AIDSTAR-One/India provided technical, administrative, and logistical support to the US Government PEPFAR team in the development of their five-year technical assistance model for supporting the India HIV response. This case study series documents programs throughout India that showcase strong practices across the HIV continuum of care.
Bringing HIV Testing and Counseling and Sexually Transmitted Infection Services to Those Most at Risk
In India, most new HIV infections are concentrated in specific groups within the population and in certain areas of the country. To effectively reach most-at-risk populations, including sex workers, people who inject drugs and men-who-have sex with men, the Mumbai-based Avert Society is working with other nongovernmental organizations in five districts of Maharashtra to deliver HIV and STI testing via mobile testing clinics. Although the mobile clinic program is less than a year old, it has shown promising results to date.
Chandrappa arrived at Bagalkot District Hospital unable to fully move his legs. The doctors who examined him quickly discovered he was HIV-positive and on antiretroviral therapy (ART). After studying his medical history, conducting a detailed clinical examination, and discussing the findings among themselves, the doctors ordered an X-ray. The procedure confirmed their suspicions: Chandrappa (not his real name) had developed tuberculosis (TB) of the spine. He immediately began anti-tuberculosis therapy and recovered rapidly. Given the limitations in health care capabilities in remote parts of India, such as this rural area of Karnataka state, chances are that TB of the spine would not have been diagnosed so promptly. But Chandrappa was fortunate that the hospital has integrated TB and HIV services, enabling staff to develop advanced diagnostic skills and offer the best possible treatment and care to patients co-infected with both diseases.
The deadly synergy between HIV and TB is well known. HIV weakens the immune system and makes the body susceptible to such opportunistic infections as TB, while TB infection speeds the progress of HIV-related disease. The higher the number of people living with HIV in a population, the greater the probability that they will contract TB, and the greater the resulting morbidity and mortality, even though TB is a curable disease. In some countries, TB is the greatest killer of people living with HIV.
The attempt to control the HIV epidemic is on exhibit in the city streets of the Aurangabad and Nagpur districts of Maharashtra. Looped red ribbons, symbols of this effort, adorn the walls and lamp posts, publicly expressing the district administration’s commitment to the prevention and control of HIV. Billboards, signposts, and prominent display ads on public transport vehicles are designed to boost public awareness of the virus. But are government commitment and public outreach enough to make a positive impact on public and individual perceptions of HIV, when social stigma and fear turn the detection of vulnerability into a Herculean task?
In these two districts, where HIV prevalence among specific most-at-risk populations is very high, the Avert Project in collaboration with the Government of Maharashtra, funded by the U.S. President’s Emergency Plan for AIDS Relief through the U.S. Agency for International Development, has launched a broad-based and participatory strategy for HIV prevention and management. This strategy, the District Comprehensive Approach (DCA), links available public, private, and community resources to identify and reach those who are most vulnerable to HIV with comprehensive services.
It is a blisteringly hot day in the city of Sangli in Maharashtra, a southern state in India. A group of women and men living with HIV have come together at the Aamhich Aamache Drop-In Center (DIC) to talk. Several women tell harrowing stories of the stigma and discrimination they received at the hands of their family and community. Speaking in a whisper, a man talks of his wife who, after months of such stigma, took her own life, leaving him behind to raise their children.
As time passes, though, the stories move from despair to triumph. Many of the women are involved in income-generating activities which, for the first time in their lives, provide them with economic stability and freedom. Men and women alike describe how addressing their own internalized stigma has allowed them to advocate for themselves with clinic staff, service agencies, and communities, demanding that their rights be honored and they be treated and cared for with dignity and respect. They are able to better navigate a complex system of clinical and social support services, with the assistance of counselors and peer advocates.
The Samastha Project in Karnataka, India
A 10-year-old girl and several field workers are sitting in a room in the village of Kurugodu in the southwestern state of Karnataka, India. The girl looks happy and healthy. However, the small green booklet she carries shows that she is a child living with HIV. She is on antiretroviral therapy (ART) and outreach workers from Vimukthi, a nongovernmental organization (NGO) and partner in the Samastha project, have identified adherence problems. Because she accompanied her mother on a trip to a neighboring district and ran out of medication, the girl has missed her ART drugs for a number of weeks. The outreach workers are talking to her and her guardian to help determine the best way to get her back on treatment and avoid missing ART doses in the future.
Her situation is not unusual: adhering to long-term HIV care and ART is challenging for all people living with HIV (PLHIV). It is especially so for PLHIV in rural villages such as those in Kurugodu, which is about three hours away from the nearest HIV care and ART center. Though the number of ART centers in Karnataka has increased dramatically over the past years, such problems as transport and incomplete information remain obstacles to care for PLHIV, and many are lost to follow-up (LFU) after diagnosis. Those who drop out of care will not receive the care or treatment for which they are eligible. And those who are on ART may have adherence problems or may default, rendering them more likely to transmit HIV or become ill.
Peer outreach workers (PORWs) in coastal Andhra Pradesh, India, say that they’ve become more confident in their HIV outreach work as a result of training in micro-planning,1 part of a range of skills they learned under the U.S. Agency for International Development’s (USAID) Samastha Project. One worker who received the training recalls, “We used to go to the villages not sure as to how to approach clients and what to say to them.” Now, she says, she feels confident that she can help vulnerable clients deal with a wide range of problems—including prevention of parent-to-child transmission, early identification of new infections, and timely registration for antiretroviral treatment (ART) at government-run clinics.
Community-based micro-planning was a critical element of the training that Samastha’s PORWs received to prepare them for their work in community-based care and support. Another PORW explains, “Micro-planning helped us to understand the service delivery systems and how we can maximize [clients’] utilization of services.”
Samastha’s Technical Assistance
A newly qualified physician, Dr. Ramakrishnan (not his real name), the new medical officer of a community care center (CCC) in Gulbarga city in the state of Karnataka, India, attended the Samastha Project’s basic training course on HIV prevention and care in June 2008. During the six-day training, he was found to be rather withdrawn. Several months later, when on-site mentoring for the trainees began at the CCC, the mentor, a senior physician from St. John’s Academy of Health Sciences, Bangalore, felt that Dr. Ramakrishnan’s development as a clinician was impeded by his lack of confidence. He would not attempt to carry out even simple clinical procedures, and his diagnostic and management skills were rudimentary at best. The mentor suggested sending Dr. Ramakrishnan to Snehadaan Learning Site, a comprehensive care and support center for people living with HIV.
Over the course of two weeks at the Learning Site, Dr. Ramakrishnan worked with a more experienced doctor and learned how to provide comprehensive care to sick patients. His confidence blossomed, and he became more proficient in diagnostic and therapeutic procedures. He returned to his CCC with new enthusiasm and confidence, and a greater willingness to learn and apply new knowledge to solve clinical problems. He began discussing clinical problems with his mentor on the phone, rather than requiring on-site visits. The CCC coordinator reported that the care provided to clients had improved greatly (Chatterjee and Washington 2011).