Journal of Medical Evidence

: 2022  |  Volume : 3  |  Issue : 1  |  Page : 14--23

Referral process in tuberculosis − Human immunodeficiency virus collaborative activities – Need for a relook into policy implementation in Uttarakhand

Ranjeeta Kumari1, Bhola Nath2, Vartika Saxena1, Priyanka Semwal1,  
1 Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, Inida
2 Department of Community and Family Medicine, All India Institute of Medical Sciences, Bathinda, Punjab, India

Correspondence Address:
Dr. Bhola Nath
Department of Community and Family Medicine, All India Institute of Medical Sciences, Bathinda, Punjab


Background: Provider-initiated testing and counselling (PITC), an essential component of tuberculosis (TB) human immunodeficiency virus (HIV) collaborative activities, is intended to translate into the increased rates of HIV testing in TB patients. Aim: The study intends to assess compliance with the referral process and other attributes of HIV testing in TB patients. Methods: The study was conducted at various designated microscopy centres (DMCs) in four randomly selected districts in the Garhwal region of Uttarakhand and included 346 patients. Results: Only 46.8% of patients went for HIV testing. The most common reason cited for not going was the absence of specific advice by the health staff at DMC. In addition, the long waiting time at Integrated Counselling and Testing Centres favoured the spread of infection to susceptibles in the waiting area. Binary logistic regression analysis also found that patient's importance towards HIV testing, advice by the health worker and higher education and age were significant predictors of HIV testing. Conclusions: The referral process at DMC requires closer monitoring and supervision for improvement in qualitative parameters. Training and supportive supervision of health staff at DMC for 'counselling' of patients during referral for testing are also necessary to preserve the essence of PITC.

How to cite this article:
Kumari R, Nath B, Saxena V, Semwal P. Referral process in tuberculosis − Human immunodeficiency virus collaborative activities – Need for a relook into policy implementation in Uttarakhand.J Med Evid 2022;3:14-23

How to cite this URL:
Kumari R, Nath B, Saxena V, Semwal P. Referral process in tuberculosis − Human immunodeficiency virus collaborative activities – Need for a relook into policy implementation in Uttarakhand. J Med Evid [serial online] 2022 [cited 2022 Nov 30 ];3:14-23
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India has a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) infections and faces a high burden of HIV-associated TB. TB-HIV co-infection is a fatal combination with extremely high mortality rates (15%–18%) reported among HIV-infected TB cases notified under the Revised National TB Control Programme (RNTCP), now named as National TB Elimination Programme.[1] India's RNTCP and National Acquired Immunodeficiency Syndrome (AIDS) Control Programme (NACP) addressed the dual burden of TB and HIV through the systematic implementation of collaborative TB/HIV activities across the country. Provider-Initiated HIV Testing and Counselling (PITC) of TB patients implemented across the country is part of the intensified HIV/TB package implemented jointly by NACP and RNTCP. Early detection of HIV/TB cases and prompt provision of Anti-Retroviral Therapy (ART) and Antituberculosis therapy are key interventions to reduce morbidities and mortality on account of both diseases. TB-HIV collaborative activities have been implemented in the country since 2001. 'National framework for TB-HIV Collaborative activities' was developed in 2008, which was further strengthened in 2013, to address the dual burden of the disease.[2]

Uttarakhand, a hilly state in North India, endorsed this national policy and implemented it in 2011. TB-HIV collaborative activities have been implemented at all levels of TB care settings in Uttarakhand. TB-HIV cross-referral activities have been expanded through approximately 1621 Integrated Counselling and Testing Centre (ICTCs), 27 ART Centres, and 52 linked ART Centrs in the state.[3] A four-pronged strategy was proposed to enhance early case detection and initiate prompt treatment of co-infected cases. An important strategy amongst these highlights the importance of 100% coverage of PITC of all patients registered under RNTCP (2017).[3] This PITC is intended to translate into enhanced knowledge about various aspects of TB and HIV and increased rates of HIV testing in TB patients.

The effectiveness of PITC is assessed by the number of cross-referrals made at designated microscopy centers (DMCs) and ICTC. A better index of the effectiveness of PITC would be the proportion of people actually tested for HIV through cross-referrals and knowledge of people about their own HIV status. The present study intends to study the effectiveness of PITC at DMCs and correlates of HIV testing among patients registered under RNTCP in the Garhwal division of Uttarakhand. No attempt to explore these aspects of PITC under TB HIV collaborative activities has been made in the state of Uttarakhand to date, which justifies the need for the current study.


The present study was conducted among patients undergoing treatment for TB at the DMCs in the Garhwal region of Uttarakhand, a hilly state in North India. Uttarakhand has two regions-Garhwal and Kumaon consisting of seven and six districts, respectively. Garhwal region consists of six districts: Chamoli, Pauri, Uttarkashi, Dehradun, Rudraprayag, Haridwar, and Tehri Garhwal. The health facility for recruitment of the patients was selected by multistage stratified random sampling. Four districts were selected from the seven districts of the Garhwal region. Two districts were randomly selected from hilly areas, namely Pauri and Rudraprayag, and the rest two from plain areas (Dehradun and Haridwar) to account for geographical variability. Each of these districts has one or more TB units (TU), depending on the population size. One TU was randomly selected from all the TUs in each district. Each of these TUs has DMCs under it, where patients are diagnosed and treated. Two DMCs were randomly selected from each of the selected TU to recruit the patients. The study was conducted over 12 months. The eligibility criteria for inclusion in the study were those patients >18 years old, non-pregnant women, patients who were not critically ill, patients who had no problem of hearing or speaking and those who volunteered to participate in the study. All TB patients attending the selected health facilities during the study period and meeting the eligibility criteria were included in the study. Sample size: The study's primary aim was to estimate the proportion of Directly Observed Treatment Short Course (DOTS) patients complying with the advice of referral to ICTC center for HIV testing. Taking this percentage as 69%.[4] (based on a study from Tamilnadu), and an absolute error of 5%, the sample size was calculated using the following formula:[5]

n = Z(1−α/2)2 pq/d2

Z(1-α/2)2= (1.96)2 = 3.84 (Normal deviate for 95% confidence limits)

p = 69%=0.69 (Proportion of patients complying with the referral to ICTC centre.)

q = 1-p = 0.31

d = 5% = 0.05 (Absolute error)

Sample size = 3.84 × 0.69 × 0.31/0.05 × 0.05 = 328.55 ≈ 329

Adding a 10% non-response to it, the sample size came out to be 329 + 32 = 361

The number of patients to be recruited at each DMC was determined based on probability proportional to size, based on the previous year's attendance. Patients were recruited consecutively at each DMC till the completion of the required sample size. Data collection was in the form of an interview conducted by the field investigator recruited and trained to avoid any interviewer bias. The investigators prepared the questionnaire and translated it into Hindi for administration to the patients and back-translated for validating it. It was also pilot tested on a sample of patients for checking its accuracy and subsequently modified. The interviewer collected information related to the socio-demographic profile of the patient, knowledge about access points for the care of TB-HIV co-infection, knowledge about various aspects of HIV, current HIV status of self, and different referral-related variables at DMC and ICTC. Analysis was done for completed data collected from 346 patients. An association between various socio-demographic characteristics, knowledge-related variables, and other variables related to the referral process was assessed with compliance to HIV testing. Also, a binary logistic regression analysis was carried out to determine the independent predictors of HIV testing. Ethical clearance for conducting the study was obtained from the Institutional Ethics Committee (AIIMS/IEC/13/24 dated 17/09/2013). Patient information document was provided to all the respondents, and informed written consent was obtained from all the participants before starting the interview. Patients had the autonomy to quit the interview at any point in time.


It was observed that only 46.8% of the patients had gone for HIV testing. Exploration about knowledge related to HIV testing showed that only 57% of males and 35% of females had heard about HIV testing. 55% of males and 34% of females knew about the place of HIV testing, and even lesser number (51.3% and 32.2%) thought that it is essential for TB patients to get HIV testing done. Only 55% of males and 34% of females had knowledge about their current HIV status (Not shown in table).

We also tried to study the process of referral for HIV testing among TB patients. It was observed that more than 85% of patients were diagnosed with TB at a DMC for the first time, with a median number of three visits for diagnosis and a range of 1–7. Almost all of them were told about another blood test, but specific advice about HIV testing was given to 55% of males and 33% of females only. Twenty-five percent of the male patients reported being referred for testing at an ICTC center, 29% at any government hospital, while 45% were not told about any place for testing. The corresponding proportions in females were 11%, 22%, and 67%, respectively. The person who advised for the testing was the doctor on most occasions (35%), as reported by the respondent. Of those who were told about HIV testing, 13.8% males and 6.0% females were told that HIV testing is mandatory; only one was told that it is voluntary. The rest were not said anything. None of the respondents, except one, received advice about HIV testing from any other health personnel. Sixty percent of males and 70% of females reported feeling awkward by the presence of others in the room when advised for HIV testing. Significant differences were observed between the advice given to males and females regarding what was told and the place of testing (P < 0.001) [Table 1].{Table 1}

On eliciting the status of counseling and testing process at ICTC for patients referred from DMC, it was observed that the TB patients who went for HIV testing were not given any preference over the rest of the people. The mean waiting time was about 13 min for men and 19 min for women, and the median waiting time is 10 min. The waiting time ranged from 2 min to 240 min. The average cost of traveling for HIV testing was more than 20 Rs and ranged from zero in case of walking to 250 Rs. in some patients. 56% of males and 34% of female patients registered under DOTS went for HIV testing. The overall percentage of TB patients who went for HIV testing was 46.8%. 54% of males and 32% of females reported being given a referral form for HIV testing. The most common reason cited by the patients for getting their HIV status known was the advice by health staff at the DMC, and the sole reason for not getting HIV testing done was the absence of advice by the health staff. Significant differences were observed between males and females with respect to the proportion of HIV testing, referral form, and waiting time [Table 2].{Table 2}

Bivariate analysis to study the association of socio-demographic characteristics and HIV testing showed that patients with the following characteristics i.e., ≥30 years, males, Hindus, general caste, single, higher education of self or spouse, higher income (>10,000), students or employed, were observed to go for HIV testing significantly more as compared to the other groups [Table 3].{Table 3}

An analysis to study the association of various accessibility and referral-related variables with HIV testing showed that previous knowledge about DOTS center, presence of treatment for HIV, HIV testing, and place of HIV testing were significantly associated with HIV testing. Also, advice about the place of HIV testing by the health care professional at DMC, explaining the need for HIV testing, giving the referral form, and talking about the HIV testing in terms of it being mandatory or voluntary, were significantly associated with HIV testing in the patients [Table 4].{Table 4}

We also tried to study the association of HIV testing with knowledge regarding various aspects of HIV such as its symptoms, modes of transmission, the association of TB and HIV, its effect, and also the perception of patients in terms of stigma. It was observed that ignorance about these aspects was found to be associated with lower rates of HIV testing [Table 5].{Table 5}

A binary logistic regression by Backward Stepwise (Wald) method was performed to determine the effects of various variables on the likelihood of patients going for HIV testing after adjusting for confounding factors. The logistic regression model was statistically significant, Chi-square value = 384.44, P < 0.005. The model explained 89.6% (Nagelkerke R2) of the variance in the likelihood of going for HIV testing and correctly classified 95.4% of cases. Increasing age of the patient (odds ratio [OR] 1.048), patient education (OR 3.188), and explanation about the need for testing by the health care worker (6.054) were associated with an increased likelihood of testing. On the other hand, those who felt that it was shameful to be diagnosed with HIV were 0.119 times less likely to go for HIV testing (95% confidence interval [CI] 0.038–0.373). Similarly, those patients who did not consider HIV testing as necessary for TB patients had 0.159 times less likelihood of going for HIV testing. Also, those who were not given a referral form had 0.192 times less likelihood to go for HIV testing (95% CI 0.085–0.436). The rest of the socio-demographic variables did not affect the tendency to go for HIV testing after controlling the effect of confounders [Table 6].{Table 6}


Joint TB-HIV collaborative activities had been planned and conducted in the country to detect early detection of TB-HIV co-infection for improving outcomes of the deadly combination. PITC is an essential component of these activities, which is often overlooked and it's potential underestimated. The effect of PITC on the knowledge and perception of patients registered under DOTS was studied. Also, translation of this into the practice of going for HIV testing was also evaluated.

The current study showed that PITC could not have a very significant impact on the above-mentioned aspects related to TB-HIV in the current settings. This was evident from the low percentage of patients who thought HIV testing was important for them and who knew their HIV status in the present study. These results are pretty low as compared to a similar study in South India where 92% of the patients reported being referred and 97% completed HIV testing.[4] Another study by Gupta AK has reported that during the third phase of the National AIDS Control Programme, 30749/130503 (23.6%) TB/HIV cross-referrals were lost to follow-up. There was missed opportunity for 940/1884 (49.9%) HIV-TB co-infected patients to initiate ART during TB treatment.[6] These findings are also substantiated by another study from two districts in South India, which reported the compliance with a referral for HIV testing to be 70%.[7] The effectiveness of this approach has been demonstrated in other countries also.[8],[9]

The differences observed as compared to other studies could be because of some gaps in the method of prescription of TB patients for HIV testing, few of which are detailed subsequently. As reported by the patients, almost all of them were asked to go for another blood test, but specific advice about HIV testing was given to lesser numbers, and those who were explicitly advised complied with the direction and went for HIV testing. Advice about the place of testing was also not uniform, which may have led to the drop-out of patients reporting for HIV testing. It is imperative to note that more than 85% of the patients were diagnosed for the first time at a DMC, thereby implying that we need to strengthen the referral process at DMCs and train the staff who gives the results of investigations for TB, to simultaneously ask the patients to go for HIV testing at the ICTC centre, specifically. This is also substantiated by the observation that, of all the patients who were told about HIV, only one was told that it is voluntary. Patients reported that the doctor advised them on most of the occasions for testing, but as per the observations by the investigator, it was found that most of the time, it was the technician or other support staff who conveyed the results of TB and advised them for HIV testing or other blood tests. While the study observed that young individuals, males and individuals with better education and income were more likely to go for HIV testing, yet the advice by the health-care worker was of utmost importance in determining their HIV testing, as shown in the results of logistic regression analysis also. Not giving a referral form was also found to be an independent predictor for lower compliance. Another study from Tamil Nadu to assess cross-referrals in people attending ICTC centres reported that 83% attended the DMC while 17% dropped out. The reasons cited for dropping out included health system (51%), disease status (62%) and personal reasons (62%).[10]

The study also observed that knowledge about HIV and TB-HIV co-infection had a significant bearing on the probability of HIV testing, which further strengthens the case for training the health-care workers at DMCs to educate the patients regarding the various aspects of both diseases. This is more important in the case of females, older individuals, people belonging to marginalized communities, patients with lower levels of education and income. Knowledge regarding TB, HIV and TB-HIV has been lower among female patients and needs to be addressed accordingly. Myths regarding HIV are still prevalent and were a significant predictor for lower compliance in the present study.[11]

Training of health-care staff needs to be supplemented with mechanisms to monitor the quality of cross-referrals instead of just the number of cross-referrals. As observed from the regression analysis, explaining the need for HIV testing by the health-care worker was an essential factor for HIV testing by the patients. Therefore, training of the staff for appropriate referrals of the patients for HIV testing and the simultaneous strengthening of the health system to prevent drop-outs might be a promising intervention for enhancing early detection of TB-HIV co-infection. Improving patients' educational level is a long-term goal and is expected to have better compliance rates, as shown by regression analysis.

HIV testing at the ICTC center was also very depressing and favoured cross-infection in the waiting area of ICTC, as was evident from high waiting time. Also, since the patients with TB were not given any preference for HIV testing, they had to wait in the shared waiting area of the ICTC, where other people, which include people who might be infected with HIV, antenatal women with their young children are also waiting. This common waiting area and overcrowded conditions, and poor ventilation in government hospitals create a perfect milieu for transmission of TB bacilli to other susceptible individuals in the waiting area.

In view of the findings stated above, the present study highlights the need for some important interventions in implementing TB-HIV collaborative activities in the state. First, the health care workers at the DMCs and ICTCs need to be trained, motivated and supervised to share important, relevant information to the patients regarding TB and HIV to prevent both diseases in susceptible groups of people effectively. Second, the HIV testing facility for TB patients can be located in the DMC itself, by capacity building of the laboratory technicians and reallocating the logistics for avoiding the drop-outs due to cross-referrals, as was evident in the present study. It would also decrease the chances of TB spread in susceptible people exposed in the waiting area of ICTCs. A similar model, which required HIV-positive TB suspects to be referred to the DMC in the same hospital, was found to be effective on evaluation.[7] We recommend to go a step ahead and train the DMC staff in the testing of HIV since in our setting; it was found that the patients dropped out even though ICTC was located in the same hospital on many occasions. It would also curtail travel costs and other indirect costs involved, such as that during multiple visits for testing, as that reported in a study from South India.[12]

If this modification is not feasible in the government health system due to various reasons, a separate waiting area for patients referred from DMCs should be kept at ICTC, so that the chances of transmission of TB in other people is reduced. Furthermore, quality-focused supervision, monitoring and evaluation need to be instituted at ICTCs so that the TB patients and other people are provided the required information about HIV during the counselling, and it does not serve as a mere laboratory testing facility. It should be coherent to the essence of ICTC, the objective with which it was created. Apart from these individual counselling sessions, ICTC and DMC staff may also be utilised for conducting monthly awareness programmes for TB patients and other people coming to the health facility for diagnosis and treatment, since people are more receptive to health education messages when they are delivered by their health providers rather than some other agency.


It can be inferred from the findings of the present study that the referral process at DMCs in the Garhwal region of Uttarakhand was not found to be very effective in terms of HIV testing among TB patients, as evident from a large number of drop-outs and their knowledge about their HIV status. Also, the conditions at ICTC favoured the spread of TB infection among susceptibles in the waiting area. Quality indicators for referral may be included in the monitoring process along with some significant policy changes in the form of concurrent HIV testing at DMC itself, if possible. In addition, training of staff at DMC is indispensable for an effective cross-referral and appropriate utilisation of testing and counselling services available at ICTC.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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