TB/HIV coordination through public private partnership: Lessons from the field.

Background: Co-infection with tuberculosis adversely affects the quality of life of HIV infected individuals and additionally, HIV testing among TB patients gives an opportunity for prevention and treatment of HIV infection. TB-HIV coordination activities are therefore a good public health intervention. Methods: It was a three-year Public Private Partnership Project, implemented in four districts of Maharashtra, to improve access to public health facilities through community awareness and motivating referrals. Outreach workers were engaged to motivate patients attending Integrated Counselling and Testing Centres (ICTCs) and Designated Microscopy Centres (DMCs) for cross referrals and adherence to services. Community leaders and private health providers were sensitized to issues around TB and HIV/AIDS. Observations: 357 outreach workers referred 17,200 individuals for HIV testing and 32,549 TB suspects were referred for testing. An average of 18% TB cases (13% to 26%) and 7% (4% to 13%) HIV infected cases were identified. Involvement of PLHA and cured TB patients can better motivate symptomatics to avail of diagnostic services. Erratic funding affects smooth implementation of programmes. Conclusion: Public Private Partnerships improve access to care. Constant dialogue between all stake holders is essential for successful implementation of such partnerships.

Survey of diagnostic services in the private health sector of Mumbai for assessment of TB case detection.

Background: The exact burden of tuberculosis remains unknown due to the fact that there are many health care providers who continue to provide care to patients suffering from tuberculosis and remain unregulated despite the DOTs strategy being implemented on a nationwide scale. RNTCP has initiated interventions to involve these providers in case reporting protocols through Public Private Mix Projects. Results: Our study highlights the issues concerning the reporting of cases of tuberculosis seeking private care in Mumbai where there is an Act, which makes TB a notifiable disease. Conclusion: This study shows that there is a need to establish formal mechanisms for case reporting and control among all health care providers.

Urban private practitioners: potential partners in the care of patients with HIV/AIDS.

BACKGROUND: The private medical sector is an important source of healthcare in India. Increasingly, concerns have been raised about its role in the care of patients with HIV/AIDS. Evidence about private practitioners' existing management practices will help to create policies addressing this sector. METHODS: A central urban area of Pune city was selected for its high density of healthcare facilities. Private practitioners in the area were interviewed using a structured interview schedule. Based on a 1-year recall period, the schedule covered different aspects of the practitioners' HIV/AIDS management practices including diagnosis, treatment and referral. RESULTS: Of the 215 practitioners interviewed, 66% had tested and diagnosed HIV infection. Fifty-four per cent had been consulted by HIV-infected clients 'shopping' for alternative diagnoses or treatment. Overall, 75% of the respondents had been consulted by HIV-infected clients for treatment. Of these, 14% had prescribed antiretroviral drugs, sometimes without adequate knowledge of the guidelines for their use. Other supportive and symptomatic treatments were also frequently prescribed. Private practitioners commonly referred HIV-infected clients for management to other private doctors, or to public hospitals. There were variations in respondents' practices by sex and system of medicine. CONCLUSION: Private practitioners are actively involved in diagnosing and managing patients with HIV/AIDS. Some of their management practices are inappropriate and need to be remedied. There are also concerns about gaps in the continuity of care of HIV-infected persons, for which networks between providers need to be strengthened. Public-private partnerships must be created to improve the flow of information to private practitioners, and Include them in the national health framework.

Importance of blood samples for diagnosis and drug sensitivitytesting in HIV positive patients with suspected tuberculosis.

Background: Diagnosis of tuberculosis is difficult in HIV positive patients since they often present with atypical symptoms and are susceptible to pulmonary infections that mimic tuberculosis. Sputum collection may not be possible even in patients with pulmonary involvement since a productive cough is not always present. In such patients, blood smear and culture for AFB apart from serving as a diagnostic tool can be used for testing drug sensitivity. Objectives: This study was undertaken to explore the value of blood culture for diagnosis in patients with suspected TB. In addition, a comparison of drug sensitivity patterns of blood and sputum isolates in 10 of these patients was also carried out. Methods: Blood and sputum samples were processed, cultured and isolates tested for their drug susceptibility and for niacin production, nitrate reduction as well as catalase activity at 68o C. Results: All 24 blood samples were culture positive although only 6 were smear positive. On the basis of the biochemical investigations, 22 strains were identified as Mycobacterium tuberculosis. All the 10 sputum samples were culture positive despite 4 being smear negative. Comparison of drug sensitivity profiles from blood and sputum revealed concordance to five first or second line drugs in 5 of 10 patients. Additionally, 2 patients demonstrated discordance for only one first or second line drug. Conclusion: The study demonstrates the importance of blood culture in confirming diagnosis of tuberculosis and testing for drug sensitivity in HIV positive patients without a productive cough. The level of discordance in drug sensitivity profiles between blood and sputum the same individual is suggestive of infection with multiple strains. Testing for the occurrence of multistrain infections through individual colony examination of a single isolate is necessary since such infections would affect treatment of non-responder patients having HIV-TB dual infections.