India has the highest tuberculosis (TB) burden and the third highest HIV burden country in the world. People living with HIV have a 26-31 times higher risk of developing tuberculosis as compared to those without it, making it the most common opportunistic infection (OI) in HIV-infected individuals. Also, HIV infection is a significant risk factor for acquiring a TB infection.
National and international studies indicate that an integrated approach to TB and HIV services can be extremely effective in managing this dual menace. The government of India's Revised National Tuberculosis Control Programme (RNTCP) and the National AIDS Control Organisation (NACO) jointly implement HIV/TB activities based on a National Framework for HIV/TB (last updated in November 2013).
People living with HIV have a 26-31 times higher risk of developing tuberculosis as compared to those without it.
India has been implementing HIV/TB collaborative activities since 2001. These were initially rolled-out in six high burden states and scaled to nationwide interventions by 2012. India has been successful in increasing access to HIV testing among registered TB patients from 30% in 2010 to 79% in 2015, with more than 90% treatment linkage for co-infected patients.
Some of the recent pilot initiatives, which have been widely acclaimed, are:
- A single window service delivery for TB and HIV at ART (antiretroviral therapy) centres—30 so far.
- Upfront testing with the Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) to rapidly diagnose TB and rifampicin resistance among people living with HIV.
- Roll-out of a daily fixed dose combination regimen for co-infected patients from ART centres at 30 sites.
- Use of innovative mobile-based treatment adherence.
- E-modules for capacity building and training of RNTCP and National AIDS Control Programme (NACP) staff.
The coordination activities by the RNTCP and NACO have demonstrated considerable success. Changing the epidemic scenario of HIV, however, will continue to pose a challenge in the days ahead.
As a NACO 2015 report states, "The HIV epidemic in India is concentrated among High Risk Groups (HRGs) and is heterogeneous in its distribution." Although the overall HIV infection trends indicate a declining epidemic at the national level, regional variations continue to persist with some new pockets emerging. This is because, according to NACO, the "vulnerabilities that drive the epidemic are different in different parts of the country." The changing epidemiological scenario, drivers of the HIV epidemic, and the emergence of drug-resistant tuberculosis all warrant attention for addressing the TB-HIV situation in India.
India is moving forward to achieve the global targets set by the World Health Organisation's END TB Strategy, and launched the "Call to Action for a TB-Free India" on 23 April, 2015. Intensive efforts are being made to engage various stakeholders and further strengthen ongoing efforts to reduce the incidence of TB, including among people living with HIV. These efforts include raising awareness about tuberculosis, intensifying TB case finding in high-risk groups, using rapid diagnostics for early diagnosis, and increasing the collective involvement of the private sector, NGOs and community-based organisations in working for a TB-free India.
Dr. Rajesh Deshmukh, Program Officer, HIV TB, National Aids Control Organisation
Views expressed by the author are personal