by 3 metres, new smear-positives, relapse cases,

and those diagnosed with extrapulmonary tuberculosis queue up for

their dose of medicine under the watchful eye of DOTS provider

Intezzar Ali. Getting patients to adhere to the DOTS regimen is not

an easy job when they are on the move and when time and space are in

short supply, says Ali.

India has the distinction of being a country with one of the highest

tuberculosis burdens (one-third of the global case load) and one of

the fastest expanding DOTS programmes for the treatment of

tuberculosis. Launched in 1993 as a pilot project, India's revised

national tuberculosis control programme (RNTCP)—an application of the

universally accepted DOTS strategy—covers more than 744 million of

the country's 1·068 billion population. The RNTCP performance report

for the third quarter of 2003 (latest available) also boasts a

treatment success rate for new smear-positive patients of around 86%

and a case detection rate of 63%.

But there is a new worry. Of mounting concern to the country's health

establishment is the emerging challenge of a tuberculosis-HIV

coinfection. Of the approximate 4·6 million HIV-positive people in

the country—the second highest number in the world after South Africa—

around 1·8 million are estimated to be coinfected with tuberculosis.

Tuberculosis accounts for one-third of deaths due to AIDS worldwide.

Treatment with DOTS not only prolongs and improves the quality of

life of HIV-infected people with tuberculosis, it also quickly

renders the person non-infectious, blunting the increasing

tuberculosis caseload. " The coinfection is a very serious issue for

us " , says L S Chauhan, Deputy Director General (TB) in India's Health

Ministry.

But collaboration between the AIDS and the tuberculosis control

apparatus in the country—the mantra in the corridors of Nirman Bhavan

which houses India's Health Ministry—is a daunting task.

A sheet of paper lying among a pile of documents in Nirman Bhavan

holds out a ray of hope. Unlike in the past when such documents were

replete with gaping blanks, columns are duly filled up in this

one. " And the quality of data has improved " , notes a WHO consultant

attached to the Central Tuberculosis Division. The document

summarising recent tuberculosis-HIV coordination activities in the

six states with the highest HIV sero-prevalence in the country is one

sign of the concerted efforts being made to control tuberculosis in

higher-HIV-prevalence populations and to step up links between RNTCP

and the national AIDS control programme (NACP) in recent times.

The tuberculosis-HIV coordination mechanism has been in existence in

the six states with the most HIV-infected people (Andhra Pradesh,

Karnataka, Tamil Nadu Maharashtra, Manipur, and Nagaland) since

November 2001. But even up to 3 months ago, says Chauhan, " monthly

meetings between the chief medical officers of the voluntary

counselling and testing centres (which come under NACP) and the chief

medical officers of the sputum microscopy centres (which report to

the Tuberculosis Division) were not regular in many states even when

the two units functioned under the same roof " .

Today, as the tuberculosis and HIV/AIDS coordination mechanism is set

to expand to eight more states and union territories in the country,

including Delhi, feedback from the six states is becoming a critical

component of future planning.

One of the immediate priorities, says Chauhan, is to ensure that the

monthly meetings take place regularly and there is better

coordination between the voluntary counselling and testing centres

and microscopy centres through a system of referral slips and

involvement of non-governmental organisations so that there is better

information on how many tuberculosis patients are diagnosed HIV

positive and vice versa.

Another critical problem is the shortage of key medical staff

implementing the programmes. In many states, there is a dearth of

laboratory technicians at the sputum microscopy centres. Yet another

fundamental requirement is training. Unless those manning voluntary

counselling and testing centres and microscopy centres are

sufficiently aware of tuberculosis-HIV coinfection and its

implications, much of the effort will be dissipated.

Soumya Swaminathan of the Chennai-based Tuberculosis Research centre

points out some of the other key challenges on the ground. " The

biggest challenge is the definitive diagnosis of tuberculosis in HIV-

positive persons, as the clinical features are often atypical. Sputum

smear examination and chest X-rays are the only tests widely

available, whereas you need mycobacterial culture facilities and

often other investigations for extrapulmonary tuberculosis. "

Finally, there is the unanswered question of the stigma attached to

HIV in this country, as in many other parts of the world. In such a

context, a question raised by Dinesh Kumar, editor of TB News from

India, an electronic newsletter published by the Health and

Development Initiative, India, is a valid one. " Who will ensure that

the HIV status of the HIV-tuberculosis co-infected will not affect

their care by DOTS providers? "

Patralekha

E-mail: patralekha_chatterjee@...