CNS: 2013

Beginning of a novel experiment in politics

Dr Sandeep Pandey, Magsaysay Awardee and CNS Columnist

With the formation of Aam Aadmi Party government in Delhi the country is going to witness a novel experiment in politics. The first target has been the VIP culture. Arvind Kejriwal has refused to accept security, beacon fitted vehicle and a government bunglow not only for himself but all his ministers. In a country where most people become politician to avail of all these facilities it is going to be a trend setting decision. In fact, the facilities given to people’s representatives and bureaucrats should be drastically cut down. This is an unnecessary wastage and burden on the tax payer.

Hom L. Shrestha - CNS
The World Health Organization (WHO) and its allies are taking a bold step to challenge Big Tobacco’s bullying and ‘intimidation by litigation’ by exposing the undue influences of Tobacco Industry (TI) and are responding to the industry’s disregard to the sovereignty of governments to protect health of its citizens. The WHO FCTC (Framework Convention on Tobacco Control) enshrines effective tobacco control initiatives across the globe and has been ratified by 175 countries, protecting nearly 90% of the world’s population from tobacco health hazards. Article 5.3 of FCTC guidelines explicitly recognizes the need to protect tobacco control programmes from commercial and other vested interests of the tobacco industry.

Shaleen Rakesh - CNS

On 11 December 2013, the streets outside the Supreme Court of India thronged with a dazed crowd, hugging, sobbing and not quite sure what had happened. Inside the hushed courtroom, the judges had just passed a devastating ruling. Lesbians, gays, bisexual, transgender (LGBT) in India had once again been labelled as criminals. Section 377, the 149-year-old colonial law that banned gay sex, had been upheld by the Highest Court of Law of India saying that amending or repealing Section 377 should be a matter left to Parliament, not the judiciary.

Despite evidence to prevent occupational exposure to HIV for surgeons and other healthcare providers, people living with HIV (PLHIV) requiring surgical procedures for treatment often face heightened stigma and get discriminated within healthcare settings. But all is not that black and there are surgeons who have championed the cause of treating PLHIV without stigma and challenged discrimination in healthcare settings as well. Few of these surgeon-heroes were sharing their experiences of over 20 years in treating PLHIV at the 6th National Conference of AIDS Society of India (ASICON 2013).

"Co-infections and HIV beget each other": Dr Dilip Mathai

(This article is based upon a CNS interview with Professor (Dr) Dilip Mathai, Dean, Apollo Institute of Medical Sciences and Research)

Dr Dilip Mathai (left): ASICON 2013

HIV in today's context is a chronic condition of the human immune system. HIV is a retrovirus and the infection leads to a progressive reduction in the number of CD4+ T-helper cells (so called because CD4 glycoprotein is found on their surface) which are an essential part of the human immune system. They are the main targets of HIV which destroys infected CD4 cells leading to an overall weakening of the immune system, said Dr Dilip Mathai, Dean, Apollo Institute of Medical Sciences and Research, and former Head of Medicine Department, Christian Medical College (CMC), Vellore.

A study found that prevalence of human papilloma virus (HPV) among women living with HIV was 26.85% which was much higher than the HPV rates in HIV-negative women. Dr Ankita Chourasia, a researcher from Banares Hindu University (BHU) whose oral presentation of this study was awarded at the 6th National Conference of AIDS Society of India (ASICON 2013), strongly recommended regular HPV screening for women to cut down rates of HPV-caused cancers such as cervical cancer. HPV is the most common sexually transmitted infection (STI).

AIDS is just one of the manifestations of HIV, said a veteran health advocate. A range of co-infections and co-morbidities also need as much attention as AIDS-related treatment and care. HIV and hepatitis B virus (HBV) co-infection was in spotlight at the 6th National Conference of AIDS Society of India (ASICON 2013). HBV is a viral infection that attacks the liver and can cause both acute and chronic disease. Mode of transmission of HBV and HIV both are similar: they get transmitted through contact with the blood or other body fluids with high viral load of an infected person. About 600,000 people die every year due to the consequences of HBV.

To tackle any disease it is not merely only diagnosing correctly and offering quality treatment but ensuring that the patients adhere to treatment that is of paramount importance. Timely and correct diagnosis and availability of standard, evidence-based and effective treatment cannot be of much help unless the patient takes the prescribed drugs for the complete duration of time. So over and above everything else it is the patients' willingness and determination to take their medicines regularly that can bring relief.

An estimated 3.4 million children are living with HIV, thus accounting for 10% of the total global HIV infected population. At the same time, the number of children newly infected with HIV dropped drastically by 52% between 2001 and 2012. And yet as per the UNAIDS Global Report 2013 currently only 34% of children under 15 years of age in need of antiretroviral therapy (ART) in the world are actually receiving it. This is just half of the ART coverage for adults. To reach the goal of an AIDS-free generation we have to focus on elimination of HIV in children.

Although historic scale-up of antiretroviral therapy (ART) is keeping people living with HIV (PLHIV) alive, 1 in 10 of them succumb to cardiovascular diseases (CVDs). “The good news is that survival of PLHIV has improved, but CVD is increasingly becoming one of the important causes of morbidity and mortality” said Dr K Naik of Lokmanya Tilak Municipal Medical College (LTMMC), Mumbai. Dr Naik was speaking at the 6th National Conference of AIDS Society of India (ASICON 2013).

On one hand the new mantra of ‘zero new HIV infections, zero deaths and zero AIDS-related stigma and discrimination by 2015’ is increasing decibels and on another hand Indian AIDS response is dealing with a complex matrix of challenges impeding programme outcomes. To compound the situation there are policy conflicts against public health such as the Supreme Court’s decision to re-criminalize same sex behaviour that further will slow down the AIDS response in the country (as men who have sex with men and transgender people are HIV key affected populations as per the government’s National AIDS Control Organization).

One size does not fit all. Likewise we need an expanded basket of evidence-based interventions and approaches to meet the unique needs and contexts of different key affected populations to prevent HIV. Deliberations on the first day of the 6th National Conference of AIDS Society of India (ASICON 2013), discussed amongst other things, effective strategies for HIV prevention and control.

The 6th National Conference of AIDS Society of India (ASICON 2013) which has brought together over 700 HIV medical experts from across India with a distinguished national and international faculty opened in Mumbai. Dr IS Gilada, President of the conference and also of AIDS Society of India (ASI), said: “to strengthen south-south collaboration between Africa and India and to promote mutual information exchange and learning in fight against AIDS, ASICON 2013 is being inaugurated by Minister of Health from Tanzania.”

Shobha Shukla - CNS
Mumbai will be host to the 6th National Conference of AIDS Society of India (ASICON 2013) from 13th to 15th December. As its theme HIV/AIDS: Scaling New Heights – From Prevention & Treatment …Towards Cure suggests, the conference will focus on vital issues in the journey of the HIV epidemic from prevention and treatment towards possible cure. 45 national and 25 international eminent speakers are expected to share their expertise on a variety of subjects during this 3 day long event, informed Dr IS Gilada, President, AIDS Society of India.

Alice Tembe - CNS
In this years' event, the Swaziland Business Coalition on HIV-AIDS (SWABCHA) launched the integration and mainstreaming of gender in the HIV and TB response programmes in the workplace. The US Ambassador to Swaziland, Ms Makila James, the guest speaker, said in her remarks that the progress and milestones gained so far in the HIV and TB response will go to waste if due diligence is not accorded to the gender dynamics at play in the society. She noted that gender based violence, has undoubtedly contributed to new infections among the Swazi population. Further, these two epidemics, have increased the burden of care on women and reduced the chances of women growing in the workplace as they are bound to withdraw from work to care for their loved ones.

Dr Carolyn Kavita Tauro - CNS
Recently, Ahmedabad was host to an International Conference on Inequity in Maternal and Child Health organized by the Indian Institute of Public Health (IIPH) Gandhinagar and Public Health Foundation of India (PHFI). It brought together national and international public health professionals to discuss about various issues affecting an equitable delivery of health care to mothers and children in India.

Xpert MTB/RIF in Delhi

Bobby Ramakant - CNS

There is no doubt that research and development of new diagnostic technologies and effective drugs must go ahead with full thrust. But there is no single 'magic wand' intervention and therefore deploying existing diagnostic tools optimally and managing treatment well are no less a priority to reach the formidable tuberculosis (TB) related goal of zero new infections, deaths and suffering.

Chhatra Karki - CNS
(First published in Kapan Online, Nepal on 1 December 2013)
Since the governments have not taken effective integrated steps for controlling HIV-TB, the challenges to control the two diseases continue to compound and experts rue over the absence of effective programmes to prevent TB infection in HIV infected people. It is well known that there is a much higher possibility of TB infection in people living with HIV (PLHIV) than in those who are HIV negative. Researches reveal that they have an estimated 21 to 26 times greater risk of developing active TB once infected. In 2012, among the 35.3 million PLHIV in the world, 11.8 million were also infected with TB. Globally 320 000 PLHIV co-infected with TB lost their lives in 2012. The number of these deaths would have been less, if somehow TB infection in them was prevented.

Sam Banda Jnr - CNS
The world, on December 1, joined hands to commemorate the World AIDS Day which every year gives an opportunity to people to renew their commitment to the fight against HIV, advocate for the rights of people living with HIV (PLHIV), and remembers brothers and sisters who died of AIDS related conditions. Malawi is one of the countries in sub-Saharan Africa which is severely affected by the HIV-epidemic. The TB-HIV co-infection is one of the prime challenges that this Southern African country continues to battle and the NTP Programme Manager James Mpunga notes that the high mortality rate of the TB-HIV cases is mainly due to diagnostic challenges. TB is the most prevalent opportunistic infection in HIV patients and Mpunga says it contributes significantly to HIV associated deaths in Malawi and Africa as a region.

Bobby Ramakant - CNS
Neglecting Hepatitis C Virus (HCV), Hepatitis B Virus (HBV), Visceral Leishmaniasis (VL), tuberculosis (TB), among other HIV co-infections and co-morbidities threaten to reverse gains made by remarkable scale up of HIV specific services. Number of people who inject drugs (PWID) with HCV is 3.5 times higher than those infected with HIV. Number of people infected with HBV is not behind at 6.4 million PWID exposed to it in 59 countries. 1.2 million PWIDs are estimated to have developed chronic HBV infection.

Dr Sugata Mukhopadhyay - CNS
Overall 10% of HIV infections globally, and excluding Africa nearly 30% of all new HIV infections are attributable to IDUs. About 20% of 15.9 million IDUs globally are infected by HIV. Drug Users have 10-30 times more chances of TB diseases and IDUs living with HIV have a 1 in 10 chance of TB disease per year as evidenced by scientific studies.

Dr Sugata Mukhopadhyay - CNS
“I am infected with HIV and not scared of AIDS, but definitely of TB. I know TB can knock me down at any time.” Space to discuss crucial issues of TB/HIV co-infection and management appears to be extremely limited in the current ICAAP. Surprisingly, community advocates and activists are also not very vocal on what should be a burning issue for the region.

Shobha Shukla - CNS
(Based on an interview with Gilles Cesari Regional Director, International Union Against Tuberculosis and Lung Disease (The Union)
Every year nearly 9 million people continue to suffer from TB. Among them, 3 million people are not diagnosed or misdiagnosed or not started on treatment and care-- and many of these are migrants. It is estimated that there are approximately 200-250 million migrants (documented, undocumented, refugees, asylum seekers, etc) in the world. Unfortunately, migrant workers are more vulnerable to develop active TB disease or get infected by HIV because of their poor living/working conditions, low wages, poor nutrition, overcrowded living quarters, no or little access to healthcare (especially undocumented migrants).

Joseph Elunya, Uganda
(First published in The Continent Observer, Uganda on 30th November 2013)
As countries around the world commemorate the World AIDS Day on Sunday 1st December experts are calling for the scaling up of treatment for Tuberclosis and HIV/AIDS. The experts note that with more than one million people needing simultaneous treatment for TB and HIV, it is essential that services for the patients be scaled up and coordinated within the general health system.

Dr Rahul Pandey
In the past several days I have been a part of Aam Aadmi Party (AAP)'s campaigning in Matiala constituency of Delhi. In this small period I have been witness to some inspiring processes and moments – motivation and hard work of persons volunteering for AAP; responses of people from various strata to AAP’s canvassing; decentralized and chaotic yet, in some ways, organized management of AAP’s campaign activities at the levels of constituencies and wards; and AAP’s unique model of local and democratic governance with a hint of Gandhi’s vision of ‘Swaraj’ or ‘Self-rule’.

Shobha Shukla - CNS
India HIV/AIDS Alliance, through a Global Fund supported Pehchan (meaning identity) project is working to build the capacity of 200 Community Based Organizations in 17 Indian states by reaching out to 453, 750 MSM, transgenders and hijras (MTH) using a community driven and rights based approach. Pehchan conducted a cross sectional midline study across 23 districts in 6 Indian states to understand the demographics, behaviour, programme impact and needs of the MTH ensuring protection of rights of these communities by involving them in this research. Active community involvement was prioritised at all steps of the study right from its design to report finalisation. The research instrument was developed using a community led process and the 601 MTH respondents were interviewed by community members and engaged in data analysis and report writing.

Bobby Ramakant - CNS
According to Jim Pickett, Chair of International Rectal Microbicides Advocates (IRMA): Rectal microbicides are products currently under research – that could take the form of gels or lubricants – being developed and tested to reduce a person's risk of HIV or other sexually transmitted infections from anal sex. The risk of becoming infected with HIV during unprotected anal sex is 10 to 20 times greater than unprotected vaginal sex because as the rectal lining is only one-cell thick, the virus can more easily reach immune cells to infect.

Shobha Shukla - CNS
According to a new UNAIDS report on HIV in Asia and the Pacific, there is mixed progress on eliminating new HIV infections in infants. Cambodia, Malaysia, Myanmar and Thailand have over 50% coverage of all services to prevent PTCT (parent to child transmission) of HIV while Pakistan, Nepal and Sri Lanka lag behind with less than 30%. All countries in the region are trying to introduce WHO recommended PPTCT treatment option B to provide early and immediate ARV treatment to all HIV+ positive mothers. Yet overall there has been only 9% reduction in new infections among infants between 2010 and 2012. Cutting down the number of such infections by 90% requires great effort.

Shobha Shukla — CNS
Based on pre-ICAAP interviews conducted by Jeanne Marie Hallacy: Voices of affected community representatives
Repeal punitive laws
“Almost 90% of countries in the Asia Pacific region have retained laws that come from colonial times and are not progressive. They are making it difficult for the communities to access services or even address stigma and discrimination. Repeal of punitive laws in this region is very important.”
Moi Lee Liow, Asia Pacific Council of Aids Service Organizations (APCASO)

Nenet Ortega - CNS
Two decades ago, people living with HIV and AIDS (PLHIV) including their families had been stigmatized in all areas of social life, from communities where they lived and in areas where they normally do their daily grind.

Shobha Shukla - CNS
The Regional assessment of HIV, STI and other health needs of transgender people in Asia and the Pacific (jointly developed by the WHO and the Asia Pacific Transgender Network, and the United Nations Development Programme) identifies a clear need to scale up and improve sustained, comprehensive and effective HIV prevention efforts for transgender people (people whose gender identity differs from their biological sex assigned at birth). The assessment reports that ‘HIV prevalence among transgender women in the Region appears to be very high, ranging from 7.5% in Australia, 13.5% in Thailand and 31.6% in Indonesia to 41% in India. Throughout Asia and the Pacific region, transgender people are still very much underserved by health services…, putting them at increased risk for HIV….’

Lwin Lwin Thant - CNS
Since the launch of the Global Commission on HIV and the Law report in July 2012, there have been significant positive outcomes shaping in the Asia-Pacific region. “Today there are 82 countries across the world where UNDP, UN partners, civil society organizations among others have been working together and followed up on the recommendations of this report. We assume this is a good follow up which includes reviewing legal environments in the country, working with judiciary, police, and parliamentarians, and increasing access to justice programmes. There has been very interesting follow-up in the Asia Pacific region too on a range of issues including key populations, intellectual property (IP) and treatment access, among others” said Mandeep Dhaliwal, Director (HIV, Health and Development Practice), UNDP.

Citizen News Service - CNS
Zimbabwe has the dubious distinction of having an estimated 15% of all 15- to 49-year-olds to be living with HIV and 74% of the 38,720 tuberculosis patients co-infected with HIV. A TB-HIV integrated care project managed by The Zimbabwe Office of the International Union Against Tuberculosis and Lung Disease (The Union) has shown in its second-year results, significantly improved care for people requiring simultaneous treatment for both diseases. The Union project, which was launched in October 2011, is being implemented in 23 clinics in 17 urban areas in Zimbabwe with funding from the US President’s Emergency Fund for AIDS Relief (PEPFAR). The aim is to strengthen both TB and HIV diagnostic and treatment through decentralisation and integration of TB-HIV services in urban primary health care clinics.

Diana Esther Wangari - CNS
Recently, the international media was flooded with reports of a baby in Mississippi who was cured of HIV. The miraculous procedure was performed by Dr. Gray, a pediatrician with the University of Massachusetts alongside Dr. Persaud of John Hopkins University. The daring move to treat the child was done thirty hours after the child’s birth, even before getting confirmatory test results of infection. In addition, Dr. Gray went a step further to use three drugs instead of the usual one. This could have posed a health risk, but against all odds the child survived and even after 30 months was found to have no viral load despite her antiretroviral therapy being discontinued at 18 months as reported by the mother.

Nenet Ortega - CNS
Gender diversity has a long and rich history in the Asia-Pacific region. Most societies are patriarchal, leaving women in general as second-class citizens who face significant economic, social and health challenges compared with men. The situation is even worse for transgenders and sex workers. Stigma and discrimination force most to live on the margins of society. Due to fear, discrimination and isolation, they are often unable to seek out and obtain adequate health and social services. Partly for those reasons, they have long experienced HIV and TB prevalence far above national averages.

Jamie Uhrig - CNS
As many people from around the region head to Bangkok to be on time for the opening of the ICAAP 11, those from Indonesia carry a special piece of news with them. Quietly, The Ministry of Health is encouraging the practice of Test and Treat.

Bobby Ramakant - CNS
At 11th ICAAP, all delegates must have heard the words: stigma and discrimination. But often we refer to external factors that contribute to stigma and discrimination for key populations living with HIV, and might fail to look inside. “We also need to look at stigma and discrimination keeping the ‘self’ factor in mind - on how young men who have sex with men (MSM) and transgender people absorb external stigma and discrimination for instance” said Tung Duy Bui from Viet Nam. Bui is also the Regional Coordinator of “Youth Voices Count (YVC)” which is a network of young MSM and transgender people in Asia Pacific. He spoke to 11th ICAAP Insight team after the symposium on self-stigma among young MSM and transgender.

Bobby Ramakant - CNS
Despite significant momentum to responding to childhood TB in 2013 with launch of first-ever roadmap, are we groping in the dark with very little data on TB in children? Charalambos Sismanidis, a noted expert who was speaking at the 44th Union World Conference on Lung Health, said that childhood TB data was first reported by countries to the WHO in 2012 but this is not enough. There are gaps in surveillance system as childhood TB does get under-reported (and under-diagnosed).

Hara Mihalea - CNS
In response to the numerous unmet needs of women, girls, and transgender people-- especially those affected by HIV, TB or malaria—the Women4GF (women for Global Fund) initiative was launched earlier this year (2013) as part of The Global Fund Gender Equality Strategy. Preceding the 11th ICAAP held recently in November 2013 in Bangkok, a two day workshop on Gender Equality for advocates and activists of Key Affected Populations (KAPs) was organized by the AIDS, Strategy Advocacy and Policy (ASAP) and funded by the Global Fund for TB, AIDS and Malaria (GFTAM or simply GF).

Citizen News Service - CNS
Recent guidelines by the International Diabetes Federation (IDF) state that metabolic surgery is a treatment option for any overweight person with a Body Mass Index (BMI = weight in kilograms/ height in metre square) of more than 30 and with co- morbidities like cardiovascular disease risk factors, uncontrolled diabetes, hypertension, hyperlipidaemia and obstructive sleep apnoea.

Photo credit: Vinai Dithajohn/UNAIDS

Hara Mihalea and Bobby Ramakant
Signalling an essential shift away from tokenistic participation of young people in HIV programming to encouraging genuine leadership by them was given strong emphasis at the first ICAAP media briefing ahead of the opening ceremony. “We should put the responsibility of fighting AIDS in the hands of people who have a future, rather than in hands of people who had a history,” declared Mechai Veravaidya, Chairperson of the ICAAP local host organization, The Population and Community Development Association.

Sumita Thapar – CNS
“A man is not a financial plan”, a website advises young women in the Philippines. “Babies are not blessings” it further asserts. Through active use of social media and mobile phone ‘apps’ the web site sexandsensibilities.com reaches out to young, middle class girls with positive notions about sexuality. “Sexuality is about self-identity, self-worth, it is our ‘divine’ right – it is part of being human,” asserts Ana P Santos, the journalist and sex educator who runs the site.

Shobha Shukla - CNS
The complexity in addressing sexual orientation and gender identity in the HIV response has marginalized the issues and needs of transgenders (TGs). While HIV programming in the Asia and the Pacific has scaled up considerably, TGs do tend to get subsumed under the MSM (men who have sex with men) category. Calls to separate programming and resource allocation to address their specific needs and concerns are growing louder.

Shobha Shukla – CNS
Born in 1948 in India, Shivananda Duncan Khan migrated to the UK when he was ten years old. In 1988 he founded an organization for South Asian LGBTs in London called Shakti, followed by health support groups for MSMs across India, Bangladesh and other South Asian countries. After losing a close gay Muslim friend to AIDS in the early 1990s, Mr Khan became active in the AIDS response and founded the Naz Foundation International based in London and Lucknow.

Ishdeep Kohli – CNS

A number of countries in the Asia and the Pacific are showing commitment and leadership by increasing domestic investments for HIV. Malaysia currently funds 97% of its own AIDS response, China 88% and Thailand 85%; India too has committed to increase domestic funding to more than 90% in its next phase of the AIDS response.

Nenet Ortega - CNS
The Global Fund has helped governments and civil society organizations to ‘jump start’ their programmes by funding national HIV, tuberculosis (TB) and malaria initiatives. This has included support to community work, and ART provision etc. This has also helped stimulate domestic health spending, as governments are expected to provide counterpart funds, and eventually to address issues of longer-term sustainability.

Citizen News Service - CNS
You may think that superheroes only fight crime, but they can also fight serious public health issues like drug overdose – a major and often overlooked cause of death among people who inject heroin or other opioids. Armed with naloxone the safe, effective, and easy-to-use antidote to opioid overdose, I travel the world fighting the overdose epidemic. And I’m not the only superhero with naloxone. Drug users, their families, outreach workers, and police around the globe have been trained to use naloxone to save lives.

Nenet Ortega – CNS
“Getting to Zero” is UNAIDS’ strategic mantra for attaining zero new infections, deaths and discrimination. To get there, countries are expected to adopt innovating preventive approaches, scale up and scale out treatment care and support, and advance human rights while capitalizing on gender equality to mitigate discrimination and stigma.

Le Nguyen – CNS
Discussions and split opinions about the next ICAAP are swirling around the corridors of the Queen Sikirit Convention Center. On Wednesday, they crystallized in the form of debate session entitled: The future of ICAAP: Do we need one in 2015? That the question is being openly asked is healthy. The AIDS ‘community’ must be confident that investment of collective time, attention and resources is made for the best impact. And even though the decision about ICAAP2015 will most likely be made behind firmly closed doors, such a debate should be welcomed.

Ishdeep Kohli - CNS
Many developed countries in Asia and the Middle East rely on migrant workers to keep their economies functioning. Migrants send back valuable economic resources to their origin countries and contribute to the economies of the destination countries. Migrant populations are vulnerable to violence, discriminations and lack of social and healthcare services. In some countries the policy and practice of mandatory HIV testing for migrant workers is discriminatory and violates the migrant’s human rights.