Intensified TB Case Finding [ICF] in HIV testing Settings

Intensified Case Finding (ICF) in TB-HIV Collaboration

ICF is the systematic screening for evidence of Tuberculosis (TB) in people infected with Human Immunodeficiency Virus (HIV), at high risk of HIV, or living in congregate settings. It helps in the early detection and treatment of TB, thereby reducing morbidity and mortality due to HIV-TB co-infection. It also prevents ongoing TB transmission and is an initial step to rule out active TB disease to enable early IPT initiation. 

All individuals who visit a HIV-testing site should be screened for presence of for the 4 TB symptoms (4S) at every encounter:

4S in adults and adolescents - Current cough, fever, weight loss and/or night sweats

4S in children - Current cough, fever, poor weight gain and/or history of contact with a TB case 

The presence of at least one symptom is considered as 4S+ve.

ICF at Integrated Counselling and Testing Centres (ICTCs)

• Systematic TB screening should be integrated and offered at all HIV testing facilities and to all populations receiving HIV testing, irrespective of their test results. 
• All ICTC clients should be screened by the ICTC counsellors for the presence of the symptoms of TB disease (at pre, post, and follow-up counselling). 
• All clients who have symptoms or signs of TB disease, irrespective of their HIV status, should be referred to the nearest facility providing National TB Elimination Programme (NTEP) diagnostic and treatment services. 
• For better coordination in the field between the two programmes, NACP and NTEP promotes the establishment of co-located facilities.

ICF in HIV Congregate Settings (ART Plus Centres, ART Centres, Link ART Centres, Community Care Centres (CCC))

• HIV-infected clients with undiagnosed and untreated TB can be expected to seek care in ART or CCCs, posing the risk of exposing other HIV-infected persons to TB. 
• All people living with HIV (PLHIV) should be regularly screened for TB using 4S at the time of initial presentation and follow-up visits. 
• During each visit, 4S screening is done by all personnel involved in the following order: 
  • Care coordinator --> Staff Nurse --> Counsellor --> Medical Officer. 
  • 4 S screening is first done by the care coordinator. According to the results, they apply a "4S positive"(Red) or "4S negative" (Blue) seal. 
  • In the next station, a 4-symptom seal is applied by the nurse who does a detailed screening and positive symptoms are tick marked. 
  • In the next two stations, the counsellor and medical officer also perform 4S screening. 
  • Screening at multiple levels ensure that no symptoms are missed.
• PLHIV/ children living with HIV (CLHIV) found positive for any of the four symptoms (4S+), should be considered presumptive TB and fast-tracked for TB diagnostic work-up using molecular diagnostic tests by the medical officer.

ICF among HIV Key and vulnerable population  

• Operational research conducted in high HIV prevalent states has shown that key and vulnerable population like female sex workers (FSW), men who have sex with men (MSM), injecting drug users (IDU), etc. are more likely to have TB compared to the general population. 
• Also, it is known that HIV prevalence among key and vulnerable population is several times higher than in the general population. 
• Among the HRGs, IDUs have the highest HIV prevalence thus provision of ICF services and prompt linkage to care support and treatment to IDUs is treated as a priority at the centres.

References

• National Guidelines for HIV Care and Treatment, NACO, MoH, GoI, 2021.
• National Framework for Joint HIV/TB Collaborative Activities, Department of AIDS Control, MoHFW, GoI, 2009.
• WHO Consolidated Guidelines on Tuberculosis: Module 2: Screening: Systematic Screening for Tuberculosis Disease.

Assessment