Reaching Them When They Move, Meeting Them When They Hide

Issue: Growing industrialization, increasing mobile men with money, strict administrative vigilance, disintegration of large brothels are pushing sex workers into widely scattered geographic areas including rural areas. Invisible soliciting is popularized through mobile phones, internets, escorts and other legally accepted entertainment services.

Project: Hotel, tourism, entertainment and transportation industries are not sufficiently engaged in current HIV projects. Punitive law against condom-carrying sex workers is hampering the region’s fight against AIDS. Modifying risky behavior of mobile clients is hugely challenging because of absence of appropriate outreach strategies and programs. Opportunities to propagate ‘safe sex’ messages through internet and mobile technology remain untapped. Current advocacy is not yet fully effective to modify the religious sensitivity and socio-cultural intolerance towards sex workers.

Results: Till now, only 20% of sex workers are estimated to have access to basic HIV prevention services in the region. Persistently high STI prevalence and low condom use are still prominent features including alarming increase of HIV transmission among sex workers in certain parts of SE Asia.

Lessons learnt: Strategies to reach indirect, mobile and hidden sex workers and address their issues are not sufficiently established in the current HIV projects of SE Asia, thus a large portion of sex workers are still being missed.

Sugata Mukhopadhyay

 

Challenges Of STI Case Reporting In The Context Of South-East Asia Region

Issue:  South-East Asia is lacking in adequacy and standardization of STI case reporting.

Project: STI services are mostly project based, dependent on funding from different donors with variable donor specific reporting requirements, available in multi-centric facilities like govt. hospitals, NGO run health clinics meant specially for high risk groups, private doctors,  unqualified practitioners & pharmacists, so collecting regular uniform case reporting from those facilities and their centralized compilation to produce standardized and comprehensive country report is extremely challenging. Initiative from national programs to engage private providers in STI management and reporting is in nascent stage. Many STI patients receive treatment at private sectors, thus remains chronically missing in country reports. Stigma, marginalization and criminalization hinder health seeking, mostly with MSM and transgender.

Result: As per global estimate nearly 500,000 curable STIs occur daily in Asia. Inadequacies in case reporting hamper our understanding about exact nature of STI morbidity and evolving pattern of service utilization and safe sex practices, especially among high risk groups, in the region.

Lessons learnt: Selected high volume STI clinics, located at govt. and non-govt. sectors and recognized by national programs can be utilized as STI sentinel sites with adequate resources and technical support to improve and standardize STI case reporting.

Sugata Mukhopadhyay

Protect Our Children From Prostitution, Sexual Abuse And HIV

Issues: Child prostitution is showing dangerously increasing trend in South-East Asia.

Project: Poverty, economic recession, unemployment, migration, human trafficking continuously push children between 11 – 17 years, mostly girls, into sex trade within an environment where increasing need for virgin sex objects and growing fear of contracting HIV through sex with adults creates strong demand for young children in South-East Asia.  Escalating demand for children in porn industries is an important observation. Child labor and sexual abuse are common phenomenon in unorganized job sectors. Voluntary entry to sex trade by ambitious children for easy ‘pocket money’ is also noted.

Results: There are no recognized evidences to know about the extent of HIV problem among children in prostitution but field experiences and media reports strongly suggest increasing frequency of unprotected sexual activities with children, making them extremely vulnerable to HIV and STI transmission as they are much prone to genital/anal injuries during forceful and violent sexual acts by adult partners.

Lessons learnt: Innocence, helplessness, lack of negotiation capability and adventourism of children is being constantly utilized in making hugely profitable business through extreme level of human right violation by a section of sinful people. We, together, must stop them from continuing this dehumanizing act.

Sugata Mukhopadhyay

(This abstract is submitted to the forthcoming ICAAP'10 Conference)

"I am infected by HIV and I am stopping TB"

Issue: It looks like large number of TB/HIV co-infected cases are being continuously missed in the South-East Asia Region due to inadequacies in TB/HIV collaborative operations.

Project: Community DOTS and home based care programs are not sufficiently linked, hampering early TB case detection in PLWHA. PLWHA networks have overall poor TB orientation. Their representation in TB/HIV coordination bodies is limited. HIV C & T of TB cases is insufficient. TB case detection in HIV high risk groups (sex workers, IDUs) is inadequate. Private providers are not adequately sensitized to strategies and programs of TB/HIV collaboration.

Results: In 2009, only 14% of notified TB cases tested for HIV (N=316,000), 13% of tested was HIV infected. 75% and 52% HIV-infected TB patients started CPT and ART respectively. Only 9% of 3.5 million PLWHA of the region (N=310,000) were screened for TB and 5000 PLWHA put on IPT. HIV prevalence in new TB cases in South-East Asia ranges from less than 0 .1% in Bhutan to 17% in Thailand with average regional prevalence 5.7%.  

Lessons learnt: TB/HIV collaboration must actively involve networks of PLWHA, sex workers, MSM/Transgender and IDUs, private providers and Community DOTS program to timely reach and support adequate number of co-infected cases within unified initiative.

Sugata Mukhopadhyay

(This abstract is submitted to ICAAP' 10 on behalf of UNIVERSAL Health)

TB/HIV collaboration at the community level

We wholeheartedly welcome GeneXpert that will make TB diagnosis easier in coming future. But we should not also perceive the current non-availability of GeneXpert as an absolute hindrance to the collaborative program of TB/HIV.

We should remember few points in TB/HIV.

Pulmonary TB is the most common form of TB disease among PLHIV which generally manifest similar clinical features, namely cough, fever, night sweats, coughing out blood and weight loss like an HIV uninfected person. The presentation may sometimes vary with the degree of immune suppression. In PLHIV with mild immune suppression the clinical picture of TB resembles usual adult post-primary pulmonary TB; that is sputum smear is frequently positive for TB bacilli, and the chest X-ray typically may show unilateral or bilateral upper lobe infiltrates, cavitations, pulmonary fibrotic changes and volume loss.

In the advanced form of immune suppression, the clinical picture becomes complex due to involvement of organs other than lungs (extra-pulmonary TB) with disseminated nature of the disease. The clinical picture of pulmonary TB also shows more atypical pattern with sputum smear result showing frequently negative result. Diagnosis, and especially management of TB becomes extremely challenging during this phase.

It is very important to suspect and detect TB among the PLHIV in the early stage when the diagnosis of sputum smear positive pulmonary TB can be easily conducted through sputum smear microscopy available at RNTCP and the affected person can be treated and cured by DOTS strategy without major difficulties.

Efforts to detect TB early should be intensified in all the home based care programs of PLHIV. TB should be suspected on the appearance of any early warning symptoms (a person infected by HIV and with cough of any duration is a TB suspect) like cough, evening rise of temp, night sweats, loss of appetite, loss of weight etc. and the person should immediately report to the local RNTCP services. The HIV infected persons should be thoroughly educated on TB and RNTCP in the home based care programs. They should be continuously motivated to seek the services of RNTCP on the slightest doubt of TB. This is extremely important, especially for those people who generally don’t visit ART centres or other HIV service points either due to relatively ok health or lack of knowledge about those services. It is estimated that about 80% of the PLHIV don’t visit the healthcare outlets and making those clinic absentees aware on TB, TB symptoms and RNTCP services is hugely critical to protect their lives from the menace of TB.

The PLHIV networks at national and state level should take the primary and key steps to reach the HIV infected people located at the peripheries with the necessary TB messages through a strong collaboration with National AIDS Control and TB Control Programs.

Those national and state PLHIV networks should ensure that,

1)   TB screening, referral to RNTCP and awareness generation is regularly happening in the home based care programs of the PLHIV

2)   There is representation from the PLHIV members in the District TB/HIV coordination Committees

3)  The local PLHIV groups are regularly advocating for quality TB/HIV collaboration in the districts

4)      TB patients are regularly reaching ICTC for HIV counseling and testing

5)  TB patients infected by HIV are receiving Co-trimoxazole Prophylactic Therapy and also accessing the services of ART centers

TB transmission through droplet nuclei can be minimized by adopting appropriate measures of airborne infection control like maintaining strict cough etiquette and cough disposal, personal hygiene both at home, healthcare facilities and outside places. The PLHIV networks once again can take key role to sensitize the members of infected communities on airborne infection control and ensure their safety from possible TB transmission. The necessary technical support can be always sought from the National Programs.

TB is preventable and completely curable. Let’s respond to the need of the people living with HIV promptly to make their lives well protected from TB.  I am confident this can be largely achieved with the services we currently have in our National Programs.

The discussions and advocacy activities for GeneExpert can always go side by side.

Sugata Mukhopadhyay

UNIVERSAL Health

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