SAFE HEALTH INITIATIVE PROGRAMME NIGERIA FIGHTING HIV/AIDS

UCHENA ANOZIE, NIGERIA

Safe health initiative programme was born out ingenuity of Uchenna Anozie and Johnpaul Onwuaso both Nigerians and with the utmost mentorship and support from Dr, Sugata from In India.

Both initiators have been in the field of battling HIV/AIDS for more than 7 years in Nigeria,  They have worked for many local , national and international organizations. It is with their gathered experiences that they decided to launch a pet programme in a pilot scale to fight against AIDS.

They decided to have a peer education program for sex workers in 2 states outs of 36 states in Nigeria namely Ebonyi and Anambra State. In the course of running this programme they found out that people living with HIV/ AIDS in Ebonyi state lacked attention from the Government and even concern of the health facilities, it is due to this factor that safe health initiate programme extended her hands to work with people living with HIV/AIDS using a private health facility (Fellysussy Memorial Hospital)  as an ambulatory hospital for PLWHA in the state.

Today Safe health initiative Programme has 15 sex workers that receive support from the programme and over 16 PLWHA’s receiving support from the initiative, these supports ranges from health promotion, psychosocial support, linking patients to main hospitals that administer (HAART: Highly active antiretroviral treatment)at Federal Teaching Hospital Abakaliki, education on nutrition, free distribution of mosquito nets, HIV screening, ambulatory treatment for PLWHA, blood donation for anemic patients, and even vocational support through other NGOs.

The programme is facing lots of challenges, especially in the area of ensuring that patients receive appropriate attention from Hospitals that Administer HAART but recently through the help of a Nurse in Federal Medical Teaching Hospital Abakaliki called Sister Ann and a Doctor known as Dr. Eze, things are much easier now.

Another challenge is that most people living with HIV/AIDS in our area are women, more especially pregnant women, they are mostly low income earners therefore lots of financial support is needed to help them transport to health facilities, have micro-gardens at homes, vocational trainings and even money to supply them with relief materials such as sanitary materials, mosquito nets and food supplements.

So far we observed that 80% of the women enrolled in the programme are HIV  discordant with their husbands thereby creating  huge social problems for them but it’s part of the programme to educate their spouses on how to cope with HIV discordant relationship.

The initiative hopes to expand her services and even enroll much number of sex workers and PLWHA in future and we solicit for fund, health support materials, food supplements and vitamins, malaria drugs, cloths, food for babies living with HIV/AIDS etc.

The initiative appreciates in a special way Dr. Sugata who has been a mentor and a technical adviser to the initiators of this pet programme we also thank Nurse Ann for her special way of facilitating protocols that are observed in the HAART center in Abakaliki for our patients.

The programme also remembers all her enrolled members both sex workers and people living with HIV/AIDS and encourages them to keep practicing safe and positive health practices.

If you are moved by our programme (Safe health Initiative Programme) please do not hesitate to comment or even write us at: donuchman@yahoo.com or sms+2348033746531 or post mails to No 12 Onitsha street, Abakaliki, Ebonyi State Nigeria. If you want to give any support by donating materials or giving financial support to the programme, please do write us with the above email address so that we can facilitate your donation.

Remember your ideas are very important and we count on them.Thanks for reading.

NJPHA visits Tent City Lakewood

Sarah Simpson, USA

The New Jersey Public Health Association recently visited Tent City located in the Pine Barren woods in Lakewood, New Jersey. For those of you unfamiliar with tent cities, they are makeshift, homeless communities that are springing up all over the United States. These communities are labeled as such because residents live in tents and other collapsible, mobile living quarters. Started in 2005, Tent City Lakewood consists of a community of about seventy people from diverse backgrounds. The camp is led by Reverend Steven Brigham, who was kind enough to show us around the grounds. While, these communities continue to spring up around American cities, this tent city and others like it do raise some concern for the health of its inhabitants and their local communities. Below are some areas of concern observed during our visit to Tent City Lakewood.

Solid and Human Waste Disposal

One of Tent City Lakewood’s biggest issues is their solid and human waste disposal. There is currently a dumpster on the outskirts of Tent City, which is collected by the municipality. However, trucks often have trouble getting to the dumpster, which is located in a small, pot-holed clearing of the woods. Allowing for road paving would help make garbage collection easier.

Another concern is that their bathroom facilities currently consist of pit latrines, which are made by digging a hole into the ground and placing an outhouse type structure over it. Once this hole is filled waste, it is filled in with dirt and a new hole for the latrine is dug. While there are some advantages to using a pit latrine, such as they are cheap and simple to build, there are also some worrying disadvantages. One disadvantage is that this system can lead to the attraction of insects such as mosquitoes and horseflies and vermin such as rats. These possible vectors are attracted to the odor and gases of decaying fecal matter. Another disadvantage is possible seepage into underground water tables because of its location on porous sandy land. If the weather is bad enough, local flooding could flow human sewage into local water systems or into gardens grown by the residents, which can lead to health problems such as norovirus. Some other health issues that were noted were the lack of adequate hand washing facilities at the toilets and in the communal kitchen area.

Food Safety

Unsafe food handling practices might also be a cause for concern, as there is only one chest freezer.  Food is prepared in a central location with grills where residents prepare shared meals using donated food; however the food handling methods employed might be unsafe. Factors such as improper holding temperatures for potentially hazardous foods and inadequate storage of the mostly donated food supply, especially with the summer heat, can lead to serious food-borne illnesses. A closer look at their food safety practices is definitely needed. 

Injury Risk

During the cold New Jersey winters, the residents use wood burning stoves as the primary way to heat their tents, along with propane tanks. While there is a fire extinguisher located near every housing structure, these stoves and propane tanks pose a great risk to injury in the case that there is a fire. With no carbon monoxide detectors, carbon monoxide also poses a risk if smoke ventilation isn’t good. Injuries such as sprains, falls and other accidents should also be of concern along with hypothermia in case residents are not able to properly heat their homes.

Animal and Pest Control

As the community lives with domesticated animals such as dogs, cats and chickens, it is important that there is proper animal and pest control. Cats and dogs must be vaccinated, receive flea treatment and fed properly. If they are not properly being cared for, they become infested with ticks, mosquitoes, and lice, or can be infected with diseases like rabies. Mosquitoes, ticks and other insects also pose a risk to human health,  and exposure to such pests is increased by its location.

There is also a population of chickens being bred on the grounds. Chickens being raised within such close human contact pose a health risk as there are diseases that are communicable from chickens to humans. Bacterial diseases such as salmonella and campylobacteriosis can be contracted through direct contact and exposure to manure. Elderly and other susceptible persons are at risk to severe illness if exposed. However, it should be noted that there are no children living in the Lakewood Tent City.

Other Potential Risks for Illness

Some of the potential risks for illness such as those associated with unsafe food and hand washing safety practices, inadequate waste disposal and animal pest control were mentioned above. Some other illnesses of concern would be influenza and tuberculosis, which are transmitted through the air. For example if residents don’t receive their yearly influenza vaccination and become sick, they pose a greater risk to other residents. Coupled with inadequate hand washing practices and the other risks mentioned before, this could lead to a highly infected population who pose a risk to the local community during regular interactions.

Mental Health Services

We also learned that many residents might suffer from mental health illnesses, which would require targeted mental health services. A needs assessment should be performed in order to see if they are indeed in need of such services. 

Lessons Learned

Overall, tent cities can present some serious environmental health challenges. Even with support, they require vigilance in order to avoid or mitigate pending public health issues. Some recommendations can include adopting guidelines used for disaster camps and shelters such as the Center for Disease Control and Prevention Shelter Assessment Tool. Portable toilets are a short term solution to the human waste problem, but unpaved roads hinder waste pickup by trucks. Proper hand-washing and food safety practices should be reinforced, perhaps through signs and through classes taught by a health educator from the local health department. Proper training can prevent disease transmission and contraction. Tent City Lakewood also provides us with a unique opportunity to understand environmental health issues associated with disaster camps. As we continue to experience extreme weather events, such information would be important to public health responders in understanding critical human needs and protection in disaster situations. NJPHA recognizes that a more in depth assessment is needed, so be sure to stay tuned for our continued involvement with Tent City Lakewood.

About the author of the article: Ms. Sarah Simpson is presently the MPH Epidemiology Candidate, University of Medicine & Dentistry of New Jersey, NJPHA secretary

A problem of millions and a creative solution

María Inés Guaia, Argentina

 The problem: Chagas disease, the most important parasitic disease in Latin America, spread by the blood-sucking insect ‘vinchuca’ (Refer to her previous article on the same subject)

The solution: insecticide-laced wall paint.

Dr. Pilar Mateo, a Spanish chemist, invented and pattented a tecnique of microencapsulation based on a polymeric mould.  After reading about the issue of bugs infestating hospital walls, she came up with the idea of introducing biocides in polymeric microcapsules using paint as a casing. The insecticides are released from the paint slowly, remaining effective for two to four years.

In 1997, a Bolivian doctor came to her seeking for help. He told her about the Chagas disease situation in his homecountry. Dr. Mateo was touched, and traveled to Bolivia in 1998 to test her technology. She has been working in developing products for vector control of insect-borne diseases ever since.

She has not only made an impact on the Chagas endemic in Bolivia. Other international initiatives include projects thoughout Latin America (Mexico, Costa Rica, Brasil, Argentina, Cuba) and Africa (Ecuatorial Guinea, Ivory Coast, Benin) to combat malaria and dengue-spreading mosquitoes, the Tse-Tse fly and arachnid vectors, among other insects.

Her work includes scientific research as well as measures of social promotion and some political negotiation. Last November, the Bolivian president Evo Morales invited Mateo to his office, and expressed his support. She is determined to overcome the various obstacles, such as insect resistance, political resistance, lack of interest from biocides companies, regulations, etc. to paint the world with health.

For more information about INESFLY and related projects visit www.pilarmateo.com

 

34 Million Friends

Jane Roberts, cofounder 34 Million Friends of the United Nations Population  Fund www.34millionfriends.org Redlands, CA USA. 

 

On July 22, 2002, ten years ago, the George W. Bush administration  refused to release $34 million to the United Nations Population Fund. As an American citizen I was angry. I started asking 34 million Americans and others to contribute one dollar. This became known as 34 Million Friends, www.34millionfriends.org, and is still going ten years later.

 

In 2003, as a guest of UNFPA, I visited Senegal and Mali. (As a former teacher of French I speak the language quite well.)  I saw babies being born safely, I saw the closets and drawers filled with family planning supplies, I visited with women whose fistulas were being repaired, I visited schools where gender equality was taught. 

 

All countries, and maybe perhaps African countries in particular, should prioritize women's health, reproductive health and family planning in particular. As I understand it, infant mortality (the first month of life), has as its basic cause the ill health of the mother when giving birth. The baby is born prematurely and is anemic. The mother isn't healthy enough to nourish the baby through breast feeding. In my view, when the world takes care of women, women take care of the world. I have written two papers which you might enjoy. Women's Health Equals Global Health http://www.rhrealitycheck.org/reader-diaries/2009/11/07/womens-health-equals-global-health-a-radical-proposal and What? You've Run out of the Pill http://www.rhrealitycheck.org/reader-diaries/2010/12/07/what-youve-pill-iuds-either

 

And at the 34 Million Friends site there is a plea for more family planning from UNFPA's executive director Dr. Babtunde Osotimehin and a very recent radio  interview I did with National Public Radio in Chicago concerning 34 Million Friends, the Family Planning Summit in London in July sponsored by the British Department for International Development and the Bill and Melinda Gates Foundation and about population in general. http://www.wbez.org/globalactivism/fighting-contraceptive-rights-abroad-and-home-101414

 

The world is in big trouble. Hillary Clinton has said: "Of particular concern to me is the plight of women and girls who comprise the majority of the world's unhealthy, unschooled, unfed, and unpaid." And Secretary General of the U.N. Ban Ki-moon has stated: "In women the world has the most significant but untapped potential for development and peace." 

 

Please join 34 Million Friends.  

 

AFRICA-HEALTH- RESOURCES

Commit more Resource   to Health,a report  of  Ugandan newspaper  the NewVISION  and available  among 2012  International  AIDS Economics  Network (IAEN) pre-conference materials.

The  US Government  has  promised to Commit more  resource to health  for Africa , and  Ugandan   newspaper  the  NewVISION   explains us in this report US government commitment

.

“The  US Government has told Uganda and other African countries to put more money in their health sectors in order to save mothers and arrest the HIV/AIDS scourge.

It said that the donors cannot fully take on all the challenges of partner countries. It called for country ownership of the health programmes with the nation's efforts led, implemented and paid for by its government, communities, civil society and the private sector.

In a teleconference with journalists from several African countries, on Monday, US officials quoted the US Secretary of State , Hillary Rodham Clinton as emphasising the global public private partnership to strengthen health systems and save mothers as well as deal with HIV/AIDS. She said there is serious need for country ownership of interventions for health.

The journalists' teleconference was addressed by Lois Quam, the Executive Director, Global Health Initiative (GHI) and Ambassador Eric Goosby, US Global AIDS Coordinator. They provided the journalists with the presentation made by Clinton earlier in the day at the Global Health Conference in Oslo, Norway. The conference was themed: A world in Transition- Charting a New Path in Global Health.

According to Clinton, the development partners will offer help but that the countries political leaders "should set priorities and develop national plans to accomplish health goals in concert with its citizens." "These plans must be effectively carried out by the country's own institutions which should be held accountable," she said.

Currently in Uganda one out of every 35 mothers die due to child related complications. The maternal mortality rate stands at 430 per 100,000 mothers. Infant mortality stands at 130 out of 1,000 live births and the chances of children dying at infancy are high when their mothers are dead, according to medics.

As far as HIV, AIDS is concerned, there are 750,000 who need ARVs but only about half of them are of them are on the life saving drugs.

According to Clinton, economic growth is making it possible for many developing countries to meet more of their people's needs. She said that countries have discovered resources including oil, gas and other extractive industries.

These and other resources of these countries, she said, should be captured for the wellbeing of its people and should be channeled into health.  And that in case of its supplementary funding to the partner countries, the US will not tolerate the use of health money it provides, for other purposes.

She said that partner countries should also bring down political barriers to improving health. "That means making regulatory changes that allow faster approval of new drugs, procurement reforms to ensure drugs get to clinics on time as well as setting and delivering a living wage for health workers.

Clinton also asked the donors to do a more effective job of coordinating their resources they give to partner countries.

"All countries should do more in investing in global health and all countries should do more to ensure and put more resources into health systems to save mothers…," she said.

On the President's Emergency Plan for AIDS Relief (PEPFAR 2) which is ending next year, the US officials said that his government's intervention will not end, but that they are "in the process of looking at what that re-authorisation will look like".

The five-year PEPFAR 2 was designed for capacity which includes governance, health information systems, financing service delivery, medicines and technology and human resources development though it does not include additional recruitments.

However, the US said that partner countries should also tackle the issue of corruption. She said that in some countries leaderships there want to get the money meant for HIV/AIDS even before the targeted beneficiaries can get it. Other issues to tackles she said are gender violence and mistreatment of women.” 

 (NewVISION/IAEN)

New from  Foussénou   Sissoko

Health   Communication  Expert.

foussenou@ymail.com/sissokofouss@yahoo.fr

Insect-Borne Infections in South America: Chagas Disease

María Inés Guaia, Argentina

Chagas disease is the most important parasitic disease in Latin America, and the third most important infectious disease in the region, only after AIDS and tubeculosis. According to WHO figures, an estimated 10 million people are infected worldwide, and more than 25 million are at risk, most of them in Latin America.

This disease is caused by the parasite Trypanosoma cruzi, a flagellate protozoan, which is most often transmitted to men and other animals by an insect vector commonly named ‘vinchuca’. Vinchuchas are blood-sucking insects of the family Reduviidae, subfamily Triatominae.

                                                       (Vinchuca)

The transmission generally happens at night, when the bugs emerge to feed.  Unfortunately, vinchucha often take to dining on human blood.  They bite humans, ingest their blood and immediately defecate liquid feces on the wound. The infection occurs if the Tripanosoma cruzi parasites in the insect feces enter the organism through mucous membranes or breaks in the skin.  This is more likely to happen if the bitten person, likely asleep and unaware, scratches or rubs the feces into the bite wound.

Blood transfussions, infected organ transplants and mother-to-child exchanges during pregnancy are other, less common, avenues for transmission.  In rare cases, Chagas has been transmitted through consumption of uncooked food contaminated with feces from infected bugs, or even accidental laboratory exposure.

The incubation phase of the disease lasts about a week. Following it, the disease evolves in three stages:

Acute phase: During the first 20 to 30 days, there may be inflammation in the place of bite, with local redness and temperature. Trypanosomas can be seen moving just by examining a drop of infected blood with the microscope.

Intermediate or latent phase: This is a variable period during which symptoms are absent. It can last for many years; generally, for the rest of an infected person’s life. The existence of parasites can be confrimed by observing antibodies in a blood test.

Cronic phase: The last phase depends on the severity of the case. This phase ussually starts 10 to 20 years after the infection. In many cases, patients realise they have the disease in this stage. Symptomes related to the affected organ/s (most commonly heart, colon or esophagus) arise. The most common alteration is the dilation of the organ/s involved. Chagasig cardiopathy is the most common cause of cardiac impairment and sudden death in the endemic zones of South America. It develops as right cardiac impairment and conduction dysfunctions.

Chagas is mainly a disease of the poor. The substandard housing conditions in which millions of people in LatinAmerica live provide plenty of cracks and holes in which the vinchuca can nest and develop confortably. Crowding and poor hygienic conditions also facilitate the proliferation of the bug.

The Chagas disease problem should not only be addressed from a medical and sanitary point of view, but also as a socioeconomic and infrastructural issue. 

SELECTED ABSTRACTS IN 2012

Title: TB services for the High-Risk-Groups (HRGs) of HIV programs through Targeted Intervention (TI) –TB collaboration: good practices from South-East Asia

Author: Dr Sugata Mukhopadhyay

Background:  In Asia, HIV epidemic is mostly concentrated within HRGs (sex workers, IDUs, MSM/Transgender, migrants, prisoners). They are equally vulnerable to TB due to unhealthy and over-crowded living conditions, poor socio-economic status, lack of nutrition, sheer ignorance and poor infection control in overcrowded health facilities, especially within high TB burden and concentrated HIV epidemic settings. But TB case detection efforts and expanding services are still limited for those groups, who are already covered under HIV programs despite unmet TB case detection targets.

Methods: The 'Targeted Intervention' (TI) HIV Prevention projects of HRGs give platform for dissemination of key TB messages, TB case detection in HRGs and linkage development with local TB services through existing peer outreach programs. The STI clinics marked for HRGs perform regular TB screening among clinic attendees and referral. Selected peer Educators of TI projects function as community DOTS providers through training and motivation.

Results: In 2001, Sonagachi STI/HIV Project, Kolkata, India initiated TB case detection in sex workers and their clients with the assistance of City RNTCP Office and CARE West Bengal with encouraging results. In 2005, a pilot project of TI-TB collaboration in Allahabad by CARE India detected 33 TB cases in 18117 high risk population including 10 co-infected cases in 6 months. In 2004 -05, similar pilot project in Bangladesh, the attendees of a STI clinic which was earmarked for HRGs were also screened for TB and 135 TB cases detected  within an year. The success of Avahan project in TI-TB collaboration (2006-07) in India prompted emergence of TB/HIV schemes in RNTCP for the NGOs though this scheme has, so far shown grossly insufficient utilization rate.

Conclusion: The initiative needs good advocacy and support to mobilize optimum resources and facilitate strategies and guidelines to saturate HIV TI projects with TB services.

(Selected for poster presentation in 43rd World Lung Conference, Nov'12 in KL)

Title: Southern Health Improvement Samity efforts to serve the underprivileged and difficult-to-reach TB affected people of the islands of Sundarban

 

Authors: Dr Sugata Mukhopadhyay, Mr M.A. Wohab

Aim: The abstract describes contribution of SHIS, a premier NGO of West Bengal India and partner of India’s Revised Tuberculosis Control Program (RNTCP), to provide TB services to remote islands of Sundarban Delta region at the Southern most part of West Bengal, India as part of country’s ongoing efforts of Universal TB care.

Method:  Inhabitants of 54 islands of Sundarban have extremely limited civic amenities like electricity, education and healthcare. Boats and launches are only modes of commutation. Working in TB control since 1982, SHIS has so far covered 39 islands which are home to 2.56 million people. The unique mobile boat dispensary services of SHIS have been reaching marooned villages of the islands, spreading awareness through local folk singers, screening TB suspects through Sputum Microscopy and Chest X-ray as per RNTCP guidelines and providing DOTS to TB patients through local Community DOTS Providers. SHIS has developed a network of 943 of providers across Sundarban who, are mostly cured TB cases and received TB services from the initiative of SHIS.  

Results: From 2009 to 2011, SHIS have screened 46866 TB suspects and detected 6707 TB cases with around 58% NSP cases in the islands. NSP case detection rate 67%, 62% and 62% in 2009, 2010 and 2011 respectively. The cure rate of the NSP is 94% in 2009, 99% in 2010 and 94% in 2011. 

Conclusion:  SHIS already achieved 85% cure rate and will soon achieve 70% NSP CDR through sustained and more intensified mobile boat dispensary services for the underprivileged islanders of Sundarban

(Selected for oral presentation in 43rd World Lung Conference, Nov'12 in KL)

Title: Scaling up of sexual & reproductive health (SRH) services for the sex workers, with the sex workers, by the sex workers – an unique model of Durbar, sex workers’ organization of Kolkata, state of West Bengal, India (35)

Authors: Dr Sugata Mukhopadhyay, Dr Smarajit Jana, bharati Dey, Mrinal Kanti Dutta, Pintu Maity, Dr Protim Roy

Background: Durbar, a sex workers’ organization of Kolkata, West Bengal, India, is working for establishing socio-political and reproductive rights of sex workers. Durbar is pivotal to provide SRH services to sex workers and their clients which were initiated in 1992 in Kolkata through WHO-supported pilot project. Since then, SRH services have been scaled up through unique empowerment model across the state of West Bengal.

Methods: Durbar followed core principles of 3Rs (Reliance, Respect, Recognition), kept sex workers in forefront of SRH project management and leadership since inception and built their capacities on SRH. This helped sex workers to meticulously map and establish effective networks with other peripherally located sex workers across the state. SRH services were scaled up in Kolkata city through 12 SRH clinics which were established between 1992-95 to cover more than 5500 sex workers and clients.  By following same principles and strategies, by 2000, SRH services were expanded in 11 more districts of West Bengal with 27 SRH clinics that have been catering SRH services to local sex workers and clients.  A network of about 600 well-trained peer counsellors and 30 community nurses has been created from sex workers’ communities in Durbar’s SRH projects that further empowered sex workers through direct SRH service delivery to their own community. Evening SRH clinics have been established exclusively for male clients.

Results:  Durbar’s SRH services currently cover over 20,000 sex workers and 60,000 clients in the state. In 2010-11, Durbar provided STI/RTI treatment to 12701 sex workers and 5506 clients, distributed 3424827 condoms and around 50,000 OCPs, screened 22098 persons for syphilis, referred and followed up around 900 women for ANC and referred 21 women for infertility to hospitals.

Conclusions:  Durbar model is a unique example of scaling up of SRH services for the sex workers, with the sex workers, by the sex workers.

(Selected for poster presentation in International AIDS Conference 2012)

Title: Total Control of Epidemic (TCE) Program of Humana People to People - A Community Driven Response to the Fight Against AIDS

Authors: Ib Hansen, Sugata Mukhopadhyay, Marie Lichtenberg

Background:  The Total Control of Epidemic (TCE) Program of Humana People to People aims to reduce spread of HIV and its impact by systematically engaging individuals and communities to take control of their own risk factors, while increasing access to prevention, treatment and support services. Implemented in close partnership with respective Ministries of Health and National AIDS Councils across Sub-Saharan Africa and Asia TCE has made major impact in HIV control. 

Method: TCE model works through two primary strategies:

a)      Individual HIV Counselling to Prevent New Infections: Every person in target areas was provided with counselling for behaviour change and was assisted to develop individual risk reduction plan by multiple follow-up sessions of Field Officers of Humana People to People. Home-based testing consistent with country guidelines was conducted as an integrated part of the process.

b)      Community Mobilization to Change Social Norms: To change social norms across the full range of HIV related issues (stigma, discrimination etc.), community-wide mobilization was carried out with local leaders, activists, PLHIV to project them as role models for others along with intensified promotion of existing services.

Results: Since the first TCE pilot in Zimbabwe in 2000, 11 million people were covered in 12 countries. 28 million individual HIV counselling sessions were delivered. As a result, 2 million people were tested for HIV and got results. Over 500,000 women attended PMTCT services. In Blantyre, Malawi, 4 times increase of PMTCT utilization within 3 years and in Ehlanzeni District, South Africa, 6 times increase of PMTCT utilization within 4 years after TCE implementation were observed.  More than 600,000 community activists were trained and engaged in community mobilization activities.  

Conclusion: With average cost of U$ 2/person/year, TCE model represents cost effective community-based interventions for HIV control and care with proven results, that might be replicated across the most HIV affected countries.

(Selected for oral presentation in International AIDS Conference 2012)

 

Public health system of India – an overview (focusing mainly on rural health system)

National Rural Health Mission (NRHM) is the unique initiative of Govt. of India which encompasses all the National Health and Disease Control Programs (except AIDS and Non-Communicable Disease control programs) to provide operational synergy and additional financial, administrative and technical support to those programs. One of the key objectives of NRHM is to strengthen the primary healthcare services at the rural set ups and its referral linkages and decentralization of responsibilities of healthcare management upto the village level.

Village Health and Sanitation Committee (VHSC): A village around 1000 population has a Village Health & Sanitation Committee. The members of the committee are selected from the local villagers like community leaders, teachers, healthcare providers, community health workers and members of the local governance body named Panchayeti Raj Institution (PRI). VHSC is responsible to develop annual health action plan of the village, its implementation & monitoring and overall decision making on the health situation of the village. The committee receives funding support from NRHM on annual basis.

Community Health Workers:  Generally, a village with 1000 population should have the following community health workers:

ASHA (Accredited Social Health Activist) worker: Eligible female volunteer of the village is selected by VHSC of the village to be trained and function as ASHA Worker who is primarily responsible for door-to-door visit, health education, basic health services and linking the community people with the existing public health system through referrals and follow up. There should 1 ASHA worker for 1000 population as per the NRHM norm. NRHM has so far introduced nearly 1 million ASHA workers in the rural health system of India.

 AWW (Anganwadi Worker): AWW works at AWC as health cum education volunteers (Anganwadi Centre) which is the most peripheral rural unit of the Ministry of Women & Child Development under the scheme of Integrated Child Development Service (ICDS) scheme. The key role of AWW is to provide free nutritional supplementation to the children below 6 years and pregnant/lactating mothers, immunization services, ANC & PNC, referral services health education to the women and non-formal preschool education to children below 5 years. There should be 1 AWW per 1000 population. Today in India, about 2 million aanganwadi workers are reaching out to a population of 70 million women, children and sick people, helping them become and stay healthy.

Traditional Birth Attendant (TBA): They are traditional birth attendants in the villages who assist women to deliver at home. Govt. of India has decided to train theis cadre of community health workers to ensure positive outcome of deliveries conducted at home.

Sub-district/block level health services:  India has 640[1] administrative districts within its 28 states and 7 Union Territories and each district is divided into administrative divisions and divisions into several administrative blocks.

1)      Sub Health Centre or Sub Centre: For 5000 population of the block (5 – 6 villages), there is a sub-centre (SC)[2] which is manned by a Multi Purpose Worker/MPW – female or ANM or Auxiliary Nurse Midwife plus a Multi Purpose Worker/MPW – male. In the public sector, a Sub-health Centre is the most peripheral and first contact point between the primary health care system and the community. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. Of particular importance are the packages of services such as immunization, antenatal, natal and postnatal care, prevention of malnutrition and common childhood diseases, family planning services and counseling. They also provide elementary drugs for minor ailments such as ARI (Acute Respiratory Tract Infection), diarrhea, fever, worm infestation etc. and carryout community needs assessment. Besides the above, the government implements several national health and family welfare programs which again are delivered through these frontline workers like ANM and MPW.

2)      Primary Health Centre (PHC): For every 30,000 – 40,000 population[3] there is one PHC, which acts as a referral point of 4- 5 SCs (30 – 40 villages) and manned by 1-2 Medical Officers and 14/15 para-medical staff like Staff Nurses, Lady Health Visitors, Health Educators, Health Supervisors etc. It has facilities of basic institutional care including delivery with 4 – 6 beds, basic laboratory services and ambulance for referral services. PHCs are the end-point of primary health care.

3)      Community Health Centre or Community Care Centre (CHC/CCC): This is the referral point for 4 PHCs with specialized services, covering a catchment area of 100,000 population (100 villages). The specialized services include emergency medical/surgical/obstetric care, ambulance services for referral, institutional care (30 beds) and laboratory services. CHCs are the starting point of secondary healthcare.

4)      Sub-District/Sub-Divisional hospitals: These are 51 – 100 bedded hospitals to be located in the divisional headquarter of the district.

District health services: Every district is expected to have a district hospital linked with the public hospitals/health centres down below the district such as Sub-district/Sub-divisional hospitals, Community Health Centres, Primary Health Centers and Sub-centres. As per the information available, 609 districts in the country at present are having about 615 district hospitals. However, some of the medical college hospitals or a sub-divisional hospital is found to serve as a district hospital where a district hospital as such (particularly the newly created district has not been established. Few districts have also more than one district hospital. These hospitals are 100 – 200 bedded and generally equipped with specialist health and laboratory services. The District Hospitals are actually the end-point of secondary health care.

Tertiary healthcare: The tertiary healthcare referral points are located above district level namely State Hospitals, Regional Medical Centres, Medical Colleges and National level Medical Institutions.

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[1] http://en.wikipedia.org/wiki/List_of_districts_of_India

[2] In hilly and difficult-to-reach area there is one SC for every 30,000 population

[3] In hilly and difficult-to-reach area there is one PHC for every 20,000 population

An unique hot-spot for commercial sex work

Yesterday I visited a Targeted Intervention Project of FSWs after four long years and got a shock of my life after seeing one of the hot-spots of the project in Delhi.

The place is located in one of the filthiest garbage-dumping areas of Delhi with a canal passing by that carries black turry water mixed with all types of biological wastes of the world. We crossed that area in a complete adventurous mode through the mud and garbage and along the edge of the canal with every chance to slip and fall down into the dirty water of the canal. The hot-spot is located at the back portion of garbage area which is actually a large deserted jungle area with almost no visible human movement inside. The FSWs and clients somehow manage to sneak into that area through the heaps of garbage and mud from late morning till evening.

The FSWs generally carry a large plastic sheet with them. The sheet is spread in the convenient location between the bushes and trees for the sexual act. The only witnesses of their activities are some moving stray dog inside the jungle.

We found thousands of used condoms lying almost in all the places between the trees denoting safe sex practice by the FSWs and their clients. The cops have absolutely no idea about these activities as we were reported, so the women who hail mostly from East Delhi and UP don't have to remain worried for administrative vigilance and legal hassles. But there is chance of snake-bite, as I know jungles of Delhi like this have big poisonous snakes (mostly Cobra). When I asked about it, the women agreed, but thankfully, there is no case of snake-bite till now.

The jungle is equally filled with litter that is often brought by gushing wind from the near-by garbage spot. I just failed to understand how those clients (I saw quite a few of them, moving silently in the jungle, mostly young men in their early twenties. The FSWs looked relatively older, in their mid thirties/early forties) grow desire to have sex inside that filthy place with litter lying all-around. Some of the men, I saw were also boozing in the jungle as if they had a picnic over there.

It was truly a queer experience. I visited many hot spots including dingy lanes of Sonagachi, exotic big brothels of Indonesia, massage parlors/night clubs of Thailand and Bali, chaotic GB Road of Delhi, open field brothel of Durgapur, West Bengal, cruising points of MSWs and street-walkers in various places. But this one that I visited yesterday was unique in the sense that the place is damn difficult to reach, and in true sense, with all due respects to those sex workers and their clients, only animals can do sex in those places, not humans.

I gave a big thank to the outreach worker of the project who is responsible for that particular hot-spot, a girl, doing her graduation, who is tremendously enthusiastic and devoted in her work. She has engaged the FSWs strongly with the project activities. She also ensures condoms that have been supplied uninterruptedly to the FSWs by the project are being properly and adequately utilized by them.

We already saw their extensive usage in the jungle through the used ones scattering almost in every nook and corner of the place.

India is gradually overcoming the challenges of HIV with gradual decline of prevalence in many places of the country. The gallant efforts to confine the HIV transmission within the population of so called ‘high risk groups’ through the Targeted Intervention (TI) approaches under the National AIDS Control Program of the country has been showing the good results now.

Sugata M

TB case notification - a remarkable step of Govt. of India

Notification of TB cases is a remarkable decision of Govt. of India and how RNTCP develops the notification system in the coming years is something very interesting to observe.

Presently TB cases outside RNTCP are being reported mainly from the following two sources:

1)      Non-RNTCP govt/public sectors (Public-Public Partnership initiative):  Those sectors have their own health services like Defense, Railways, Para-Military, Mines, Education etc. Some of these sectors are already reporting TB cases detected by them to RNTCP wherever linkages between these sectors and RNTCP have been developed.

The current policy decision of TB case notification is expected to scale up and strengthen those public-public partnership linkages as TB case notification from non-RNTCP public sector should be comparatively an easier job than the same from non-govt. private sector.

2)      Non-govt. sector (Public-Private Mix/PPM initiative): RNTCP is currently linked to Non-govt. sectors through 3 Global Fund supported projects as below:

·         Project Axshya/GFATM Round 9 Civil Society project: Linking chiefly unqualified rural practitioners with RNTCP in 374 districts of 23 states

·         IMA PPM project/RCC project: Linking the qualified private practitioners who are IMA members with RNTCP in 15 states and 1 UT

·         CBCI-CARD project/RCC project: Linking Catholic healthcare facilities with RNTCP in 19 states

·         Besides, there are NGO/Private Practitioners’ Schemes of RNTCP that have been engaging Private Doctors and NGOs with RNTCP on individual basis.

But these linkages are not enough as the non-govt. and private sectors providing health services to the people of the country including TB management and care are so vast. It is estimated that about 45% of the TB cases are treated in the private sector.

 There is an urgent need to expand the PPM (Public-Private Mix) initiative of RNTCP much beyond the above-mentioned projects and on-going NGO/PP schemes to achieve the two main objectives:

1)      To standardize the TB treatment across the country

2)      To enhance TB case reporting from all healthcare providers

The policy decision of making TB a notifiable disease should help in achieving the two objectives, provided the policy will be rolled out with proper strategy and approach with clear and simple operational protocol in place that will be accepted by all stakeholders and implementable.

The role of Civil Society will be immense to help RNTCP to achieve its notification objectives. Other than advocacy, Civil Societies can function as an effective interphase between the National Program and private sector to enable and roll out the notification process.

Currently, the National Program is still finding ways to sustain the communication with private sectors as mere one/two time sensitization of the private providers has been found to be grossly insufficient to engage them with RNTCP. The private practitioners should be kept under constant communication and followed up, where the Civil Societies can play a meaningful role, definitely with some kind of external funding assistance or incentives.

Prioritization of the private practitioners according to the volume of TB cases been provided services by them should be an important strategy that RNTCP may consider in coming future to initiate the process of notification.

At the same time the national program should take proper attention and care of sensitive issues like maintaining confidentiality of the TB patients including their HIV status during the notification process.

Let me wholeheartedly congratulate Central TB Division and Govt. of India for taking such strategic and timely decision, especially at a time when the national program has taken the decision to achieve the targets of Universal Access of TB care in the country.

From: Dr Sugata Mukhopadhyay