Jhabua District HIV/AIDS Care and Prevention Program
Jeevan Jyoti Health Service Society (JHSS)
Meghnagar, Jhabua District, Madhya Pradesh
Project Report Submitted by Kristin M. Castillo, 9 June 2008
HIV/AIDS in Madhya Pradesh
In 2006, it was estimated that between 2 million and 3.1 million people were living with HIV in India.[1] Once localized predominantly to the cities, evidence suggests that HIV/AIDS is now spreading to rural communities. HIV-related knowledge is a critical component of prevention, but statistics from the 2005-2006 National Family Health Survey-3 (NFHS-3) show that while about 74 percent of women and 95 percent of men in urban areas have heard of AIDS, those living in rural communities are far less educated about the disease. Only 35 percent of women and 59 percent of men in rural Madhya Pradesh have ever heard of AIDS. Furthermore, in rural areas, far less is known about the protective benefits of condom use. Fewer than half as many women in rural areas versus urban areas (26 percent versus 63 percent) understand that consistent condom use can reduce HIV transmission. The statistics for men show slightly better, though still inadequate, rates of understanding regarding HIV transmission, thus emphasizing the vulnerability of this population to HIV (Figure 1).[2]
Figure 1. The percentage of married adults aged 14 to 49 who have heard of AIDS in 1998-1999 compared to 2005-2006 (NFHS-3). National Family Health Survey-3 (NFHS-3). Deonar, Mumbai, International Institute for Population Sciences, 2005-2006.HIV/AIDS in Jhabua
Jhabua district in the Western-most part of Madhya Pradesh is 91 percent rural, 85 percent tribal, and has among the lowest literacy rates of the country.[3],[4] More than half of its 1.2 million tribal inhabitants live as marginal farmers below the poverty line and periodically migrate to the adjacent states of Gujarat and Maharashtra.[5] In 2002, the HIV prevalence among high-risk groups in Gudjarat was more than five percent. In the same year, Maharashtra was identified as a high-prevalence state, with more than one percent of pregnant women infected with HIV.[6] Many tribal inhabitants from Jhabua work as migrant laborers in these urban areas where they are exposed to a number to risk-factors for HIV, including sexual exploitation and contact with commercial sex workers.
Due in large part to the HIV prevention efforts of organizations throughout the state, the 2006 HIV Sentinel Surveillance data shows that the prevalence of HIV in Madhya Pradesh has remained relatively stable (0.17 in 2002 to 0.11 in 2006).[7] Though state-wide data suggest stability in HIV prevalence, cases of HIV in the Jhabua area seem to be on the rise. At the project’s inception approximately one year ago, Jeevan Jyoti Health Services Society was facilitating care for 54 patients infected with HIV. This number continues to rise, with an average of six new cases being identified each month (Figure 2). Today, the program cares for 86 HIV-positive individuals, 57 of whom are male and 29 of whom are female. Ten of the male and five of the female patients are under age 14 (Figure 3). This increase in HIV cases highlights the critical need for appropriate HIV/AIDS-related programs in Jhabua.
Figure 2. Total number of HIV-positive individuals identified by Jeevan Jyoti Health Services Society from the project’s inception in June 2007 until the July 7, 2008. / Figure 3. Number of HIV-positive individuals in 2008 receiving care from Jeevan Jyoti Health Services Society, broken down by age and sex.Jeevan Jyoti Health Services Society (JJHSS) HIV Care and Prevention Program
History
In early 2006, the existing HIV-related services in Jhabua were vastly inadequate to meet the demand. There was only one operational AIDS cell in Jhabua district, which was staffed by a counselor employed only part-time at the district hospital. The district hospital itself is inaccessible to many of the districts’ residents due to inadequate, time-consuming, and prohibitively expensive transportation costs. To meet the need for HIV/AIDS-related services in Jhabua, Fabian Toegel, a physician from Germany and the Honorary Country Director for India for the Real Medicine Foundation,[8] initiated a program to increase the capacity of the Government's existing voluntary confidential counseling and testing center (VCCTC) in the district headquarters in Jhabua.
Dr. Fabian Toegel recruited the former Government HIV officer, Dr. Rathore, to be the Program Director, and he employed the Government's HIV Counselor, Shashank Nagar, to work part-time for the project. In addition, Dr. Toegel recruited two male counselors with Master of Social Work degrees to work at three strategically located Government clinics in the district. A female counselor was also appointed to perform counseling at the district hospital for female patients and pregnant women.
Today, these testing and counseling services are fully operational and function under the supervision of the Madhya Pradesh AIDS Control Society's (MPSACS) District Nodal Officer in Jhabua. All cases are documented and reported according to rules and regulations of the Government of India and the National AIDS Control Organization (NACO). The local implementing agency is Jeevan Jyoti Health Service Society (JJHSS), which runs a 100-bed mission hospital in the Northern part of the district and handles all monetary transactions for the program. Individuals who are found to be HIV positive, receive full care and treatment at Jeevan Jyoti Hospital under the guidance of Dr. Rathore. Treatment options are currently negotiated with the Government, Non-Governmental Organizations and pharmaceutical companies.
Figure 2. Jeevan Jyoti Hospital, Meghnagar, Jhabua district, Madhya Pradesh. /
Figure 3. Jeevan Jyoti Hospital medical staff.
Components of JJHSS’s HIV Care and Prevention Program
There are currently four major components to JJHSS’s activities in Jhabua district. These include:
· Four voluntary confidential counseling and testing centers
· Facilitating treatment at ART Centers for HIV-positive patients in the community
· HIV prevention, education, counseling, and testing initiatives in villages and at schools
· Capacity building for members of the community
Four Voluntary Confidential Counseling and Testing Centers
1. Jhabua: At the district headquarters, the Jhabua district hospital is a tertiary care facility. It houses the Government’s VCCTC, where Mr. Shashank Nagar, MSW performs counseling and testing. He is joined by Ms. Maya Baria, MSW, who counsels women and expectant mothers. Recently, the Government introduced incentives for pregnant women to deliver at the newly built Mother and Child Wards of the hospital. This program is likely to increase the number of institutional deliveries in an area, where they usually take place at home under the guidance of a traditional birth attendant. Testing pregnant women has an important implication for the infants as timely treatment with anti-retroviral therapy can prevent mother-to-child transmission of HIV.
2. Alirajpur: This town is an administrative headquarter for the Southern part of Jhabua district. The HIV counselor, Mr. Girish Tiwari, MSW works at the Government clinic with the Block Medical Officer, who refers all suspected cases to a counselor.
3. Petlawad: This administrative sub-unit in the North-Eastern part of the district is the site of another VCCTC. Here, HIV counselor Mr. Chandrapal Singh Rathore, MSW works at the Primary Health Center in collaboration with the Petlawad’s Block Medical Officer.
4. Meghnagar: This town halfway between Jhabua and Petlawad is the site of the Jeevan Jyoti Hospital, which has been run by Jeevan Jyoti Health Service Society for over ten years. Jeevan Jyoti Hospital is staffed with a Gynecologist, Surgeon, Anesthesiologist, Pediatrician, Physician, and an Ophthalmologist. The hospital has a blood bank and a laboratory. This is the site where VCT services are offered and patients are cared for and treated if individuals are found to be positive.
Facilitating treatment at ART Centers for HIV-positive patients in the community
Once an individual is found to be HIV-positive, it is imperative that he or she has access to appropriate care and treatment. There are currently three Antiretroviral (ART) Centers in Madhya Pradesh, located in Indore, Jagdalpur, and Bhopal. For many of the patients living in Jhabua district, the cost of traveling to these Centers is prohibitive. Therefore, JJHSS coordinates and facilitates care for these patients by directly providing transportation or by connecting patients with the resources and means necessary to travel to these ART Centers to receive care.
HIV prevention, education, counseling, and testing initiatives in villages and at schools
A survey of 500 tribal villagers conducted in 2004 by the Wockhardt-Harvard Medical International HIV/AIDS Education and Research Foundation (WHARF) showed that only 29 percent of men and 13 percent of women had ever heard of AIDS. Most of the persons interviewed were not aware of how HIV is transmitted, and many thought that kissing, hugging, eating, shaking hands, or being in the same place as an HIV positive individual could facilitate transmission. Since September of 2005, the Jeevan Jyoti Health Service Society has been educating the women of 562 self-help groups in 167 villages across the district regarding HIV. Each of these women then teaches other village members. During the school summer vacation from April through June, education programs and workshops for high school students across the district teach students about adolescent health and HIV.
JJHSS has also initiated voluntary HIV testing services in three villages in Jhabua district. Since June 2007, JJHSS has organized seven “Medical Camps” in rural villages throughout the district in which doctors, nurses, and other health care workers have provided basic health screening to village residents. The HIV Program was in attendance at three of these and provided HIV counseling and testing for approximately 300 individuals.
Capacity building of the members of the community
Once educated or trained regarding HIV, members of the tribal community can teach other community members about HIV. Capacity building also occurs through training counselors periodically. In the past, counselors were trained by the Wockhardt-Harvard Medical International HIV/AIDS Education and Research Foundation (WHARF). Counselors received their first one-week training in Mumbai in September 2005. WHARF faculty Dr. Rachna Bharadwaj and Program Coordinator Rakhi Nair visited the counselors in their workplaces in January of 2006.
Highlights of the JJHSS HIV Care and Prevention Program
During the 13 months of its operation from June 2007 to July 2008, JJHSS has facilitated counseling and testing for between 1,800 and 1,900 people at five government Primary Health Centers in Thandla, Petlawad, Alirajpur, Joburt, Meghnagar. A total of 92 patients have been found to be positive, six of whom have since passed away. Of the 86 HIV-positive individuals who are currently receiving services from JJHSS, 82 have been registered at Government Integrated Counseling and Testing Centers (ICTC) in Madhya Pradesh. The remaining four are currently in another state, and there are plans to register these individuals when they return. The graph below shows the number of cases identified by city, with Jhabua having the highest number of cases at 18 (Figure 4). Forty-eight patients in the JJHSS program are currently receiving antiretroviral therapy (ART): 38 from a Government ART Center in Indore, six from a Government ART Center in Ahmedabad, and four from private sources. Indore is overwhelmingly the ART Center used most by patients in the program (Figure 5).
Figure 4. The number of HIV-positive individuals identified, listed by city of residence, as of July 2008. / Figure 5. The percentage of HIV-positive individuals receiving antiretroviral therapy by place of receipt, as of July 2008.Other noteworthy achievements
· JJHSS connected three pregnant women with HIV care in Indore, thus helping to prevent vertical transmission in all three of the cases.
· JJHSS helped to secure housing for 12 HIV-positive patients who were abandoned by friends and family members because of the stigma associated with HIV/AIDS.
· JJHSS has identified 19 people who are at high-risk of having contracted HIV. These are all individuals whose spouses are HIV-positive but for a variety of reasons do not wish to be tested at this time.[9] Counselors from the program are working with these families to prevent further transmission and to connect the individuals with the appropriate care.
[1] HIV Sentinel Surveillance (HSS) Technical Report: India, HIV Estimates – 2006. National AIDS Control Organisation (NACO), 2006.
[2]2 National Family Health Survey-3 (NFHS-3). Deonar, Mumbai, International Institute for Population Sciences, 2005- 2006.
[3] Jhabua: Statistical Profile. National Informatics Centre, Madhya Pradesh, 2001 Census data. http://jhabua.nic.in/factfile.htm
[4] Annual Status of Education Report (ASER) 2007. Facilitated by Pratham, New Delhi, India, 2007.
[5] Jhabua: Statistical Profile. National Informatics Centre, Madhya Pradesh, 2005. http://jhabua.nic.in/factfile.htm.
[6] HIV Epidemic in India, Maps 2002. UNAIDS India, 2006. http://www.unaids.org.in/.
[7] HIV Sentinel Surveillance (HSS) Technical Report: India, HIV Estimates – 2006. National AIDS Control Organisation (NACO), 2006.
[8] Real Medicine Foundation is a non-governmental organization based out of Los Angeles, California, USA.
[9] Many of these patients do not wish to be tested because they are not experiencing symptoms. People’s knowledge and understanding of HIV testing and care in this area is a subject that has not been rigorously examined but is an area in which much research is needed.