{'fraction_non_alphanumeric': 0.04994415190681347, 'fraction_numerical': 0.04603478538375618, 'mean_word_length': 4.613524406627855, 'pattern_counts': {'":': 0, '<': 2, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Study of cross-referrals between integrated counselling & testing centre and RNTCP-Designated Microscopy Centre at a tertiary care hospital in Bengaluru, Karnataka

Introduction: HIV and TB infections continue to fuel and amplify each other. The 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 Centre at a private medical college in Bengaluru, Karnataka. Materials & Methods: This was a descriptive study comprising of all the clients visiting ICTC and TB Suspects visiting RNTCP DMC during the study period from April to December 2018. Data entry was done in MS excel and analyzed in SPSS software. Results : A total of 9405 clients visited ICTC during the study period, 68 (0.73%) of them were diagnosed to be HIV positive. HIV Seropositivity was found to be higher among 35-49 yrs age group 28 (41.17%), male clients 37(54.41%) and among semiskilled workers 19(27.94%) followed by housewives 18 (26.50%). There were 9 HIV concordant couples. 252(19.06%) of the TB suspects visiting the DMC were TB positive. 8 (3.17%) clients had HIV-TB Co-infection. Statistically significant association was observed between HIV status and TB status of the study subjects (p <0.05). Conclusion: ICTC is an excellent site for both HIV testing and screening for TB. Similarly, RNTCP DMC is instrumental in TB case finding and also for detecting individuals at high risk for HIV seropositivity. Appropriate cross referral between these two centres plays a pivotal role in reducing the burden of both infections. ……………………………………………………………………………………………………………………………...…


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. Early collaborative activities included joint training of TB and HIV programme staff and cross-referral of patients. The cross-referral included intensified casefinding (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 imple-mentation 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 program-mes 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]. This study was conducted to assess the pattern of cross-referrals between ICTC & DMC in order to find areas for improvement for better case finding & reporting of HIV-TB co-infection which is essential for effective management &better prognosis of these cases. The descriptive statistics-Qualitative variables were presented as frequency 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.

Results
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 seropositives 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].    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 & TB positive, 7 were sputum positive TB and 1 was extra pulmonary TB.

Discussion
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 byRoma 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 seropositives, 19 (27.94%) were semiskilled workers by occupation, followed by housewives 18 (26.50%) while in the study by Roma C et al [8], maximum seropositivity (32.10%) was found in agricultural workers among the females an alarming number of seropositives (38.57%) were detected in 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 the present study, Out of the total 9405 clients tested at ICTC, only 470 (4.99%) TB suspects were referred to DMC similar findings were observed in the study by Ramachandran R et al [11], of the total of 18329 ICTC clients, 1065 (6%, range 5-8%) TB suspects were referred to the DMCs. The present study shows that there is scope for improvement in identification, referral and documentation of TB suspects visiting the ICTC.
Strong emphasis needs to be given to training ICTC counsellors with respect to cross referrals from ICTC to DMC as ICTC initiated TB screening is now being recognized as an important tool in detecting a large burden of TB cases (both among HIV sero-positives and HIV sero-negatives). ICTC facilities are excellent sites for active TB case finding [3].
Among the cross referrals from ICTC to DMC, HIV Positive TB suspects constituted 61(12.97%). While Mehra Bet al in their study revealed that of the total of 641 TB suspects and referred to the chest clinic, 264 (41.2%) were HIV sero-positive. In the study by Shrivastava S et al [12] of the 1446 clients counseled at ICTC, 132(9%) clients were HIV-positive TB suspects.
Majority 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 crossreferrals from ICTC to DMC 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 canbe 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 extrapulmonary 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] wheretotal 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].