The adult HIV prevalence in India is estimated to be 0.27 % translating into 2.1 million people living with HIV/AIDS (PLHIV) in 2011. This is third highest burden in the world. On the other hand, India is highest Tuberculosis (TB) burden country in the world with an estimated 2.2 million new TB cases occurring annually. While TB is commonest opportunistic infection (OI) in HIV-infected individuals, HIV infection is an important risk factor for acquiring TB infection and its progression to active TB. HIV/TB together is a fatal combination with extremely high death rates (15 to 18%) reported among HIV-infected TB cases notified under Revised National TB Control Programme (RNTCP). Overall, TB is estimated to cause about 25% of all deaths among PLHIV in India. Early detection of HIV/TB cases and prompt provision of Antiretroviral Treatment (ART) and Anti-TB Treatment (ATT) are key interventions to reduce mortality rates significantly.

India’s National AIDS Control Programme (NACP) and RNTCP recognized importance of HIV/TB coinfection, in their control efforts, as early as 2001. The two programmes jointly developed interventions to ensure early detection and prompt linkage of TB and HIV cases to care, support and treatment. These interventions were governed by joint national policy called National Framework for joint HIV/TB Collaborative Activities. The national (policy) framework is a dynamic document that evolved as the programmes gained experience of field implementation, also assimilating the changes in global guidelines and evidence generated through operational research. The current revision of national Framework coincides with finalization of the vision documents of both national programmes for next 5 year i.e. the NACP-Phase IV and RNTCP National Strategic Plan, (NSP) 2012-2017, and update in WHO HIV/TB policy recommendations.

History of Joint HIV/TB activities in India

The joint HIV/TB activities in India started in 2001 with 6 states, Maharashtra, Manipur, Nagaland, Karnataka, Tamil Nadu and Andhra Pradesh. These early activities included joint training of staff and cross referral meaning intensified (TB) case-finding at Integrated Counseling and Testing Centers (ICTC) with referral of presumptive TB cases to RNTCP Designated Microscopy Centers (DMCs), and referral of TB patients having HIV risk factors to ICTC for voluntary HIV counseling and testing. These Collaborative Activities were extended to 8 additional states in 2004 (Delhi, Gujarat, Himachal Pradesh, Kerala, Orissa, Punjab, Rajasthan and West Bengal) and to cover entire country by 2008. The first national policy framework was developed based on experience gained during programme implementation in initial years, important operational research (OR) studies instituted by NACP and RNTCP and the WHO HIV/TB interim policy. The OR included, the first demonstrating feasibility of decentralized delivery of co-trimoxazole preventive therapy (CPT) for HIV infected TB patients through RNTCP and 2 second showing feasibility of provider-initiated HIV testing and counseling (PITC) for TB patients. The first National Framework was published in November 2007, which endorsed differential strategy for implementation of HIV/TB activities in the country, reflecting the heterogeneity of HIV/TB epidemic in India. This strategy included “essential” HIV/TB interventions to be implemented nationwide and an “Intensified TB/HIV package of services” for states having high burden of HIV/TB. The selection of states for implementation of intensified package was based on HIV prevalence, absolute HIV burden, availability of decentralized HIV testing and treatment services and programme management capacity. In 2008 it was started in 9 states (Andhra Pradesh, Goa, Karnataka, Maharashtra, Manipur, Mizoram, Nagaland, Puducherry and Tamil Nadu). Review of this implementation demonstrated that it was a highly useful strategy for early detection of HIV in TB cases and prompt linkage to HIV care and support. The National Framework was therefore revised in 2009 with a decision to implement full spectrum of HIV/TB activities including scale-up of Intensified HIV/TB package uniformly across the country by 2012. This revision established uniform set of activities at all ART centers and ICTC including intensified TB case finding and reporting. It also strengthened joint monitoring and evaluation with specified national HIV/TB programme indicators and performance targets. Current revision of National Framework also aims to incorporate recent policy updates in NACP and RNTCP and align with respective national strategic plan for next 5 year along with recommendations in WHO HIV/TB policy guidelines 2011. The formerly-named ‘intensified package’ of HIV/TB services is now the national TB/HIV policy standard for all states. A single and uniform policy, national policy framework exists.

Purpose of National Framework:

The overall purpose is to articulate the national policy for TB/HIV Collaborative Activities between RNTCP and NACP so as to ensure reduction of TB and HIV burden in India.

Objectives: