Feedback on TB/HIV guidelines

[Guest guest]

To NACO

I would like to commend you on the development of guidelines on this important

topic. I have been actively searching for such material for the last two years.

The community in which I work has a high prevalence (>30%) of HIV amongst the

local injecting drug users. Our experience over the years has been of the

under-diagnosis of TB through both sputum smear AFB and radiography.

Respiratory conditions are among the leading causes of death amongst men in this

locality

I have four points of feedback regarding your draft.

Firstly, the guidelines for diagnosis are too theoretical. I suggest the

inclusion of step by step operational procedures. Without simple, operational

guidelines for diagnosis, people's TB will remain undiagnosed, particularly in

the DOTS sub-centres. Similar to this document, NACO's guidelines for the

clinical management of HIV give prominence to the difficulty of diagnosis, but

they completely ignore the practicalities before moving on to treatment. I

commend you that this document is addressing that ommission from those

guidelines.

Secondly, there needs to be a comment about the treatment of secondary

infections such as PCP and bacterial pneumonia. In many parts of the world,

including India, doctors advise people living with HIV to take

cotromoxizole(septran) while on DOTS, and even for the rest of their lives.

This advice is life-saving, cheap, and worthy of comment in your guidelines.

Thirdly, the operational practicalities of diagnosis and treatment need to be

made simple and available in Hindi, and other regional languages for the benefit

of programme operators and communities accessing the services. This again will

provide a greater chance of effective diagnosis and full compliance with the

treatment.

Finally, promote a commitment to treatment for people living with HIV. To do

this, I suggest you put the section on 'the impact of TB on HIV' ahead of the

section of 'the impact of HIV on TB' and rework the overview accordingly. By

doing so, you would be stating your commitment to providing good treatment to

people living with HIV, rather than (wrongly?) promoting another way in which

people living with HIV are dangerously infectious. As it stands, you introduce

the document with a statement about 'public health concerns', but the following

data supports 'treatment concerns' more than it does the 'public health

concern'. That is, it highlights the personal risks to people living with HIV.

In addition to this, you later point out that people living with HIV and TB

cough less and " excrete significantly fewer organisms per ml of sputum than HIV-

negative patients " . You have an opportunity here to appropriately assert

'treatment concern' ahead of 'public health concern'. In the current struggle

against stigma and discrimination, it would be timely to take this opportunity.

The community I work in in Delhi have faced many problems with TB diagnosis

amongst people living with HIV. This has led us to support our community to

work on a short educational video on TB diagnosis and treatment for people

living with HIV and service providers. The content of the video is much like a

simplified version of your guidelines and we would like to ensure that it is

consistent with the guidelines. The video will be in Hindi, and designed to be

useful to people with little or no formal education. We expect to begin field

testing the rough draft of this video within the next month. If you are

interested in collaborating with people living with HIV in the development and

dissemination of diagnosis and treatment literacy material which would ably

support your guidelines, you can contact me at kgrc@...

I look forward to your reply.

Greg Manning

Coordinator

Community-based Care and Support programme

Sharan - Society for Service to Urban Poverty

Delhi

e-MAIL <kgrc@...>