Early TB testing is vital for an effective AIDS response: Government and civil society come together to reinforce this pledge on World TB Day

At the World TB Day press conference, representatives from the Department of AIDS Control, Central TB Division, civil society and affected communities discussed the need for early TB testing for PLHIV.

At the World TB Day press conference, representatives from the Department of AIDS Control, Central TB Division, civil society and affected communities discussed the need for early TB testing for PLHIV.

World TB Day is observed every year on March 24th. To mark this occasion, India HIV/AIDS Alliance today joined the Department of AIDS Control (DAC) and the Central TB Division (CTD) to create awareness about the importance of early detection and treatment of tuberculosis (TB) among people living with HIV (PLHIV) and strengthening HIV/TB collaborative activities at all levels.

In collaboration with DAC and with support from the Global Fund, Alliance India implements Vihaan, a care & support programme for PLHIV in 31 states and territories. The programme works with 17 regional and state level partner organisations and is establishing 350 Care & Support Centres across India that will help expand access to services, increase treatment adherence, reduce stigma and discrimination, and improve the quality of life of PLHIV.

Vihaan is actively working to ensure that its frontline workers are supporting a range of HIV/TB collaborative activities in coordination with the district level TB units. James Robertson, Executive Director of India HIV/AIDS Alliance commented, “Vihaan is committed to increasing awareness of TB among the PLHIV served by the programme and, through intensified testing, ensuring that co-infected clients are fully supported to complete the full course of treatment.”

Tuberculosis (TB) is a major concern for PLHIV as their impaired immune systems make them particularly vulnerable to the disease. In spite of this, it remains difficult to persuade PLHIV to undergo testing for TB. The double stigma of TB and HIV often keeps PLHIV from visiting clinics to learn their TB status.

Manoj Pardesi, General Secretary of the National Coalition of PLHIV in India (NCPI+) said, “PLHIV are among the most vulnerable to falling ill with TB. We need to do more to diagnose PLHIV infected with TB and reach out to them with treatment.”

The total number of PLHIV in India is currently estimated at 21 lakh, which is third highest in the world (Source: Annual Report 2012-13, Department of AIDS Control). India is also has the highest TB burden in the world with an estimated 2.2 million new TB cases occurring annually. TB is the most common Opportunistic Infection (OI) among PLHIV in India.

Dr. R.S. Gupta, Deputy Director General, CTD, said at the event, “Regular screening of all PLHIV for TB is utmost important for prevention of TB mortality in this group.”

HIV and TB co-infection can be fatal. It is estimated that nearly 25% of AIDS deaths in India are TB-related. TB infection increases progression of HIV infection to AIDS and contributes to accelerated mortality. In 2007, it was estimated that 4.85% of TB cases in India are in patients who are also HIV-positive. Of more than 100,000 presumptive TB cases identified among PLHIV at ART Centres, more than 20% were found to have TB (Source: TB India 2011-Annual Status Report).

Dr. A.S. Rathore, Deputy Director General, Care, Support and Treatment at DAC observed, “It is important for PLHIV in India to get tested for tuberculosis. A lack of early testing increases morbidity and mortality in HIV/TB co-infected patients.”

Mona Balani, a woman living with HIV, noted that, “In too many cases, detection of TB happens too late. Many PLHIV patients reach treatment facilities at a terminally-ill stage.”

Early detection of HIV/TB co-infection and prompt provision of Antiretroviral Treatment (ART) and Anti-TB Therapy (ATT) are key interventions to reduce mortality in this population. Increased joint action by government and civil society to initiate early detection of TB among PLHIV is an important step toward addressing the challenge of HIV/TB co-infection and improving the health and wellbeing of PLHIV in India.

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India HIV/AIDS Alliance (Alliance India) is a diverse partnership that brings together committed organisations and communities to support sustained responses to HIV in India. Complementing the Indian national programme, Alliance India works through capacity building, knowledge sharing, technical support and advocacy. Through our network of partners, Alliance India supports the delivery of effective, innovative, community-based HIV programmes to key populations affected by the epidemic.

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World TB Day 2014: New poster campaign to increase awareness among PLHIV of TB co-infection (Hindi version)

FB_TBposters_hindiMarch 24 is World TB Day. Tuberculosis (TB) is a major concern for people living with HIV (PLHIV) as their impaired immune systems make them particularly vulnerable to the disease. Providing the right care & support to PLHIV with TB co-infection remains a priority to reduce related morbidity and mortality.

With support from the Global Fund, our Vihaan programme is launching a national campaign on March 24, World TB Day 2014, to increase TB testing and treatment among vulnerable PLHIV. Under the campaign, Vihaan Care & Support Centres (CSCs) will launch posters and organise TB/HIV co-infection awareness activities for clients across the country. A look at the posters launched today:

Poster: Promoting early testing of TB among PLHIV

Hindi Poster-1

Poster: Encouraging adherence to TB treatment among PLHIV

Hindi Poster-2

Poster: Encouraging completion of DOTS for TB treatment among PLHIV

Hindi Poster-3

World TB Day 2014: New poster campaign to increase awareness among PLHIV of TB co-infection (English version)

FB_TBposters_englishMarch 24 is World TB Day. Tuberculosis (TB) is a major concern for people living with HIV (PLHIV) as their impaired immune systems make them particularly vulnerable to the disease. Providing the right care & support to PLHIV with TB co-infection remains a priority to reduce related morbidity and mortality.

With support from the Global Fund, our Vihaan programme is launching a national campaign on March 24, World TB Day 2014, to increase TB testing and treatment among vulnerable PLHIV. Under the campaign, Vihaan Care & Support Centres (CSCs) will launch posters and organise TB/HIV co-infection awareness activities for clients across the country. A look at the posters launched today:

Poster: Promoting early testing of TB among PLHIV

POSTER-1

Poster: Encouraging adherence to TB treatment among PLHIV

POSTER-2

Poster: Encouraging completion of DOTS for TB treatment among PLHIV

POSTER-3

World TB Day 2014: Increasing PLHIV Access to TB Testing and Treatment in India

India has the highest TB burden in the world, and it is estimated that nearly 25% of AIDS deaths in India are TB-related. (Photo of Mycobacterium tuberculosis bacteria, courtesy of CDC/Dr Ray Butler/Janice Haney Carr)

India has the highest TB burden in the world, and it is estimated that nearly 25% of AIDS deaths in India are TB-related. (Photo of Mycobacterium tuberculosis bacteria, courtesy of CDC/Dr Ray Butler/Janice Haney Carr)

Tuberculosis (TB) is a major concern for people living with HIV (PLHIV) as their impaired immune systems make them particularly vulnerable to the disease. In spite of this, it remains difficult to persuade PLHIV to undergo testing for TB. The double stigma of TB and HIV often keeps PLHIV from visiting clinics to learn their TB status. Unfriendly attitudes of clinical staff only makes things worse.

Take the case of Shanti (name changed), a PLHIV from East Godavari district in Andhra Pradesh. She was found bedridden by an outreach worker (ORW) from our Vihaan programme during a routine visit. Shanti’s son explained that she had rapidly lost weight in the previous weeks and was coughing continuously. The ORW noted some other symptoms possibly indicating TB and suggested that Shanti get a TB test. She refused as during earlier visits clinic staff had not treated her well due to her positive status. She remembered how they had made her rush from one department to other for a simple test.

After much persuasion by the ORW and assurance that she will be treated respectfully, Shanti agreed to visit the district medical centre. She was found TB-positive and was immediately put on Directly Observed Treatment, Short-Course (DOTS). Shanti is now three months into her treatment course. She has regained weight and is on her way back to good health.

Shanti’s experience is all too familiar. India has the highest TB burden in the world, with an estimated 2.2 million new TB cases occurring annually. It is estimated that nearly 25% of AIDS deaths in India are TB-related. In most cases, detection of TB happen too late. Many patients reach the hospital at a terminally-ill stage. Managing side-effects and complications of anti-TB treatment (ATT) and anti-retroviral treatment (ART) is another major challenge for co-infected patients. Ensuring adherence to both treatment regimens remains an uphill task. It has been observed that when some clients show improvements within four to six months, they stop taking their ATT, believing they are fine. But incomplete treatment can lead to further complications, including multi-drug-resistant (MDR) TB.

Providing the right care & support to PLHIV with TB co-infection remains a priority to reduce related morbidity and mortality. With support from the Global Fund, our Vihaan programme is launching a national campaign on March 24, World TB Day 2014, to increase TB testing and treatment among vulnerable PLHIV. Under the campaign, Vihaan Care & Support Centres (CSCs) will launch a poster campaign and organise TB/HIV co-infection awareness activities for clients across the country. The CSCs will also hold special sensitisation workshops for stakeholders on the need for friendly and responsive services for co-infected patients.

Over the course of the following month, CSCs will hold support group meetings (SGMs) on TB/HIV co-infection. District TB Officers (DTOs) will be engaged to train CSC staff across India on TB/HIV co-infection, the importance of early detection, verbal screening and TB care. Wherever feasible, DTOs and other medical officers will be called to facilitate discussion in these SGMs. Since more than 50% of staff at CSCs are from the PLHIV community, staff members will also be encouraged to go for TB screening to set an example to fellow community members.

In solidarity with World TB Day, Vihaan is committed to increasing awareness of TB among the PLHIV served by the programme and, through intensified testing, ensuring that co-infected clients are fully supported to complete DOTS. As our campaign posters say, TB can be cured! Access to TB care is a basic human right, and Vihaan will do all we can to ensure that PLHIV in India have full access to TB testing and treatment!

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The author of this post, Mona Balani, is Programme Officer: Vihaan at India HIV/AIDS Alliance in New Delhi.

With support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Vihaan is establishing 350 Care & Support Centres across India that will help expand access to services, increase treatment adherence, reduce stigma and discrimination, and improve the quality of life of PLHIV. The centres will support PLHIV, including those from underserved and marginalized populations who have had difficulty in accessing treatment including women, children and high-risk groups in 31 states and territories.

Advocating for Stigma-free Healthcare for Female Sex Workers

Advocacy coalitions under Koshish have successfully engaged with stakeholders to identify sexual and reproductive health needs of vulnerable populations like female sex workers. (Photo by Peter Caton for India HIV/AIDS Alliance)

Advocacy coalitions under Koshish have successfully engaged with stakeholders to identify sexual and reproductive health needs of vulnerable populations like female sex workers. (Photo by Peter Caton for India HIV/AIDS Alliance)

While conducting community consultations in East Godavari district of Andhra Pradesh, the Koshish programme team learned that female sex workers (FSWs) in the district faced numerous challenges in accessing healthcare services, including stigmatizing behaviour, discrimination, and apathy of service providers. A majority of FSWs who spoke at the consultations mentioned that counsellors at the Integrated Counselling and Testing Centre (ICTC) at the government hospital at Kakinada were highly insensitive and asked unnecessary questions while providing them services.

The advocacy coalitions set up under Koshish took note of the matter and decided to collect evidence from the community and flag the issue to relevant authorities. The team documented experiences of 50 community members and approached the Additional District Medical & Health Officer for redressal. After the initial briefing on the project and its activities, the community members shared their concerns. They narrated how clients were asked irrelevant questions by the counsellors and faced deliberate delays in testing and reports.

Appreciating the difficulties faced by FSWs, the official instructed his office to issue a circular to all ICTCs to remind them of their obligation to provide client-friendly services and not delay sample collection deliberately. He also facilitated the provision of other social security schemes and entitlements to these community members like Aadhar cards, Antyodaya cards, caste certificates and even voter registration. Later, the officer organized a review meeting with all counsellors in the district and invited Koshish partners. In the meeting, the official emphasized to the counsellors, “Key populations are to be given priority in availing health services.”

Supported by the European Union, Alliance India’s Koshish programme advocates for policies and strategies on sexual and reproductive health (SRH) and rights for people living with HIV (PLHIV) including key populations in India. The programme is implemented in Maharashtra, Tamil Nadu, Andhra Pradesh and Gujarat. The advocacy coalitions under Koshish have successfully engaged with stakeholders and identified unfulfilled SRH needs of PLHIV. With these coalitions in place, Koshish makes sure that voices of communities affected by HIV/AIDS are heard by decision makers and the problems they face every day remain at the heart of the programme’s state-level advocacy agenda.

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India HIV/AIDS Alliance works closely with PLHIV in India through its Koshish programme which strengthens civil society organizations and networks that represent and work with PLHIV and other marginalized groups, such as MSM, transgenders, sex workers and IDUs, to effectively advocate for policies to improve the sexual and reproductive health and rights of PLHIV in India. This project is funded by the European Commission and is implemented in partnership with MAMTA, PWDS, VMM and CHETNA, along with state-level networks for PLHIV in Maharashtra, Tamil Nadu, Andhra Pradesh and Gujarat.

‘207 against 377’: A Step Towards Reclaiming Our Rights

The national Pehchan consultation on Section 377 was attended by more than 100 community stakeholders and activists, including prominent transgender leader Lakshmi Narayan Tripathi. (Photo by India HIV/AIDS Alliance)

The national Pehchan consultation on Section 377 was attended by more than 100 community stakeholders and activists, including prominent transgender leader Lakshmi Narayan Tripathi. (Photo by India HIV/AIDS Alliance)

December 11th, 2013 was a black day in the history of India’s human rights movement. On this day, the Supreme Court of India set aside the historic judgment of Delhi High Court in 2009 and, by affirming the constitutionality of Section 377 of the Indian Penal Code, recriminalized same-sex sexual behavior. The judgment, best described as ‘regressive’ and ‘derogatory’, noted that lesbian, gay, bisexual and transgender (LGBT) people are a ‘miniscule minority’ and our rights are ‘so-called’.

The Constitution of India guarantees a life of equality and dignity to every citizen, irrespective of caste, creed, religion and sex, but the Supreme Court lost the opportunity to protect the rights of sexual and gender minorities. The denial has made India’s LGBT community yet more vulnerable to stigma, harassment and violence. The court dealt another blow to the community in early 2014 when it also rejected all petitions to review the judgment.

The judgment was a huge setback to a marginalized and often hidden community that was beginning to come out of the closet after the 2009 decision, but the spirit to fight back and reclaim our rights is now even stronger. There has been a concerted effort by a range of civil society organisations, such as Voices Against 377, Lawyers Collective and Naz Foundation (India) among others, to make sure that this community momentum leads toward a coherent movement that will in time overturn the Supreme Court’s backward judgment.

The Global Fund-supported Pehchan programme is joining the challenge. Pehchan works with MSM, transgender and hijra (MTH) communities on issues of HIV and health in 17 states of India through consortium partners including India HIV/AIDS Alliance, Humsafar Trust, SAATHII, Sangama, SIAAP, Pehchan North Region Office (PNRO) and Alliance India Andhra Pradesh. In collaboration with the 200 community-based organisation supported under Pehchan, these 207 partners leveraged their collective passion and determination and launched the 207 against 377’ campaign.

Through the campaign, partner organisations will reach out to various stakeholders including political parties, religious leaders, media and educational institutions to sensitise them on the challenges facing LGBT communities. The campaign will contribute to the public discourse on Section 377 and will highlight how the law undermines the fundamental rights of LGBT people in India. The campaign will influence general attitudes and government policies so as to protect the wellbeing and dignity of LGBT Indians.

To initiate this national effort, Pehchan organized a daylong national consultation on February 6th that was attended by LGBT community members and leaders from across India including Ashok Row Kavi, Lakshmi Narayan Tripathi and Manohar Elavarthi. Speakers emphasized the importance of political engagement and the involvement of religious leaders. It was agreed that there is a need for a clear strategic plan of action against the Supreme Court judgment.

During the consultation, community members voiced their concerns about Section 377. Arvind Narain from the Alternative Law Forum provided a legal overview of the judgment and Anand Grover from Lawyers Collective discussed the next legal steps. The consultation generated an active dialogue and generated multiple ideas to build advocacy momentum. As next steps, the consultation identified priority actions to move advocacy forward:

  • Documentation of cases of stigma, discrimination and violence faced by the LGBT community;
  • Sensitization of judges at district, state and national level;
  • Dialogue with religious leaders and political parties;
  • Engagement of the media to highlight the challenges caused by the judgment;
  • Regular rallies; and
  • Linking activities to other rights movements in India.

The ‘207 against 377’ campaign will also organize 17 state-level consultations – one in each Pehchan state – on Section 377 and 200 district-level consultations through Pehchan CBOs.

This is just the beginning. The national campaign will reach out to the LGBT community and stakeholders at all levels. We will keep you updated on progress.

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The author of this post, Yadavendra Singh, is Advocacy Manager at India HIV/AIDS Alliance in New Delhi.

With support from the Global FundPehchan builds the capacity of 200 community-based organisations (CBOs) for men who have sex with men (MSM), transgenders and hijras in 17 states in India to be more effective partners in the government’s HIV prevention programme. By supporting the development of strong CBOs, Pehchan will address some of the capacity gaps that have often prevented CBOs from receiving government funding for much-needed HIV programming. Named Pehchan which in Hindi means ‘identity’, ‘recognition’ or ‘acknowledgement,’ this programme is implemented by India HIV/AIDS Alliance in consortium with Humsafar Trust, PNRO,  SAATHIISangama, and SIAAP and will reach 453,750 MSM, transgenders and hijras by 2015. It is the Global Fund’s largest single-country grant to date focused on the HIV response for vulnerable sexual minorities.

International Women’s Day 2014: Managing Cervical Cancer in Women Living with HIV in India

Women living with HIV are five-times more susceptible to cervical cancer than other women. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

Women living with HIV are five-times more susceptible to cervical cancer than other women. (Photo by Prashant Panjiar for India HIV/AIDS Alliance)

Cervical cancer is the most common cancer among women in India, and the leading cause of cancer-related mortality. Women living with HIV (WLHIV) are at a higher risk of developing cervical cancer than women in the general population. Most significant reason for this is the high prevalence of persistent human papillomavirus (HPV) infection, which is known to be the causal agent for most cases of cancer of the cervix.

HPV has been found in over 99% of cases of invasive cervical cancer (Sankaranarayanan 2008) and like HIV, is sexually transmitted. The virus has more than 100 subtypes and it is estimated that more than 50% of the sexually active population globally is infected with one or more subtypes of genital HPV; however, the infection resolves by itself in most cases. Only a few high-risk subtypes (mostly subtype 16 and 18) can trigger abnormal growth in infected cells and lead to development of cervical cancer. HIV, smoking, multiple births, early initiation of sex and long-term use of hormonal contraceptives are other co-factors that increase the risk of progression from cervical HPV infection to invasive cancer.

A weakened immune system due to HIV puts WLHIV at a higher risk of HPV infection. There is evidence that WLHIV have a higher incidence of HPV infection, especially with cancer-inducing subtypes. They also have a higher viral load of HPV; and HPV infection progresses more rapidly to cancer in these women. Worldwide, infection with HPV among WLHIV varies between 55 to 30% (Clifford 2006). A recent study in 103 HIV positive women in North India (Pundhir 2014) reported co-infection with HPV in 24% cases and 10% of the population had cervical dysplasia (pre-cancerous lesions). In another study in Mumbai (Isaakidis 2013), HPV DNA was detected in 32% of the WLHIV studied.

With decreasing CD4 counts, the prevalence of HPV infection increases, the infection is more persistent and progresses rapidly. There is up to a 10-fold risk of having an abnormal pap smear among HIV-infected women than uninfected women, with a higher risk of these lesions progressing to invasive carcinoma. In a cross-sectional survey of 786 WLHIV conducted by Koshish, a  programme implemented by India HIV/AIDS Alliance to improve the sexual and reproductive health of PLHIV and most-at-risk populations, 5.6% had abnormal pap smear.

Globally, it is estimated that 500,000 women are diagnosed with cancer of cervix every year and 275,000 women die, with India contributing over a quarter of these deaths. This is particularly unfortunate as cervical cancer is preventable and curable if detected early. The development of cervical cancer takes about 12-15 years from the time of HPV infection. During this period, the abnormal cervical cells pass through several precancerous stages offering multiple opportunities for early detection.

With more than a million women living with HIV in India, who now have increased longevity due to improved access to anti-retroviral treatment (ART), more WLHIV are likely to develop cervical cancer. ART does not appear to have much impact on reducing progression of cervical dysplasia. Yet despite the fact that the country is facing a dual epidemic that is having a significant impact on the lives and health of women, India still does not have an organized screening programme for detection of cervical cancer. Lack of awareness among women, social power structures, lack of control of women over family resources, cultural taboos and silence over reproductive health issues make the situation worse.

Pap smear is the conventional screening method and has been successfully used in developed countries to screen women for cervical cancer, resulting in decreased incidence of the cancer in these countries. The test, though simple, requires trained cytology technicians and pathologists and good health infrastructure, and it is not widely available in India. Even in the places where the test is available, uptake of the test remains low because of low awareness, high associated cost, and multiple visits required to the health facility, since the test is not a point-of-care test. Moreover, the conventional Pap test is associated with high sampling and interpretation errors, leading to false negative results in 10-25% cases; and 30% of these false negative cases have been found to develop cancer cervix every year (Shingleton H, 1995).

Alternative screening approaches to pap smear, such as visual inspection with acetic acid (VIA) or Lugol’s Iodine (VILI) and HPV-DNA studies, have recently been considered for use in low-resource countries including India (Sankaranarayanan 2007, Isaakidis 2013). These studies have shown that VIA is more sensitive and the results become available immediately, allowing for the lesions to be treated during the same visit.  Recently, the Government of Tamil Nadu has introduced VIA testing in primary healthcare centres (PHCs) and has plans to scale-up to the entire state. Other low-cost rapid tests have been developed but not yet commercially available.

A higher prevalence of cervical cancer and an improved life expectancy of WLHIV with increased access to ART make a compelling case for initiating a well-organized regular screening programme. The American College of Gynecologists (ACOG) recommends cervical screening of HIV-positive women twice: a) once during the first year after HIV diagnosis and b) annual screening thereafter. Apart from introducing the screening at PHCs, there is an opportunity to integrate cervical cancer screening at India’s Integrated Counselling & Testing Centres, ART Centers and the STI clinics that support Targeted Interventions for HIV prevention among high risk groups, such as female sex workers. A network of these clinics is already established in all districts with high HIV prevalence; expanded services to WLHIV and most-at-risk populations that includes cervical screening and related services will help increase utilization of these clinics and improve health outcomes.

Finally, primary prevention of HPV will go a long way in reducing cervical cancer. Correct and consistent use of condoms is known to have reduced genital HPV infections, genital warts and cervical cancers. Recently, two vaccines, one quadrivalent (against subtypes 16, 18, 6 and 11) and one bivalent (against subtypes 16 and 18) have been developed that provide more than 95% protection against HPV. Suitable for both females and males, these vaccines are effective only if given before infection with these subtypes of HPV. The efficacy and safety of vaccine among HIV-positive women requires more research.

Echoing this year’s theme for International Women’s Day, equality for women living with HIV is progress for all. Increased investment in the overall health needs of WLHIV, including their sexual and reproductive health needs beyond HIV, will pay dividends for these women, their families and for society more broadly.

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The author of this post, Saroj Tucker, is a medical doctor working in the field of HIV and SRH for the last 12 years.

With support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Vihaan is establishing 350 Care & Support Centres across India that will help expand access to services, increase treatment adherence, reduce stigma and discrimination, and improve the quality of life of PLHIV. The centres will support PLHIV, including those from underserved and marginalized populations who have had difficulty in accessing treatment including women, children and high-risk groups in 31 states and territories.

With funding from the European Union, our Koshish programme strengthens civil society organizations and networks that work with PLHIV and other marginalized groups, such as men who have sex with men, transgenders, sex workers and people who inject drugs, to effectively advocate for policies to improve the sexual and reproductive health and rights of PLHIV in India. This programme is implemented in partnership with MAMTA, PWDS, VMM and CHETNA, along with state-level networks for PLHIV in Maharashtra, Tamil Nadu, Andhra Pradesh and Gujarat.