FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

                                          No condom No sex 

Part Three

1.11 How STI management can help

Treatment and cure from STIs decrease -

• Susceptibility to HIV
• Concentration of viral load in genital secretion
• Shedding of HIV in genital secretion
• STIs & HIV both associated with unprotected sex with multiple partners. So same measure that prevent STIs can also prevent sexual transmission of HIV
• Spread of HIV infection in the community
• Reduces serious complications of mothers & children like cervical cancer, ectopic pregnancy, infertility, still birth

1.12 Objectives of STI Management and control:

·        To prevent new infections

·        To treat those who are symptomatic & seeking treatment

·        To treat those who are symptomatic but not seeking treatment

·        To treat those who are symptomatic, seeking treatment without success due to lack of quality STI services

·        To identify and treat those who are asymptomatic

·        To treat the partners of the cases

1.13 Basic approaches of prevention and control of STIs

There are three basic approaches to prevent and control STIs: -

1. Reduction of STI load/burden of the community (prevalence)
2. Reduction of  new STI cases (incidence)
3. Strengthening STI reporting and surveillance

Table 1: Reduction of STI prevalence

Major activities •         Quality STI services •         Early diagnosis and treatment of STIs among high risk groups •         Presumptive treatment of STIs •         Simultaneous treatment of the partners of the STI cases •         Promotion of STI services and health seeking

Table 2: Reduction of STI incidence

Major activities •         STI prevention by correct and consistent use of condom •         Creating sufficient awareness on STIs and HIV through strategic communication •         Prevention of STI relapse/re-infection after treatment by consistent safe sex •         Creating enabling environment of safe sex •         Practice of non-penetrative sexual acts •         Practice of abstinence, fidelity, delayed sexual debut •         This is applicable to prevention of sexual route of HIV transmission as well

Table 3: Comprehensive package of STI Services

Syndromic management of STIs Etiologic management of STIs Presumptive Treatment for asymptomatic infections Treatment of the partners STI Screening through risk assessment & screening tests Condom promotion Information Education Communication Promotion of services and health seeking

            (Peer Educators of STI clinic of Sanur, Bali, Indonesia)

FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

Part Two

1.5 STI Transmission Dynamics

Many of the STIs, especially those among female are asymptomatic. They create serious reproductive health complications if remain untreated or incompletely treated. Infertility, still birth, ectopic pregnancy, repeated abortions and cervical carcinoma are some of the grave complications of STIs in females. Asymptomatic STIs take a major share of the STI load of the community. Moreover, poor decision making and lack of access to appropriate services affects treatment outcome among females.

Many STIs remain hidden due to stigma. People seek medical care in places such as unqualified practitioners, pharmacists of the medical shops, street ‘doctors’ and receive improper and ineffective treatment. Recurrence is common among STIs such as genital herpes, genital warts. In general viral STIs are difficult to treat.

Asymptomatic, hidden, maltreated and recurrent STIs are responsible for the STI load of the community (STI prevalence). This STI load acts as the potential reservoir of the sexually transmitted diseases and infections.

New STI cases (STI incidence) appear due to continuing unprotected sexual activities, especially, among those who have multiple sexual partners. The new cases of STIs add on the existing STI load of the community. Unprotected sexual acts with many partners help to spread STIs and consolidate the community burden of STIs.  This is a vicious cycle.

1.6 Flow of STI & HIV Transmission through sexual and perinatal routes

Transmission of STIs is common among high risk groups because of sexual acts with multiple partners either as a profession (sex workers) or as a preference (MSM, Transgender). Clients and partners of the sex workers act as the bridge because they carry the infections back to the relatively low risk groups (house wives, spouses of the clients of the sex workers). STIs like HIV, syphilis and gonorrhoea are also transmitted from infected mother to the child.

1.7 Factors facilitating STI in HIV positive individuals

• Poor immune status
• Lack of awareness on STIs
• Low risk perception specially those on HAART
• Desperateness in sexual expression and behavior
• Absence of proper counseling system

1.8 Non STI genital conditions which increase vulnerability to HIV

• Poor genital hygiene
• Anal intercourse as it is more likely to injure tissues of receptive partner
• Exposed adolescent girls as cervix is less effective barrier to HIV and less production of mucus in the genital tract
• Post menopausal period due to thinning of genital mucosa and less production of mucus in the genital tract
• Unprotected sex during menstruation due to abrasions of the skin or mucus membrane
• Sexual violence like rape resulting in genital injury

1.9 Complications of STI

• Cervical cancer
• Ectopic Pregnancy, Infertility
• Miscarriage & stillbirth
• Foetal transmission
• CVS & CNS complications
• HIV infection

1.10 Challenges of STI management in women

• Asymptomatic infection more frequent (chlamydial/gonorrhoeal cervicitis)
• Delay in treatment seeking
• Complications more serious than men

FROM THE STI CONTROL & MANAGEMENT DESK OF UNIVERSAL HEALTH

Part One

1. Sexually Transmitted Infections

1.1 Reproductive Tract Infections

Reproductive Tract Infections/RTIs are infections which affect the reproductive tract in males and Females.

RTIs can be caused by organisms which are normally present in/near the reproductive tract or they can be introduced by outside, (Sexual route or medical procedures).

RTIs are basically of three types,

1. Iatrogenic infections: Infections caused by medical procedures in women like unclean delivery, unsafe abortion, IUCD insertion. Example: Staphylococcus aureus, Pseudomonas

2. Endogenous Infections: Infections caused by overgrowth of organisms in the reproductive tract of women in conditions like diabetes, immune deficiency.  Example: Candida albicans and bacterial vaginosis

3. Sexually Transmitted Infections (STI): Infections caused by unprotected sexual act with multiple partners or with partner or spouse who has multiple partners.

STIs are basically of two types

Viral (Difficult to treat)

* Ulcerative: Genital herpes

* Non ulcerative: HIV, Genital Warts, HPV

Non viral (Treatable & curable)

* Ulcerative: Syphilis, Chancroid

* Non ulcerative: Gonorrhoea, Chlamydia, Trichomoniasis

1.2 STI increases vulnerability to HIV

A randomized control trial was done to evaluate the impact of improved STI case management at primary health care level on the incidence of HIV infection in a rural region of Tanzania. HIV incidence, or numbers of new HIV infections, was compared in intervention communities and control communities where no intervention was conducted.

The improved STI services were designed to be feasible for resource-poor settings and were integrated with the Tanzanian primary health care system. Patients in the intervention community were treated according to WHO recommended syndromic STI case management guidelines. As part of the intervention, an STD reference clinic was established in each community, staffs were trained, a regular supply of effective STI drugs was provided, regular supervisory visits to health facilities were conducted, and health education about STIs was delivered.

Over a two-year period, the trial demonstrated a 42% reduction in new sexually transmitted HIV infection in the intervention communities compared with the control communities. This study provides strong evidence of the impact of improved treatment of symptomatic STIs.

1.3 HIV-positive individuals who have other Reproductive Tract Infections are more likely to transmit HIV to others

Studies have shown that when HIV-positive individuals are also infected with other STIs and reproductive tract infections, their bodies are more likely to shed or release HIV cells in both ulcerative and inflammatory genital secretions. They are also more likely to shed more numbers of HIV infected cells compared to people with HIV infection alone.

A study conducted recently in Malawi measured the concentration of HIV-1 RNA (the genetic material of HIV virus) in cell free seminal plasma from HIV-1-seropositive men with urethritis before and after antibiotic therapy. The results were compared with those seen in HIV-1 seropositive men who had no clinical evidence of urethritis. Results showed that HIV-1 positive men with urethritis had HIV-1 concentrations in seminal plasma eight times higher than those in seropositive men without urethritis. After the urethritis patients were treated for their STI, the concentration of HIV-1 RNA in semen decreased significantly.

 
These results suggest that urethritis increases the infectiousness of men with HIV-1 infection and that programmes which include detection and treatment of STDs in patients already infected with HIV-1 may help to curb the HIV epidemic.

1.4 STIs and HIV – biological relationships

a)  Increased Susceptibility

• 10 fold increased risk of HIV transmission in presence of Ulcerative STIs

      and 4 fold increased risk of HIV transmission in presence of Inflammatory

      STIs/RTIs

• Ulcerative STIs results in breaks in genital tract lining or skin and create a portal of entry for HIV. Micro erosions caused by STIs also facilitate HIV entry.
• Both Ulcerative & Non ulcerative STIs & RTIs increase the concentration of T-cells in the genital secretions and genital linings that can serve as target of HIV.

b) Increased infectiousness

• HIV positive individuals who are also infected by STIs have shown increased concentration of HIV (viral load) in the genital  lesions.
• Both ulcerative & Non Ulcerative STIs and RTI increase HIV shedding in the genital secretions of HIV positive individual. Bleeding from the genital ulcer is another contributory factor.
• There is mounting evidence that some STI pathogens become more virulent in presence of HIV related immune deficiency.

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

TB challenges in India

According to the recent WHO Global TB report, India, annually, is hit by approximately 2 million new TB cases. Almost 50% of them are infectious TB (sputum smear positive Pulmonary TB) and if remains undiagnosed and untreated, each of those infectious TB cases has the capacity to infect 10-15 persons per year. So TB has tremendous potential to spread fast in a densely populous country. And India is one of such brightest examples in the globe.

Many TB cases receive treatment at the private sector. Those cases are not reported to anywhere so we have no idea about their numbers/estimates. The public-private mix (PPM) schemes have been initiated to imrprove involvment of the private doctors in the National TB Program (RNTCP) of India.

HIV is a very powerful enhancer of TB epidemic that has been already experienced in Sub-Saharan Africa where as high as 40% of the country's population is infected by HIV. High load of HIV can easily trigger TB in a country with equally high TB burden.

Fortunately, for India, HIV is not that strong driving force of TB epidemic with the low prevalence rate (0.3%). Approximately 5% of the TB affected population is co-infected by HIV. The key challenge of TB/HIV collaboration is to reach the HIV infected population with adequate and appropriate TB services in politically and geographically difficult places like North-Eastern states, and in highly vulnerable states like UP, Bihar, Orissa, WB etc where public health systems are comparatively weaker as a result of inadequacies in infrastructure and political committment.

On the other hand, TB is a bigger threat in a country where more than 40% of the total population (1.2 billion) is estimated to be infected by TB. The key driving forces of TB in India are poverty, malnutrition, unhealthy living, smoking, migration and increasing trend of diabetes. Though the country has achieved the targets of 70% case detection rate and 85% cure rate, there are a number of districts consistently showing poor performances in terms of low case detection and cure rates. Besides, there are greater number of high risk population groups who have still extremely poor access to TB services and information. That include poor homeless people in urban set ups, slum dwellers, tribal groups, sex workers, drug users, prisoners, migrants, refugees, internally displaced people etc. The support of NGOs is a must to help those underprivileged and underserved population groups utilize the TB services from the National Program. RNTCP has already started schemes that can be adopted by the NGOs to provide meaningful contribution to the National TB care and control initiatives. But the responses of the NGOs, so far, are not encouraging like the HIV program.

Engaging the private doctors in the TB program is one of key strategies to achieve the goal of universal access. The PPM strategy has mainly 2 objectives: 1) improve TB case reporting from the private sector, 2) encourage private sector to follow the RNTCP drug regimes and the DOTS strategy. It targets both the qualified and unqualified private doctors. So far the experience of PPM is mixed but remains always challenging.

RNTCP will be going into its third phase from 2011 with the target of 100% TB case detection that will make the task of TB care and control steeply challenging in the coming days.

Sugata Mukhopadhyay

Universal Health

TB Programs should take more responsibilities now to strengthen the efforts for TB/HIV collaboration

The TB programs of the countries are gradually shifting focus on 100% case detection as part of universal access. This means responsibilities of the TB programs will increase many folds, especially towards the TB/HIV component in terms of facilitating TB case detection among the HIV high risk groups and PLHIV at the community level, through strategic advocacy, communication and social mobilisation (ACSM) approach.

The ACSM component is still weak in TB/HIV collaborative programs. The NGOs and CBOs working with HIV high risk groups in HIV prevention programs have shown weak linkages with the TB programs. Similarly, PLHIV networks and home based care programs are not well connected with the TB initiatives. TB case detection among HIV program participants is happening chiefly in the healthcare facilities. Those not accessing the services are remaining with undiagnosed TB and seeking treatment either in private or indigenous healthcare services, often gets maltreated/incompletely treated/undertreated for TB, thus also increasing the risk of MDR-TB.

It is a big challenge for the TB program to reach the HIV program participants, the high risk groups and infected and affected population with the required package of awareness, information and services. This can be achieved through an effective collaboration with the NGOs, CBOs and PLHIV networks, especially those who are already implementing HIV prevention, care and support programs.

In India, Round 9 TB project supported by GFATM is expected to improve and expand the ACSM component in the TB/HIV collaborative program of the country. The project will be covering 374 low performing districts of India and aiming at facilitating TB case detection in hard-to-reach areas and marginalized population including the HIV high risk groups, infected and affected people. The project will be involving the PLHIV networks in the TB program through their sensitization and capacity building on TB. Moreover, the project will be responsible to popularize the NGO-TB schemes and help the NGOs to adopt the schemes. Those schemes generally provides good opportunities equally to the NGOs already working in HIV sector to contribute significantly to the TB sector as well in terms of enhancing ACSM and TB case detection in the high risk groups, infected and affected population.

We are strongly hopeful.

Sugata Mukhopadhyay
Universal Health

Story a highly motivated TB Health Visitor of Gujarat

I met this TB Health Visitor during my recent trip to Rajkot city of Gujarat.  He requested me not to disclose his original name. I will call him Babubhai in this write up.

My primary objective was to visit the Targeted Intervention (TI) HIV project for female sex workers and MSM (man who has sex with man). The project was implemented by a local NGO of Rajkot with the support of Gujarat State AIDS Control Society. Babubhai was present in the same meeting I had with the TI project staffs.

Babubhai developed a healthy relationship with the TI project staffs. He used to bring the TB patients to the TI project counselors for counseling before referring them to ICTC for HIV testing. He actively took part to disseminate key TB messages to the HIV high risk groups targeted by the TI project. It is his initiative that prompted the TI project staffs to refer the suspected TB cases (cough for more than 2 weeks) successfully to the local DMCs from the community of female sex workers, their clients and MSM groups. He set up an encouraging example of ACSM indeed.

His rapport with the local private providers (non MBBS) was phenomenal. Those providers were closely associated with the TB program because of Babubhai’s frequent interaction with them and continuous motivation. ‘It is very important to meet the private doctors in frequent intervals during the free hours of their clinic and repeatedly appreciate their services for the National Program. I learnt the technique from the medical representatives of the pharmaceutical companies. If they can make so many visits to the doctors to sell the products of their companies, why can’t I do the same for the sake of my National Program?’ commented Babubhai.

I strongly felt he probably said the last word that can definitely bring success to the PPM (Public Private Mix) strategy.

Sugata Mukhopadhyay
Universal Health

Do we really need those powerful donors?

Public health projects are donor-driven except a few. It is the donor who, most of the time decides the fate of the programs. The programmatic activities are performed as long the funds are available. After sometimes, it so happens that activities become routine, not need-based and the program gradually starts losing its gravity. One prominent example is World AIDS Day. It is no more appealing to those who need the services and attention maximum as far as the HIV/AIDS epidemic is concerned. World AIDS Days are observed mostly because the funds are still available to celebrate them. Another striking example is Pulse Polio Program. In countries like India, Pulse Polio Programs have overtaken Routine Immunization activities in states like Bihar and UP because of the mounting pressure of the external donors and agencies and uninterrupted flow of funds. Pulse Polio is completely a donor-driven program but can polio be eradicated chiefly by the supplementary immunization activities?

The value of true partnership, though strongly advocated and highlighted, is not practically visible in the donor-recipient relationship.  The donor enjoys the heavier side of the power dynamics and freely dictates the terms and conditions to the recipients who have no option other than obliging them. The beneficiaries, in whole of the negotiation process with donor, remain in the backseat. Their needs and challenges are not expressed in their languages and emotions but through the reflections of the ‘so called’ specialists representing the recipients’ side. It is generally perceived that poor and vulnerable people having no/poor literacy generally lack capacity to deal with the donors and handle their tricks.

Community based organizations and networks have been established over years, especially associated with AIDS programs. These bodies are represented mainly by literate. English-speaking and smart folks. How many poor and underprivileged people are linked to those networks and enjoying the benefits is still doubted.

So, how long the donors will exclusively enjoy the overall authority of the public health projects? How long they will keep on providing funding to address the issues that are not exactly located in the agenda of the beneficiaries? How long they will enjoy the control over the projects and exerting the right to withdraw funding as per their own decisions and convenience without thinking a bit about the agonies and helplessness of the beneficiaries? How long they will remain ‘God’ of the public health and development sectors?

The answer is till the time the public health projects become truly the people’s program.  

About five years back, while making a field trip to Chhattisgarh I came across the community clinic which was established by the poor people of the slum.  They invested their hard-earned money into setting up their own health-centre within their slum. A local woman donated a part of her house to provide space for the clinic. The joint subscription of the local people enabled to purchase furniture including electric devices like ceiling fans and lights, medical instruments and medicines. A part-time lady gynecologist and full-time nurse were hired as salaried staffs of the clinic. Subsequently, when clinic became busier, the local district hospital sent regularly their ANM (Auxiliary Nurse Midwife) with vaccines to the clinic to immunize the local children. The local hospital also promised the slum dwellers to provide free supply of medicines and a larger space for the clinic in the near vicinity.

Five years down the line, the community clinic is still functional. The doctor and nurse are still associated with the clinic with the same kind of enthusiasm and spirit. The linkages with the local district hospital have become stronger. The local people’s investment to ensure their own healthcare is giving the dividend now.

Where do you find a better model of private-public partnership than the community clinic? Do you need an external donor to initiate and support such models?

Nothing actually can match with the power and commitment of the people.    

Sugata Mukhopadhyay
Universal Health

Prevention of sexual route of HIV – Asian and Indian context

In any kind of multiple sexual relationship scenario, correct and consistent use of condoms in all penetrative sexual acts – peno-vaginal, peno-oral nad peno-anal  (100% condom use) should be promoted as the priority strategy and it should be sustained over a period of time to achieve the desired result of prevention of HIV transmission via sexual route. Asia has already experienced the good results of 100% CUP  with the high risk communities like sex workers because the condom promotion strategy was adopted as one of the primary strategies during inception of the AIDS control programs of the Asian countries during the nineties.  HIV prevalence among sex workers have already shown downward trend in many of the Asian countries for last several years that clearly indicates effectiveness of 100% CUP to reduce HIV transmission in the context of concurrent multiple partnership within the sex work set ups. The HIV prevention projects should be designed to establish this prioritized primary intervention with the strategic advocacy in place to address the socio-cultural and religious issues that generally revolves around use of condoms.

The Indian context has actually brought the revolution in the HIV/AIDS sector by giving birth to the structural intervention concept which does not stop at BCC but tries the explore the underlying and deep rooted causes of vulnerability to HIV, especially with the high risk groups. Thus for sex workers it is their profession and criminalized status in the Asian countries that increase their vulnerability to HIV, not just behavior. The Indian programs have been designed to address the structural issues to modify the risky behaviors through interventions like collectivization of the community members and their empowerment, formation of CBOs (Community Based Organizations) and finally community ownership by keeping the community members at the driver's seat of the programs.

At the same time prevention initiative remained the topmost priority in India from the beginning of our AIDS control program with maximum resources (almost 70%) allotted to support the prevention activities.

Sugata Mukhopadhyay
Universal Health

Ensure STI management and control

http://www.facebook.com/photo.php?fbid=141949852501811&set=a.151760364854093.34802.133130480050415#!/pages/Ensure-STI-management-and-control/156563737690883

Links to TB/HIV Collaboration

http://www.facebook.com/#!/pages/TBHIV-collaboration/133130480050415

Scope of Work - Universal Health

‘Universal Health’ is a voluntary, non-profit public health agency. It is founded by some highly dedicated, motivated and thoroughly experienced public health physicians of India.

 The agency will have core governing body members with expertise in various aspects of public health and social development as the policy and decision makers of the agency. The agency will hire consultants for time-bound assignments. The agency will provide support to the public health programs globally though the main focus will be in India and South-East Asia.

Vision: Universal access to healthcare to ensure ‘health for all’

Mission: 3 ‘E’s

·         Enhance access to appropriate healthcare services

·         Ensure quality in healthcare services

·         Enable healthy practices in the vulnerable and at –risk communities

Objectives:

·         To implement and develop model community-based public health interventions as ‘demonstration sites’ for National Health Programs

·         To provide technical, managerial and operational assistance to public health programs of other non-government and government organizations

·         To enhance the capacities of the public health professionals and staffs of the health programs

·         To strengthen the community health systems for sustainable development

·         To publish burning social issues, prominent public health topics and important epidemiological information in the blog (http://universalhealth2010.blogspot.com) of the organization for creating awareness, sensitization and mobilization

Core values: 3 ‘R’s (concept adopted from Durbar)

·         Respect to the underprivileged, marginalized and criminalized community members

·         Reliance on the calibers of the community members

·         Recognition of country specific, institution specific and community specific welfare policies

Organizational key functional strategies

1)      Providing technical assistance to the public health projects[1] of various non-government and government organizations whenever such support asked

2)      Direct implementation of high quality public health projects for underprivileged, vulnerable and at-risk population and in underserved areas as ‘model projects’

Expertise available with the agency – 2 level expertise

1)      Expertise for providing high quality, timely and need-based technical assistance to non-government and government organizations in their public health projects

2)      Expertise to implement high quality public health projects and develop model interventions with demonstration of promising practices

Providing high quality, timely and need-based technical assistance to non-government and government organizations in their public health projects

 The agency will provide high quality, timely and need-based services to the wide range of clients starting from grass root level CBOs, NGOs, FBOs and community networks to district/state/national level government and non-government organizations. The agency will aim to provide comprehensive and complete services like:

·         Conduct need assessment and baseline surveys prior to project proposal development and subsequently develop project concept, design, framework, action plan, budget and M/E plan

·         Conduct review of project proposal through mock exercises

·         Review/revise/develop suitable materials for the project like training modules, operational guidelines, protocols and tools, IEC and BCC materials, flip charts

·         Conduct mid-term and end line evaluation of the project including developing evaluation plan, methodologies, tools and finally evaluation report

·         Capacity building of the project staffs, healthcare providers, community, policy makers on various aspects of the projects

·         Organizing large public health events – conferences, seminars, workshops etc

·         Provide support to roll out the projects including monitoring, mentoring and community involvement

·         Conduct pilot, operational research, clinical trial, drug trial, health camps

·         Help to identify promising practices from the past and present projects and their documentation for future growth opportunities and  publications in recognized journals and conferences

·         Help to develop institutional archives through appropriate data and information management

·         System strengthening: Infrastructure, human resources, materials and MIS at public health

Implement high quality public health projects and develop model interventions with demonstration of promising practices

·         Implement high quality public health projects for the underprivileged population and in the underserved areas with monitoring and evaluation of the project

·         Working effectively with multiple partners – government and non-government

·         Working appropriately in multi-cultural environment

·         Developing promising practices in the projects

·         Project documentation

·         Appropriate Operational Research in the project

·         Financial and administrative management of the projects

·         Provide high quality progress report to the donors

·         Scientific publication


Sugata Mukhopadhyay
Universal Health

[1] Communicable, Non-communicable, Occupational and Environmental health intervention projects 

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