Highlights of TB/HIV collaborative initiatives in Vienna International AIDS Conference

‘A marriage that made in hell’

'An old disease (TB) takes on a new partner’

‘When a virus (HIV) and bacteria (TB) can work so well together – why can’t we?’

It is so nice to see that TB/HIV has been given due importance, focus and limelight in the recently observed International AIDS Conference in Vienna. There were several oral sessions and poster presentation in the conference to share research, clinical and programmatic experiences on combined TB/HIV interventions across  the world, chiefly from Africa. The conference has given us opportunity to know about the key lessons learned from the TB/HIV collaborative activities in the countries though it is also felt that the experiences of Asia could have been highlighted more.

I have listed down the key areas, concepts, recommendations discussed in the TB/HIV sessions of the conference which might sound interesting to the members of this forum.

1)      From TB/HIV collaboration to TB/HIV integration: Experiences from rural Lesotho and South Africa demonstrated that TB/HIV services can be integrated at the primary healthcare level through 'one stop TB/HIV service' (one clinic, one doctor, one counselor, one nurse, one patient folder, one administration for the patients with two diseases). This approach is found to be more effective than the traditional TB/HIV collaborative approach mainly in the form of cross referrals, follow up and co-infection management from two different service delivery points

 

2)      Improving TB screening in PLHIV: In 2008 only 4% of the PLHIV globally were screened for TB. This area definitely needs urgent attention. Some country level experiences informed us that TB screening in PLHIV is a real challenge for them. Early TB case detection in PLHIV is strongly encouraged.

 

3)      Provision of HIV services within the TB set ups: Provision of HIV services within the TB set ups like safe sex and condom promotion, STI screening and treatment, HIV counseling and testing, CPT to TB patients co-infected by HIV

 

4)      Provision of TB services in HIV set ups: IPT at the level of VCT, TB screening of the clients of the STI clinics, sputum collection and transportation from HIV sites to TB sites

   
Others: (comments, suggestions, recommendations, promising practices reflected in the presentations of the conference) 

• Integrating TB management in HBC program of the PLHIV
•  Involving PLHIV networks in the TB related activities including their capacity building and advocacy for better TB tools
•  IPT to all PLHIV irrespective of CD4 count status according to new WHO guidelines which is safe and works
•  Early initiation of ART to prevent progression to active TB in PLHIV
•  TB friendly ART regimen for the national ART policy
•  Scaling up of integrated ART, CPT and TB services
•  Funding opportunities for community groups for scaling up TB/HIV interventions
• Community involvement in the management of HIV infected TB patients
• Treatment literacy program to promote adherence and community information on TB/HIV
• Defaulter prevention program for TB/HIV
• Mobile clinics on TB/HIV activities at community level (VCT for TB affected population, TB/HIV counseling at the community level, sputum collection of the suspected cases from the ongoing HIV projects and their transportation)
• Joint monitoring of the TB/HIV program
•  Infection control is crucial regardless of integration

One of the auspicious events of the conference was signing of the MoU between Stop TB Secretariat and UNAID Executive Director. The MoU should be helpful to ensure assistance and participation of the Civil Society Organizations globally in much greater numbers in the TB/HIV control and care programs.

Let's wait and watch.

Sugata Mukhopadhyay

UNIVERSAL Health 

                                                          

 

Elimination of congenital syphilis - a story of sheer negligence and apathy

Congenital Syphilis Makes a Comeback

In light of a resurgence, clinicians need to remember the clinical features of syphilis in infants.

— Jan V. Hirschmann, MD

Published in Journal Watch Dermatology May 7, 2010

 WHO estimate says, every year, globally, 12 million people get affected by syphilis, 2 million pregnancies get affected with 25% of them end in still-birth and 25% of the newborn are born low birth weight or with serious infection.

It is estimated that more number of children are being affected by congenital syphilis than HIV.

Congenital syphilis is a preventable and treatable disease. This can be eliminated by regularized ante-natal screening of syphilis and timely treatment of the infected pregnant women. The interventions are cost-effective and can be easily managed at primary healthcare level.

Unfortunately, very unfortunately, other than WHO, there is no global level advocacy to sensitize the countries for elimination of congenital syphilis, where, the picture is so completely contrasting in PMTCT programs. Syphilis is lacking the ‘HIV glamour’ in it and continues to stay back in the dark forgotten corner of the ‘neglected’ diseases.

In India, the picture is not different. Elimination of congenital syphilis is yet to find its place neither in RCH II nor NACP III as one of the key strategies.

Is anyone listening?

Sugata Mukhopadhyay

UNIVERSAL Health

Key link: http://dermatology.jwatch.org/cgi/content/citation/2010/507/2

UNIVERSAL Health demands for better and effective health services for MSM and Transgender

I have some experiences of working in the STI/HIV intervention programs with MSM and Transgender in India and South East Asia . I found the service delivery component the weakest in most of the programs. The MSM and Transgender have special health needs which are not captured adequately in the programs. Besides, the capacities of the healthcare providers to respond correctly to the needs of MSM & Transgender are very limited till now. This is so unfortunate after so many years of HIV/AIDS programs.

The urgent needs to enhance health services of MSM & Transgender at the country level are:

1) Standardized guideline for control and management of anal & oral STIs

2) Users'-friendly health clinics for MSM & Transgender

3) Appropriate training modules and curriculum to strengthen capacities of the healthcare providers

4) Strategic plan to scale up those services

 UNIVERSAL Health demands for better and effective health services for MSM and Transgender.

Sugata Mukhopadhyay

UNIVERSAL Health 

Engaging unqualified rural healthcare practitioners effectively in polio surveillance activities – experience from India

"We will eradicate polio soon. We will make this world safe for our children"

Objective: The intervention was targeted to improve Acute Flaccid Paralysis (AFP) surveillance in Purnia district of Bihar India as part of polio eradication initiative.

Background: Poor villagers of Purnia, due to lack of public health services in rural areas, visited mostly local unqualified practitioners. The district polio surveillance field office found it challenging to receive timely AFP case reports from rural areas due to defunct public health system. Late or no reporting was common. As a result, Purnia showed poor AFP and stool collection rates among AFP cases with increasing ‘polio compatible’ cases, indicating inadequate surveillance in 2002-03. This abstract shares experiences of improving AFP surveillance through active participation of rural, grass root level practitioners.

Methods: Popular rural practitioners were mapped through tracking histories of AFP, and compatible cases, interviewing immunization teams, PHC staffs, parents of AFP cases, villagers. About 100 rural practitioners were identified across Purnia who were reported treating paralysis cases.  Once identified, they were trained on basics of AFP identification, significance and reporting. Detailed contact particulars were provided to them for timely reporting.  Training absentees were sensitized in their clinics. Prioritized practitioners were repeatedly visited, rest regularly contacted telephonically, for constant motivation. AFP posters were pasted inside their clinics. A mail box was kept outside polio field office to enable people drop AFP reports during closing hours. Small incentives were paid for AFP case reporting.

Results: In 2004, timely reporting from remote areas, improvement in AFP and stool rates with decreasing compatible cases was observed. Rural practitioners reported 2 confirmed polio cases.

Conclusion: Where public health system is weak, alternative system run by unqualified rural practitioners can be effectively utilized to improve sensitivity of AFP surveillance.

Implication: The learning of Purnia and adjoining districts was replicated across Bihar to enhance efforts of AFP surveillance and polio eradication in subsequent years.

A brief mapping report Bali to identify the sex workers for STI/HIV intervention activities

Bali being the most significant tourism hub of Indonesia has already demonstrated its potential of housing one of the most prominent commercial sex work networks of the country.

The estimated population of female sex workers (FSWs) in Bali, concentrated in and around Denpasar city is more than 4000. About 25 % of the estimates are direct FSWs, available mainly in the Sanur area of Denpasar. Surprisingly there is no brothel like structure in Bali but some areas are earmarked for the FSWs where they wait for their clients to come, choose and pick them up to escort to the desired places (hotel rooms) for sex. The business is primarily controlled by the pimps and entertainment managers. The FSWs carry condom though consistent condom use with clients is not well established and mostly controlled by the clients. Screening of the FSWs is done chiefly in the local NGO clinic (YKP) and the local puskesmas of Sanur.

Commercial sex work is not tolerated by Bali administration and law. So the commercial sex work is of hidden nature and shows ‘indirect’ characteristic in many places.

There are basically four types of indirect sex work set ups in Bali which I describe below:   

1)      Massage parlor: Sexual services are provided to the clients on demand and high price though it is completely of hidden type due to fear of closure by the local administration. Condom use pattern is not known. The recently conducted PPT rounds in Bali covered about 400 FSWs of the massage parlors through the activities by the local NGO clinics. The massage parlor visited by us reported that a team of health workers usually comes once a month from the local NGO to do the health screening of the girls. The massage services have a wide range of costs starting from 70,000 to 250,000 INR.

2)      Karaoke bars: The karaoke bar we visited in Bali confessed about providing sexual services but not within the karaoke premises. The client can select the girl from the show room, take her to the lounge for drinks, food and singing (rate around 250,000 INR for 2-3 hours) or to the selected rooms of the bar for closer company (each room fitted with TV, audio system, air conditioner) on higher rates (starting from 600,000 INR). For sexual activities the girl can be taken to the near by hotels (arrangement can be done by the bar people on demand) and rate ranges from 1million to 1.5 million depending on the type and duration of services. The girls are generally provided condoms from the bar (Durex) but the bar managers are not sure of their uses. During our visit when we asked to see condom from their stock surprisingly we were refused. Whether the FSWs of karaoke bars were covered under the PPT round is not confirmed though the smell of sex work in this place appeared to be stronger and prominent than the massage parlor.

3)      Bars & restaurants: Not many but a few bars & restaurants (not night clubs) have girls who provide sex if asked, but on high price. If you go and sit in one of those restaurants (especially along Kuta road) you will be soon accompanied by a girl. They will generally offer full body massage at the rate of 200,000 – 250,000 INR per hour and sex on demand, with price ranging from 600,000 to 1 million within the bar premises. One can also take the girl to the hotel and in such cases the cost will be lower because the girl does not have to pay the commission money to the bar owners. Condom use is entirely dependent on the clients. The girl I talked to was willing to do even anal sex without condom on higher price. The place I visited had a unique poster inside promoting the use of Viagra as a potential stimulant of sex.

4)      Female bikers: Bikers are popular local transporters of the tourists in Bali and many local girls are involved in this lucrative business. Near Kuta beach I was approached by such a female biker who was middle aged and offered me sensual massage along with carrying me back to the hotel. After little interrogation she confessed of providing sexual services on higher rates (massage 200,000 INR and sex around 500,000 INR per hour). But condom use depends solely on the clients.

I did not notice any street based sex workers in Bali like Semarang. But soliciting for providing massage and sex services by the pimps, cab drivers, bikers is a very common experience in the streets of Denpasar.

The night clubs seem to be also favorite cruising sites chosen by the sex professionals to tap the clients in Bali.

The hidden nature of commercial sex work is challenging in terms of reaching the sex workers with the  message of safe sex and STI/HIV related services.

Sugata Mukhopadhyay

Universal Health

Female sex workers of East Africa are being forced or enticed to have sex with their clients without condom

It is disturbing to see that the sex workers of East Africa are being forced to provide their services to the clients without condom.

In the context of South-East Asia we experienced similar situation while working with the sex workers in the STI/HIV intervention projects, but we are happy to say we have documented good success stories in our sub-continent to make sex business protected from HIV and STIs to larger extent. Except very few places, HIV prevalence among female sex workers in SE Asia is showing steadily declining trend.

Condom promotion is the most primary and essential intervention in STI/HIV program. But the challenges are many, especially in terms of criminalization of sex workers, socio-cultural intolerance to sex work, harassment by police and administration, indirect and hidden form of sex work and continuous movement of the sex workers in a largely scattered geographic area.

It is very important that the sex workers should be involved in the HIV projects from the inception and their active participation in mapping, need assessment, stakeholders’ analysis, resource mapping of ‘preferred’ healthcare services, project design, program monitoring and decision making is extremely crucial that gradually makes them feel part of the project within a strategic partnership, not merely the beneficiaries of a health intervention project. Our Asian experiences account that continuous association with the HIV project related activities bring back their self-esteem and subsequently help them to collectivize to raise their voice against discrimination, subjugation and harassment by clients and cops. United they learn to say ‘No Condom No Sex’. This model has been popularized as ‘empowerment’ model.

It is equally important to sensitize the stakeholders who can directly and indirectly influence sex work and sex workers like city/village administration, cops, pimps, healthcare providers, religious leaders, public health department from strong public health and human right perspectives. Their cooperation and support is mandatory to ensure successful implementation of the HIV projects of the sex workers.

It will be pleasure and privilege of Universal Health to provide any kind of help and information to our brothers and sisters of East Africa to consolidate their war against the HIV epidemic.

Ref: http://www.plusnews.org/report.aspx?ReportID=91585

Sugata Mukhopadhyay
Universal health

New diagnostic test of TB - few questions

From public health perspective, it is critical to timely diagnoze and cure the infectious TB (sputum positive pulmonary TB) because this form of TB is responsible in discharging the bacteria in the environment and making others susceptable to TB through airborne transmission. Children, elderly and those with low level immunity (HIV, prolong steroid, anti-cancer therapy, malnutrition, diabetes, chronic smokers, alcohol) are much more prone to TB disease in the high TB burden set-ups. Sputum microscopy is the best diagnostic technique so far to diagnoze infectious TB, readily avilable in the public health systems and very cheap. But it is also not fully effective to detect all the infectious TB cases (improper sputum collection, faulty slide preparation, lab technician error) and not at all effective to detect non-infectious form of TB (EP TB). Here, we have to remember one thing that EP TB is important to detect and treat in time to reduce TB related mortalities but it has no impact to break the transmission of TB.

Timely diagnosing and treatment of infectious TB is effective to reduce the overall TB load in the community and subsequently impacts on reducing the incidences of EP TB as well. 

The success of TB control depends primarily on

1) Detection of infectious TB

2) High quality sputum microscopy to detect infectious TB in maximum numbers (or to miss in minimum numbers)

3) Quality treatment with adherence to DOTS

All these interventions are associated with a number of operational issues. I don't like to highlight them once again because they have been discussed so many times in so many forum. 

Now my questions:

1) Will the new diagnostic have the potential to replace sputum microscopy?

2) Will it be cost effective enough to be scaled up in the public health system of a low/middle income country after a successful pilot trial?

3) How much it will be effective to take care of the operational issues as mentioned above?

Sugata Mukhopadhyay
Universal Health

Children of lesser God

It has become a common scene in Delhi these days.

When your car stops at the red light signal, a group of children, young boys and girls in their early teens rush to the vehicle with a handful of books, magazine and peep through your window pan with a sheer appeal in their face and eyes. They somehow try to get their products sold by you.

I had the similar experience while traveling by an auto on 25^th Dec. But the difference is, the mobile street vendors, this time were not even five years old. That means they can be still targeted for the pulse polio drive.

The boy and girl were shivering in the cold wave. With barely anything on them, they were running around between the automobiles to sell some ‘made in China’ products. I purchased one such thing from the girl. When the boy discovered me to take the item from the girl, he put his torso inside the auto to cling my feet and cried profusely to take at least one of his products.

It is not a novel thing in Delhi. Small children are being constantly put on into this kind of smart business in the busy streets of Delhi.

Who are the people behind this act? They do not bother to push the hungry, shelter less and parentless children into a risky and inhuman business without caring damn of its implications.

We are supposed to have some acts in our legal system in the name of ‘Child Labor Protection Act’. We also have our ‘Human Rights Commission’ strongly positioned. There are long list of NGOs and voluntary organizations being constantly vigil to detect the slightest violation of human rights. But there is nobody to protect these poor children in the streets of the capital.

Sometimes, I feel we are not residing in a civilized society.

How can we say this society civilized where children are continuously getting deprived of their basic rights and undergoing treatments that simply stain humanity?

Sugata Mukhopadhyay
Universal Health