World AIDS Orphan Day,

Article of Amit Dwivedi in Swatantra Bharat on World AIDS Orphan Day, May 7 2006


भारत ६ मई, २००७

चाहत एक सामान्य जीवन जीने की

HIV TEST-The bigger picture

Deccan Herald
Bangalore, Karnataka
3 May 2007

HIV TEST
The bigger picture

By Bobby Ramakant

[The test must be part of a comprehensive rehabilitation strategy].

Karnataka has proposed mandatory HIV test for couples. Another state Andhra Pradesh favoured mandatory HIV test before marriage. Goa too proposed the testing ‘by law’ in April 2006. But will this mandatory test alone check new HIV infections? Public health experts disagree. "We need to create an awareness about HIV, and the stigma associated with HIV, especially the stigma within healthcare which keeps people away from accessing these services (which often help to extend one’s life and contribute towards prevention of the disease), strengthen primary healthcare services and enhance sensitivity to issues of confidentiality and the dignity of life of those living with HIV," said health rights' advocate Jashodhara Dasgupta of Sahayog.

We have not been thinking of prevention/treatment in its entirety. States are seen to be promoting HIV prevention strategies completely ignoring the treatment, care and support provisions for people living with HIV.

Andhra Pradesh Chief Minister Y S Rajasekhar Reddy said last month: "I fail to understand the reasons behind the objections raised by some human rights activists on the government's initiative for making HIV/AIDS tests mandatory for couples before marriage."

What human rights' advocates would like to tell Dr Reddy is that the impact of HIV positive diagnosis on an individual's life is enormous. The combination of stigma, discrimination and denial associated with HIV, thwarts an individual's life in a myriad ways. What are the plans for people who test HIV positive? Will they have to face life without even access to primary healthcare services? In violation of NACO's (National AIDS Control Organisation) confidentiality guidelines, the HIV positive status becomes public knowledge in communities of the would-be bride and groom. Are we prepared to meet the healthcare needs of people who test positive, and ensure that they will not be forced to lead a life adversely hit by HIV-associated stigmas, discrimination and denial?

A United Nation's Programme official has said that Karnataka should think about the issue again as mandatory HIV testing will prove to be counter-productive. It not only violates privacy but also affects the entire family with a stigma tag, and 'tends to create a blackmarket in false HIV test results'.

Senior Advocate Colin Gonzalves said that "any mandatory testing is wrong. Couples should rather be counselled and educated. If they want to get a testing done by choice after that, it's their business. But a mandatory test can't be imposed on them".

NACO guidelines say that "testing for HIV is more than merely biological for it involves ethical, human and legal dimensions. The government feels that there is no public health rationale for mandatory testing of a person for HIV/AIDS. On the other hand, such an approach can be counter productive as it may scare a large number of suspected cases from being detected." The HIV test alone will not result in behavioural changes. It should be a part of a comprehensive control programme which helps in the individual’s behaviour.

Providing social support, means and skills to reduce or eliminate risk behaviour. NACO official further adds that "Otherwise such testing can drive the target people underground and make it more difficult for launching intervention." As access to antiretroviral treatment is scaled up, there is a critical opportunity to simultaneously expand access to HIV prevention, which continues to be the mainstay of the response to the HIV epidemic. Without effective HIV prevention, there will be an ever increasing number of people who will require HIV treatment. Among the interventions which play a pivotal role both in treatment and in prevention, HIV testing and counselling stands out as paramount. The current reach of HIV testing services remains poor. The reality is that stigma and discrimination continue to stop people from having an HIV test. To address this, the cornerstones of HIV testing scale-up must include improved protection from stigma and discrimination especially within healthcare settings, as well as assured access to integrated prevention, treatment and care services. Just earlier this month, a pregnant woman with HIV died after being denied medical attention in Indore . Undoubtedly public health strategies and human rights promotion are mutually reinforcing. It is clear that India has a long way to go before we have a public health system strong enough to deliver effective healthcare to most underserved communities. And mandatory HIV testing alone is certainly not the short-cut.

(The author is a senior health and development journalist writing for newspapers in Asia, Middle East and Africa

online available at - http://www.deccanherald.com/deccanherald/may32007/panorama21333200752.asp

‘Multiplex Mobile Medical Units’: Responding to diverse HIV healthcare needs

‘Multiplex Mobile Medical Units’: Responding to diverse HIV healthcare needs

Bobby Ramakant from Ahmedabad (Gujarat)


[E.X.C.E.R.P.T.S... Healthcare needs of underserved communities are diverse and manifold. With HIV pandemic ravaging through India, and appalling healthcare systems, the need is compelling to integrate different tenets of healthcare services to make effective comprehensive HIV prevention, treatment, care and support a reality. Bobby Ramakant writes on such a model intervention which brings together different healthcare services under one ‘Multiplex Mobile Medical Unit’ moving through Gujarat villages in India] .


Gujarat AIDS Prevention Unit (GAP) collaborated with The Brooklyn Hospital Center, USA and American Indian Association (AIA) to respond to these needs by coming up with a Multiplex Mobile Medical Unit, which is reasonably well-equipped bringing together medical, nursing, psychosocial counselling and pastoral care services for thousands of people from underserved communities in rural Gujarat (many of them living with HIV). The Brooklyn Hospital Center (USA) has sent a team of senior medical experts as well.

HIV gradually subdues the immune system of people living with the virus so that opportunistic infections (OIs) such as candidiasis, meningitis and tuberculosis can then exploit the body’s weakened defences. People living in poorer parts of India often have no access to clean water and sanitation, have bad nutrition and already weak health status, and are constantly challenged by a variety of infectious diseases. These factors place them at greater risk of HIV-associated OIs and are believed to significantly shorten the interval between initial HIV infection and the onset of AIDS-related conditions. As a result, HIV/AIDS is often called the ‘quintessential disease of poverty’.

Stigma associated with HIV prevailing in communities is enormous and has impeded the AIDS response of India considerably, said Dr Radium Bhattacharya, President of Indian Network of NGOs on HIV/AIDS (INN) and Chairperson of Gujarat AIDS Prevention Unit (GAP).

People with high-risk lifestyles or those living with HIV have to confront huge levels of stigma at every step – even within the healthcare settings. This makes it all the more difficult for them to have access to existing health services including HIV testing, detection of sexually transmitted infections (STI), STI treatment, regular screenings for opportunistic infections (OIs) and treatments (especially TB which continues to be the largest killer of people living with HIV despite of the fact that TB treatment is available free of cost and TB is curable!), nutritional counseling and food security, and not-to-forget other specialized medical care including antenatal care, paediatric care, and general medicine as well.

Quality counseling of people (with or without HIV) is very important. Most of the people with high risk behaviours in their lives have been craving for compassion and deprived of access to information and services as well. It is vital for counselors to establish a rapport with individuals before trying to redress their problems. Nothing is more therapeutic than compassionate shoulder, says Dr Radium.

Multiplex mobile medical unit is a response to the needs of the community in rural areas. The challenge was to provide high-quality medical care, which is free of cost (affordable), within the reach of people in their own communities (mobile clinics are accessible) and provide for an array of services from counseling, testing, medical care and provision of medicines as well. All the staff working in these mobile clinics demonstrated high sensitivity to issues around HIV, and people living with HIV have themselves taken leadership in putting up the camp as well.

India at least has more than 5 million people living with HIV. The incidence of HIV in rural India is rising. With gravely inadequate healthcare system to fall back upon, it is critically important to bolster our public education and health literacy programmes in rural India, said Dr Radium Bhattacharya, who also volunteers for AIDS CARE WATCH global campaign (www.aidscarewatch.org).

With inadequate treatment programmes especially those of anti-retroviral (ARV) therapy, the number of people requiring 2nd line drugs is alarming. GAP is providing 2nd line ARV therapy to 5 patients who had developed resistance against 1st line ARV therapy earlier.

Jogender Upadhyay, a force behind community mobilization at GAP, said that Multiplex Mobile Medical Unit is a resultant of a survey on the needs of medical services carried out in the last 3 years in 20 villages of Prantij Taluka in Sabarkantha district (Gujarat). Total population of these three villages is around 60,000. These mobile medical units are providing family health counseling, reproductive and sexual health counseling, free condom demonstration and distribution, pre-test voluntary counseling, check up for opportunistic infections, sexually transmitted infections and reproductive tract infections and appropriate treatment, nutritional support, TB counseling, drug adherence counseling and treatment literacy, gender and foeticide awareness by multiple ways including poster exhibitions, street plays, games and inter-personal communication with the expert counselors.

There are some simple approaches to keep people with HIV alive. Many of them are already readily available, affordable and effective:

- Voluntary counselling and testing for HIV as the entry point for access to all health care services and self management
- Prevention and treatment of tuberculosis (TB) in people living with HIV
- Drugs to treat/prevent other opportunistic infections (e.g., cotrimoxazole, fluconazole etc)
- Home- and community-based care approaches
- Tackling HIV-related stigma, especially in health care settings, which often keeps people away from health services
- Pharmacotherapy (e.g., methadone) for recovering injection drug users
- Traditional healing and treatment approaches
- Promoting food security and micronutrient provision.

People living with HIV often become entry points to communities in the provision of integrated AIDS-related services. This initiative is also effective in community education and delivery of a broad range of AIDS care services at the doorstep of the people in rural India. Community members are glad that quality healthcare services have been brought home for them.
‘HIV is not a death sentence’ said a person living with HIV who came to this mobile medical unit. He firmly believes that AIDS-related conditions can be prevented and treated with established forms of care, support and treatment.

Such initiatives bring hope to people living with HIV. With 70% of Indian population in rural areas, the massive challenge is to make such interventions sustainable and replicable across the country.

Bobby Ramakant

(The author is a health and development journalist writing for newspapers in Asia, Middle East and Africa. He is a Key Correspondent to HDN (www.TheCorrespondent.org). He can be contacted at: bobbyramakant@yahoo.com)

Amit Dwivedi's JANSATTA Editorial article on STAYING ALIVE WITH HIV

अमित द्विवेदी का जनसत्ता का लेख

एचआईवी के साथ जिंदगी

Another Death of pregnant woman with HIV is Alarming

Online at: http://www.theseoultimes.com/ST/db/read.php?idx=5099




Another Death of pregnant woman with HIV is Alarming
Saturday 7 April 2007
The Seoul Times
South Korea

It is not only shocking that alarming levels of HIV associated stigma and discrimination runs high in MP but also that despite of repeated alerts sounded on rising maternal mortality in the state, nothing much has improved.

By Bobby Ramakant

On World Health Day 7 April 2007: A 30-year-old pregnant woman who was living with HIV died outside the hospital building in Indore (Madhya Pradesh state (MP), India) after the government healthcare staff denied to provide adequate medical care and hospital admission.
It is not only shocking that alarming levels of HIV associated stigma and discrimination runs high in MP but also that despite of repeated alerts sounded on rising maternal mortality in the state, nothing much has improved.

Madhya Pradesh figures among the list of those Indian states where maternal mortality is high, particularly in rural areas, where the healthcare system is virtually non-existent and awareness on the subject among the people extremely low.

According to UNICEF, Madhya Pradesh along with Assam and Uttar Pradesh, has a high Maternal Mortality Rate (MMR) of 700 or more per 100,000 live births as against the national figure of 407 per 100,000 live births as per the 2001 Census figures. However, regional disparities in maternal mortality are wide with the death ratio being low in Kerala, Tamil Nadu and Punjab and extremely high in most northern states in India.

President of Madhya Pradesh Network of People living with HIV (MPNP+) Manoj Verma said that on 3 April 2007, a 30-year-old pregnant woman who was living with HIV, died outside MY Hospital after the government healthcare staff refused to admit the patient. She was referred from Bhuranpur, Nehru Hospital, village Gambhirpura on 31 March 2007.

After the preliminary examination, she was referred and was taken to the ward for admission. But when the doctors came to know of her HIV positive status, they intentionally discharged the patient despite of the fact that she was in labor pains. But the doctors blatantly refused to admit her. While the patient came from the fifth floor of the hospital and reached the compound, she delivered the baby girl near the water tank of the MY Hospital. The relatives again tried to approach the healthcare staff to re-admit her but the security guards refused their entry into the hospital building.

As her condition was critical on 2 April 2007 she was brought to the MY Hospital at 9.30 am and fortunately got hospital admission, but was not fortunate enough to get proper medical attention. On 3 April 2007, her condition worsened, with no doctors to attend to her and she succumbed owing to severe medical negligence during and after child birth. She belonged to 'Banjaran' backward class and had five children.

MPNP+ President Manoj called the collector of Indore who asked him to register an FIR (first Information Report) at the nearest police station. However the nearest Sayogitha Gunj police station refused to lodge an FIR.

"I am shocked to hear of the blatant discrimination against a pregnant HIV+ woman in the hospital in Indore. This is even more so because right now there is a huge campaign by UNICEF and others to work on maternal health issues in MP" said India's noted women's health rights activist Jashodhara Dasgupta of SAHAYOG (www.sahayogindia.org).

Many reports reveal the extent to which people are stigmatised and discriminated against by health care systems in India. Many studies reveal the reality of withheld treatment, non-attendance of hospital staff to patients, HIV testing without consent, lack of confidentiality and denial of hospital facilities and medicines.

Fear of discrimination often prevents people living with HIV from seeking existing healthcare services. Perhaps the most conspicuous context for HIV/AIDS-related discrimination, stigmatization, and denial is the health care sector in India, whether public or private. Many infected people trace some of their AIDS-related fear, anxiety, and denial to their traumatic experiences in health care settings.

Health activists in India stress on the dire need to frame strategies to address women's health care, including HIV vulnerabilities, in the context of rights. The issues they seek to resolve include confidentiality, partner notification, and free and informed consent — all difficult issues for women who risk violence and neglect if their HIV status is disclosed. Without increasing gender sensitivity among health planners, healthcare workers, policymakers, judiciary, and other stakeholders, the high rates of maternal mortality fuelled with HIV associated stigma are unlikely to come down.

Bobby Ramakant, author is a senior health and development journalist, writing for newspapers in Asia and Africa.