Where there are no drugs: TB-HIV dilemma for migrants

In  late October 2010, a large group of people living in and around Mae Sot, Tak province were closing in on a terrible 'milestone' of sorts: all of them – over 60 migrant children, women and men – were living with HIV and taking antiretroviral (ARV) drugs, which they needed to stay alive. Some were also co-infected with tuberculosis (TB), the most frequent opportunistic infection (OI) experienced by people living with HIV/AIDS (PLHIV). Read more

Each group member's daily regimen of drugs – a one-year 'buffer' provided by an international non-governmental organization (INGO) pulling its operations out of the country – was about to run out, with no new supplier in sight.

"We have been unable to secure a sustainable source of ARVs for our patients," explains a staff of the Mae Tao Clinic, a clinic providing health care services to migrants and displaced people near the Thai-Burma border. "If they stop taking their medication, we face a crisis."

DRUG RESISTANCE 
--------------
Adherence to a prescribed ARV drug regimen is essential; people living with HIV and/or TB who stop taking medication for whatever reason, and even only for a few days, can develop a resistance. Drug-resistance is dangerous, because it is irreversible and the new strains of the disease can be passed on to others.

Multi-drug- and extensively drug-resistant tuberculosis (or, respectively, MDR and XDR TB) is an even greater potential threat than HIV drug resistance in terms of impact, because unlike HIV – a blood-borne disease –, TB is transmitted from person to person through the air. A rampant increase in drug resistance can thus indeed fuel a public health crisis.

The Mae Tao Clinic representative said that "from a public health perspective TB is more difficult to handle, mainly because of time-related compliance issues. People with TB have to take medication daily for six months. If they interrupt this treatment, which happens frequently with migrants who are on the move and may stop taking drugs when they feel better, then drug resistance can occur."

Another often under-estimated problem accompanying drug resistance is the subsequent need for different drugs to replace the first regimen. These second- or third-line drugs are much more expensive and difficult to procure – here in Thailand, for example, the main first-line ARV combination therapy (for example GPO-VIR S30) is locally produced and distributed, bringing down the cost; but second- or third-line drugs must be imported, tend to be much more expensive than first-line medicine and may require special handling, like refrigeration, which complicates delivery in unstable settings.

MIGRANTS MARGINALISED
--------------
Thais living with HIV have the right to, and usually receive, free ARVs through the National Access to Antiretroviral Program for People living with HIV/AIDS, or NAPHA. People without a Thai ID can buy ARVs for a minimum of 1,350 baht per month, although NAPHA set up a provisional extension programme to cover vulnerable populations who do not have access via regular channels like Thai social welfare card holders.

Access is inevitably restricted for individuals or families already subject to the most dire of circumstances: many migrants and displaced people along the Thai-Burma border live a day-to-day existence that may include a lack of food security and reliable shelter. This can, and does frequently lead to greater vulnerability to infection and illness. An HIV positive migrant in poor health is thus more likely to contract opportunistic infections (OI) like TB, or Hepatitis C, another highly problematic OI.

A representative of a community-based organization in northern Thailand shared that "along the Thai-Burma border abutting Shan State, in Chiang Mai province, we support 125 members of the Shan community living with HIV, of whom 50 currently receive free ARVs. Unfortunately, beginning in December 2010, any new patients will have to pay for treatment – so this will affect any of the 75 not yet on ARVs who might need them in the future." There are about one or two new cases every month, and some of them also have TB.

She added that they "…have a limited budget aimed at helping with general hospital costs for community members, but we've been using it to cover ARV-related costs for our PLHIV."

Given the existing obstacles to accessing adequate and appropriate treatment, it is not surprising that migrants may start with the TB six-month short course, but then, despite doctor's instructions, stop taking the drugs once they feel better. Many migrants are by nature already mobile, which further complicates consistent compliance and follow up by medical staff.

It is this population – in addition to other key populations like sex workers, injecting drug users and prisoners – that should be the main beneficiary of effective prevention efforts and increased access to a regular supply of drugs.

In a country that currently receives generous funding from the Global Fund to fight HIV/AIDS, TB and Malaria (GFATM), how is it possible we cannot manage to take care of our most vulnerable fellow humans?

SERVICES AND GAPS 
--------------
A representative of the Thai Northern Network of People Living with HIV stated that "local hospitals do provide ARVs to migrants and displaced people as part of NAPHA's extension programme, but they are bound by a quota system which always favours Thai citizens over unregistered migrants."

He admitted that "sometimes Thais who fear being stigmatized and discriminated against by colleagues will request treatment under the extension programme instead of the regular system, because this way they can remain anonymous."

Mae Tao Clinic already offers a number of relevant services for PLHIV, including voluntary counseling and testing (VCT), home-based care and peer educators. Relatively simple preventive approaches can also be applied in the context of TB-related services, such as face-masks and better ventilation in places where people go to get tested.

"A more systematic, consistent integration of HIV and TB programmes is key," claimed another Mae Tao Clinic staff; he went on to say that "since it was at this point beyond the clinic's capacity to offer TB treatment, it was essential to have one group or entity able to take full responsibility for managing a comprehensive TB programme and willing to deal with problems such as non-compliance or adherence due to mobility."

There is an international NGO currently providing TB services in Mae Sot, serving part of the area previously covered by the INGO that pulled out last year. Yet the new organisation has limited reach and cannot accept patients outside of its focal communities, including those likely to move across the border. These unfortunate ones have to look elsewhere, and more often than not, they end up at Mae Tao Clinic.

Regarding the 'stranded' HIV-positive people, clinic staff approached the closest hospitals for help, and only Propha agreed to treat 20 people under its NAPHA extension scheme. Mae Sot, Mae Sariang and Mae Ramat hospitals were not accepting any new patients.

"We are now waiting to hear whether the Regional NAPHA Extension Unit in Pitsanuloke can help coordinate the provision of ARVs directly to Mae Tao," said the first Mae Tao Clinic staff. "This is easier and more cost-effective than transporting a large group of patients back and forth each month."

WHAT NOW?
--------------
It seems that drug resistance is here to stay – at least for now – and so the best response would include not only addressing the most immediate needs to mitigate impact, but also introducing some longer-term measures.

In addition to the interventions mentioned above, anti-stigma and -discrimination campaigns targeting Thai society would help PLHIV at all levels access existing ARV providers without fear of being socially outcast.

The representative of the Northern Network of People Living with HIV wondered whether "everything could be related to national security issues and that maybe there is no real will to find a sustainable solution to these urgent cross-border issues."

Also, "there seems to be little real interest among TB service providers to collaborate more with the HIV/AIDS sector," an independent consultant supporting HIV/AIDS-related work at national and local levels in Thailand noted. "Because TB has for so long been considered 'solved' as a public health issue here, they do not have a sense of urgency…"

Well, it can't get any more urgent for those people living with HIV/AIDS and TB here, and now - and who may soon become drug resistant due to apathy and ineffective programme design and interventions. Acknowledging and fully understanding the reality of this is the first step, acting decisively and comprehensively, the second. Here, and now.

Constanze Ruprecht
(The author has worked in international development cooperation since 2000. Focusing on a broad range of areas including public health, gender, advocacy and communications, politics and the environment, she supports people and programmes in Asia, Africa and Europe.) 


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Media Dialogue With AIDS-Affected Children

To commemorate World AIDS Day, December 1, 2010 some AIDS affected children from Lucknow, Sultanpur, and Bara Banki districts of Uttar Pradesh, had a dialogue with the media at the Uttar Pradesh Press Club. The Uttar Pradesh Welfare For people living with HIV/AIDS (UPNP+) supported by UNICEF and Media Nest, a pan India body of Media professionals, facilitated this one hour long interaction under 'Media for Children'. Read more

The session saw children from different age groups have a direct dialogue with Media persons. They talked about discrimination at school, society and in health services. They rued about how nobody wants to make friends with them, with even their relatives maintaining a safe distance from them for fear of infection. Many had lost their parents and sibling to AIDS and were hurt and humiliated the way they were treated by their relatives and neighbours. The shared it all-- the pain, the trauma and the pathos of being AIDS affected children.

While UNICEF AIDS specialist Dr Khanindra Bhuyan, communication specialist Augustine Veliath, Meena Jadav, UNICEF AIDS (Primary Prevention) consultant and senior members of the UPNP+ were present, there were no formal presentations by the adults in the session.  The floor was left entirely to the children, many of them infected, but all of them ‘affected’ by HIV /AIDS. Many of these children were orphans –HIV/AIDS had claimed one (and in many cases both) of their parents. They had sisters and brothers who had died due to AIDS. All the children talked with great emotion about their traumatic living in a society that has a lot of misconceptions about HIV/ AIDS. They had to cope with not only the loss of their near ones, but also had to deal with the discrimination that they had to face as they were “AIDS affected.” 

The children spoke about their lives, their aspirations. They delved upon stigma at home, in the society, in schools, and at the hands of health providers.
 They spoke about their emotional trauma due to rude behaviour of service providers including teachers, and also the absence of facilities as well as lack of opportunities

While the electronic media persons had not been invited to this session, even the print media photographers had been requested not to click photographs or use the real names of the children. This was an attempt to guard the privacy of these very special children. The media persons were asked to freely interact with the children on a one to one basis or in groups.

“The children had total freedom. They talked reality; they talked about life as they actually lived it. It was bound to touch hearts, it did” said Dr Bhuyan, who was one of the silent observers in this session.

The media and the general public (including educators and health workers) can be partners in this noble task of ensuring social acceptability for these special children, by respecting their dignity and privacy, and by encouraging and reassuring them in all possible ways.

Kulsum Mustafa
(The author is a senior journalist and also serves as Secretary General of Media Nest) 


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Children Affected With HIV/AIDS Attend Training Workshop

Today, 1st of December, is World AIDS Day—a grim reminder of this killer disease, which has devastated millions of families all over the world. In Uttar Pradesh alone, more than 35,000 AIDS patients were registered with the state AIDS Control Office till September, 2010. How many more unregistered people would there be, is anybody’s guess. Amongst the registered ones, there are 1597 male and 777 female HIV positive children. Read more


With a view to lend a helping hand, UNICEF has organized a training workshop for such children at its pavilion at the ongoing Lucknow Mahotsava—a gala, annual event, spread over 10 days.

 The first batch of child reporters and Bal Bandhus (little friends), who arrived in Lucknow on Nov 25 have already completed a very successful training in the media tools. The second batch from Lalitpur district that started their training in the five media tools of communication at UNICEF Pavilion at the Lucknow Mahotsava from Nov 30th.

This second group of children will also be joined at the UNICEF Pavilion by HIV positive affected and infected children who will be coming from six districts of Uttar Pradesh. The children will be brought in by a non-government Lucknow based organisation named  UMEED which works for the rehabilitation and welfare of children living with HIV/AIDS and is part of the workshops from Nov 30-2 Dec 2010 .

Apart from learning the five media tools from the 18 master trainers from Maharajganj who are conducting the workshop, the HIV positive children will also be celebrating the World AIDS Day today in Lucknow at the Mahotsava.

Let all of us contribute in some way or the other to keep  the spirit of these young fighters high.

Anjali Singh - CNS
(The author is a UNICEF consultant and a senior journalist. She is also the Director of Saaksham Foundation) 

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New Science, New Hope: Microbicides and HIV prevention

At the forthcoming Biennial Conference of the Irish Forum for Global Health (IFGH) in Maynooth, Ireland, one of the two keynote guest lectures - The John Kevany Memorial lecture - will be delivered by Dr Zeda Rosenberg, Chief Executive Officer (CEO) of the International Partnership for Microbicides (IPM) on "New Science, New Hope: Giving Women Power over HIV/AIDS." The microbicides refer to a new type of product being developed that people could use vaginally or rectally to protect themselves from HIV and possibly other sexually transmitted infections. Read more

One of the defining moments in microbicides advocacy was in July 2010 at the XVIII International AIDS Conference (IAC) in Vienna, Austria where successful results of the much awaited tenofovir microbicides clinical trials (CAPRISA 004) were announced: women who used the tenofovir microbicide gel were far less likely to become infected with HIV than women using a placebo gel. The tenofovir microbicide gel users were 39 percent less likely, overall, to become infected with HIV than women who received a placebo gel. More importantly, underlining the significance of adherence and counselling in clinical trials, women who used the tenofovir microbicide gel correctly more than 80 percent of the time, HIV infection was 54 percent less likely. Also as many advocates of new HIV prevention technologies demand – these tenofovir microbicide also showed activity against genital herpes (a sexually transmitted infection), reducing its incidence by half.

Let me put a word of caution here: this is undoubtedly welcome news, but research is not over yet. There is still a long way to go which may span over years through rigorous path of clinical trials and product development, before any microbicide can truly be available to communities.

One of the big debates around using anti-retroviral (ARV) based microbicides to prevent HIV transmission is that tenofovir is also used by people living with HIV (PLHIV) for their ARV therapy. PLHIV take oral version of tenofovir in ARVs like Viread, Truvada and Atripla.

So the worry is: will using this ARV based microbicide (tenofovir in this case) make people resistant to tenofovir and thereby negate the positive outcomes of ARV based therapy later in their lives in case they become infected with HIV and require the ARV treatment?

"There is now evidence to indicate that ARVs can prevent HIV as well as some of the non-HIV STIs. The major challenge facing the Microbicides Society of India (MSI) as well as other partner research agencies globally, would be to make  a combination of different ARVs, so that these products  become more effective, safer and user friendly for preventing the HIV and some of the non-HIV STIs as well as reproductive tract infections (RTIs). It would be an icing on the cake, if few of these microbicidal products could also provide the contraceptive protection concurrently to the users of these products" said Dr Badri N Saxena, President, Microbicides Society of India (MSI), who is a globally acclaimed researcher and an inspiring advocate for new HIV and reproductive health technologies.

"One reason for engaging ARV drugs into microbicides development is to accelerate the candidates that are ready to go into clinical trials because they come from a very rich product development profile. So now we have so many good candidates, can we provide the much needed bridge to establish biological plausibility - to find out will these things actually work in clinical trials" said Prof Robin Shattock to this correspondent at the International Microbicides Conference in Pittsburgh, USA (May 2010).

Also at the International Microbicides Conference earlier this year, two key studies were presented - one study involving a mathematical model and the other assays of cells and tissue, and both these studies arrived at the same answer to the worrying question whether drug resistance could be a problem if ARV drugs become a mainstay for HIV prevention. Resistance could happen, if people, who are unknowingly already infected with HIV, use the approach. So in other words, if HIV negative people use ARV based microbicides the risk of developing resistance is not there, but if they are already HIV positive and unaware of their status, the risk of resistance is there. These two studies underscore the importance of incorporating routine HIV testing and ongoing monitoring of infection status in any prevention program that involves the use of ARVs.

Probably the forthcoming Irish Forum for Global Health (IFGH) biennial conference might offer some answers to these concerns and give a major thrust to research and eventual development of new HIV prevention technologies. We will post the audio recording of Dr Zeda Rosenberg's lecture at Irish Forum for Global Health (IFGH) biennial conference on www.citizen-news.org! Stay tuned!

Bobby Ramakant - CNS 

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Irish Forum for Global Health calls for protecting health aid funding

"Current economic crisis threatens to reverse much of the progress made in developing countries"
The Irish Forum for Global Health (IFGH) is concerned at the further cuts to the overseas aid budget in the Government's four-year plan. It urges the Government to protect aid funding for health and HIV programmes in developing countries and to keep its promise to increase aid to 0.7% of Gross National Income (GNI) by 2015. The current economic crisis threatens to reverse much of the progress made in developing countries over recent decades and UNESCO estimates that the economic downturn will cause between 200,000 and 400,000 additional child deaths each year between now and 2015. Urgent measures are needed to protect the poor and vulnerable. Read more


Ireland has a responsibility to help address the health needs of developing countries. While health in Ireland has steadily improved, the gap has widened between Ireland and the least developed countries.
External aid for health has proven to be effective. For example, more than 5 million people are now on anti-retroviral treatment for HIV in developing countries, compared to just 300 thousand in 2002. There has been a dramatic reduction in malaria deaths due to the distribution of insecticide-treated bed nets. Aid for health has also been good for economic development as tackling major diseases such as tuberculosis (TB) and malaria makes people healthier and more productive.

Developing countries are dependent on external aid to provide even the most basic healthcare. Cuts in aid budgets make it harder for governments to invest in critical service developments, such as recruiting new health workers, provision of emergency obstetric care and safe delivery services, and expanding immunisation programmes. Some of these effects will reverse hard-fought gains and have long term consequences for health in these countries.

Ireland's aid budget was reduced from €920 million in 2008 to €722 million in 2009. European Commission President José Manuel Barroso has said "The recession must not, cannot, will not be used as an excuse for going back on aid promises." Other European countries, including the UK, have managed to maintain aid levels despite recession.

Ahead of his Keynote Speech to be delivered at the Irish Forum for Global Health Biennial Conference 2010 taking place at the end of November, Professor Father Michael Kelly, well known and respected Irish Jesuit priest, researcher and author who has lived in Zambia for over 50 years gave his view on Irish foreign aid for health "Maintaining levels of aid, especially for health, makes economic sense, is the right, just and decent thing to do, and is something that even in the current difficult economic climate the majority of Irish people would want. Reducing the level of aid would bring only minor relief to the Irish budget but would mean major budgetary and human setbacks in recipient countries."

Dr David Weakliam, of the Irish Forum for Global Health (IFGH), stated: "Health is a vital part of the Government's overseas development programme. The further cuts in aid in the four-year plan will undoubtedly have a negative impact on the health of people in the poorest countries. They will also damage the excellent reputation Ireland has earned for its assistance to the underprivileged in developing countries."

The Irish Forum for Global Health (IFGH) opposes further cuts in the aid budget in order to protect the health of the world's poorest and most vulnerable people.

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Diseases of poverty to be in spotlight at IFGH biennial conference

The biennial conference of the Irish Forum for Global Health (IFGH) to mark the World AIDS Day (1 December) is focussing on the theme of "Partnerships to address health and diseases of poverty challenges." IFGH together with National University of Ireland (NUI) Maynooth and Irish Aid is organizing this two days meet (29-30 November 2010) bringing together experts from all sectors involved and working on global health - in particular, issues affecting the developing world. Read more

The media advisory issued by IFGH says: "The conference will provide an unusual combination of science, research and hands-on projects being implemented by NGOs."

This biennial conference will feature over 50 presentations on a range of issues related to health - from HIV to malaria, from eye health to climate change, from nutrition to health service provision.

The two major highlights of this conference are the coveted lectures: John Kevany Memorial Lecture and 2010 Father Michael Kelly Lecture.

The John Kevany Memorial lecture will be delivered by Dr Zeda Rosenberg, Chief Executive Officer (CEO) of the International Partnership for Microbicides (IPM) and she will speak on "New Science, New Hope: Giving Women Power over HIV/AIDS."

The 2010 Father Michael Kelly Lecture for World AIDS Day will be delivered by Father Michael Kelly on "HIV and AIDS: Accomplishments and enduring challenges." He will be joined by James O'Connor, HIV activist and development manager of Open Heart House, Dublin who will speak on "HIV and AIDS - A positive perspective." James O'Connor is acutely aware of the human cost of living with HIV and AIDS due to his personal experience of AIDS. He is one of the founding HIV positive members of Open Heart House, says the IFGH media advisory.

A new book written by Father Michael Kelly will also be released at this biennial conference, titled "HIV and AIDS: A social justice perspective."

For more information on the IFGH biennial conference, click here 

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Door to door screening by TB patients help TB detection

Berlin, Germany: Civil society initiatives continue to play an important role in the fight against tuberculosis (TB), participants of the 41st Union World Conference on Lung Health in Berlin, Germany (11-15 November 2010) heard on the first day. Door to door visits in communities by persons who have been through TB treatment help find the harder to reach TB patients who otherwise would go undetected. Read more


Lucy Chesire, TB Advocacy Advisor for ACTION (Advocacy to Control TB Internationally) in Kenya, shared details of the TBREACH project, an initiative of the Stop TB Partnership with funding from the Canadian International Development Agency (CIDA), which started off last September. The goal of the project is to enhance early and full TB case detection among selected high risk groups. The project focuses on reaching slum dwellers and people living with HIV, particularly those with limited access to health services, i.e. the poor. The project done in partnership with KAPTLD (Kenya Association for the Prevention of Tuberculosis and Lung Diseases), covers one city and three towns in Kenya, (Kisumu, Nairobi, Thika and Nakuru). These towns have continued to show increased burden of TB over the years

“One of the objectives is to enhance TB case finding and care among HIV infected people by engaging current and former TB/HIV patients in peer to peer screening approaches,” Chesire explained. For the project, 220 TB community volunteers, all former TB patients, have been recruited, as well as 55 community health workers (CHW). Of the 55 CHWs, 22 are persons living with HIV who have been through TB/HIV co-infection in the past. They will engage in door to door campaigns, community mobilization during screening camps, treatment support, referral of suspects and health education: the volunteers carry out case detection work at least three times a week, the health workers work at least four days a week. All get a monthly stipend.

“This approach enables us to reach those patients who many of times have not been able to come to the health care facilities despite presenting the signs and symptoms related to TB,” Chesire says in an interview with CNS. “For example, if a facility is detecting two patients a month we want to prove through TBREACH that we are able to bring two additional cases to make it four patients in a month. So these are patients who if it was not for the project would never come to the health care facility.”

According to Chesire the volunteers act as agents of change. “They are able to tell their story, they are able to be treatment supporters, and they are able to encourage others living with HIV to go for a TB test. Because we know people living with HIV are 50 times more likely to develop TB,” she says. The volunteers go door to door, find out if there is anybody who has the signs and symptoms and if that is the case, fill in the referral form and send it to the nearest health care facility. They also provide health education on TB, its treatment and the importance of completing treatment.

Projects like these also help fight stigma against the disease. “These volunteers are already open about their TB and HIV status, they are already recognized by the community and at the health care facilities. We work with volunteers who live in the communities,” Chesire explains. As such, they can encourage others to acknowledge their (risk of the) disease as well.

The project is expected to reduce delays in diagnosis, cut down patient costs and encourage people to seek treatment soon. “At the end of the day, it is really about empowering TB patients,” Chesire says.

Initiatives like this should continually be funded by donors, Chesire applauds the Stop TB Partnership and CIDA for realizing and supporting former and current TB patients to rightfully take their place in TB control, as this is an initiative that many donors shy away from. Such initiatives should be scaled up, as they are in line with empowering TB patients and communities, a component of the Stop TB Strategy.

Babs Verblackt - CNS
(The author is a freelance journalist, a Fellow of CNS Writers' Bureau and Associate Communications atTuBerculosis Vaccine Initiative – TBVI)

Addressing poverty in TB programmes of Tamil Nadu

Tamil Nadu has a unique context as it is among the better performing states of India in terms of addressing poverty. Poverty in the Tamil Nadu state dropped from 51.7% in 1983 to 21.1% in 2001. For the period 2004–2005, the Trend in Incidence of Poverty in the state was 22.5% compared with the national figure of 27.5%. However, it is one of the HIV high-incidence states of India and the response to HIV and TB both has been commendable, said Dr C Udayashankar, State TB Officer, Tamil Nadu. "The poverty is still high in Tamil Nadu, especially in the rural areas" said Dr Udayashankar. He was speaking at the consultative workshop of TB and poverty sub-working group of the Stop TB Partnership, the secretariat of which has now moved to the South-East Asia office of the International Union Against Tuberculosis and Lung Disease (The Union). The forthcoming 41st Union World Conference on Lung Health in Berlin, Germany (11-15 November 2010) will also address issues around TB and poverty. Read more


Dr Udayashankar said that the World Bank is currently assisting the state in reducing poverty. DOTS centres have been located at places which are easily accessible to the vulnerable group thus making drug accessibility easy. Drug supply chain to these centres is maintained as per guidelines thus ensuring drug availability at all times, said Dr Udayashankar.

Various stakeholders that are involved in poverty alleviation are also involved in TB related advocacy, communication and social mobilization (ACSM) activities thus taking the message of TB control into the vulnerable population, said Dr Udayashankar. These stakeholders working on poverty alleviation are not only working in the field of healthcare and health promotion but are also involved in socioeconomic development among the rural and urban poor. Their staff members are also involved as DOTS providers so helping them meet the required TB-related healthcare need of the community.

In Tamil Nadu, there are designated microscopy centres (DMCs) as per the population-based guidelines of revised national TB control programme (RNTCP) in India. In areas where need based analysis have shown the requirement of additional diagnostic services, these have been provided through collaborating partners in the programme under the private-public mix (PPM) schemes, said Dr Udayashankar.

Patient engagement in TB control is central to effective TB control, and the WHO Stop TB Strategy also enshrines the Patients’ Charter for TB Care that provides the rights and responsibilities based framework for community engagement. One of the outstanding features of Tamil Nadu TB programme is selecting members from affected communities and encouraging them to be the DOTS providers for their community. "This removes the barrier between the patient and the healthcare provider" said Dr Udayashankar. These DOTS providers are also paid an honorarium at the end of the anti-TB treatment which serves as an incentive as well as a motivating factor to continue as DOTS providers in the same community and to advertise available treatment services through word-of-mouth, said Dr Udayashankar.

There are efforts made in Tamil Nadu to align TB control programmes with poverty initiatives. The Tamil Nadu government has initiated a system of supporting Self Help groups (SHG) in rural areas to increase self sustenance through microfinance. The TB programme in Tamil Nadu involves these SHG as DOTS providers. The SHG leaders are also part of the advocacy, communication and social mobilization (ACSM) campaigns which are part of the TB control programme, said Dr Udayashankar.

Providing nutritional support to the undernourished TB patients has been initiated in many places in Tamil Nadu. In some TB programmes in Salem, Vellore and Namakkal, rice supplements are given, in Thoothukudi and Salem, ‘daal’ (lentil) supplements are given, and in some other TB programmes in Salem and Vellore, egg supplements are also provided.

In rural areas, the Mahatma Gandhi National Rural Employment Guarantee Act (MNREGA) has helped those looking for employment.

Tamil Nadu has demonstrated relatively good response to HIV, TB and other conditions, and health systems strengthening has yielded benefits. Dr Udayashankar informed in one of the small group discussions that TB patients are routinely tested for diabetes in Tamil Nadu. People with diabetes are at a high risk of TB. According to several studies and systematic reviews, people with diabetes might have 2 to 3 fold higher risk of getting TB.

Bobby Ramakant - CNS 


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Innovative approaches to addressing poverty in TB programmes in Jharkhand

Imagine a cycle rickshaw puller and a 'paan' or tobacco shop owner as a DOTS provider – that is a reality since 7 years now in the Indian state of Jharkhand. The state TB programme in Jharkhand has taken many innovative steps to increase new TB case detection, provision of and adherence to anti-TB treatment under DOTS, and to reach the unreached people who might need TB care, said Dr R Dayal, State TB Officer, Jharkhand state, India. Dr Dayal was speaking at the consultative workshop of the TB and poverty sub-working group of the Stop TB Partnership in India (29-30 October 2010), the secretariat of which has now moved to the South-East Asia office of the International Union Against Tuberculosis and Lung Disease (The Union). The forthcoming 41st Union World Conference on Lung Health (11-15 November 2010) will be a great opportunity to document community-centric and innovative approaches in addressing poverty in TB control programmes. Read more


In Jharkhand, there are 17,738 DOTS centres in the entire state with population of 30.9 million.

The state TB programme in Jharkhand has engaged many community healthcare volunteers, NGOs, private medical practitioners, as DOTS providers. The honorarium for these DOTS providers should be enhanced, said Dr Dayal.

There is a need to increase access of the most vulnerable communities to quality diagnostics. Laboratory services need attention in the state. Presently the state has 296 designated microscopy centres (DMCs) for a population of 30.9 million. The three notified tribal districts in Jharkhand are likely to have more DMCs soon.

Community healthcare volunteers help with sputum collection and they are provided with incentives, said Dr Dayal. There are more than 12,000 community DOTS providers in the state which includes many cured TB patients. This is also supported by the WHO Stop TB Strategy, a component of which is the Patients’ Charter for TB Care.

Dr Dayal said that there is a compelling need to align TB control programmes with the poverty initiatives being undertaken in the state, and the state TB programme is already contemplating to do so very soon. They are planning to link the state TB programme in Jharkhand to the welfare department, Red Cross society, confederation of Indian Industries (CII) in Jharkhand, among others.

Cash compensation is also being provided by the state TB programme in Jharkhand to meet expenses incurred on local transportation or to compensate for loss of daily wages or adverse drug reactions or complications.

Dr Dayal said that in 2010-2011 the state TB programme in Jharkhand is committed to further improve basic DOTS services by intensified monitoring and supervision, enhancing community-based approaches and involving other sectors. They are also planning to start DOTS Plus services in Jharkhand in a phased manner. Moreover there is a plan to strengthen TB-HIV collaborative activities to reach out and provide appropriate healthcare services to TB patients among people living with HIV (PLHIV) and PLHIV among TB patients.

Bobby Ramakant - CNS 


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Poverty increases vulnerability to tuberculosis (TB)

"So little attention has been given to the tuberculosis (TB) pandemic because it's a disease of the poor" had said Dr Nils Billo, Executive Director of the International Union Against Tuberculosis and Lung Disease (The Union) at the 38th Union World Conference on Lung Health in Cape Town, South Africa in 2007. In 2010, before the 41st Union World Conference on Lung Health opens next week in Berlin, Germany (11-15 November 2010), the issues around TB and poverty have only become more severe. At the consultative workshop organized by the TB and poverty sub-working group of Stop TB Partnership in India (29-30 October 2010), it was clear that TB continues to affect society's most vulnerable - those who live in abject poverty, are marginalized or economically and socially isolated. Poverty significantly increases a person's vulnerability to the disease. Read more


Social and economic determinants at individual, household and community levels affect a person's vulnerability to TB. Special situations such as massive population movements - the displacement of people and refugee flows - and living or working in particular conditions also increase the risk of a person contracting TB.

In developed countries, ethnic minorities and other marginalized communities are at a greater risk of contracting the disease. In Canada for instance, indigenous communities have a 20 to 30 times higher TB burden than majority ethnic groups, Dr Kim Barker and Dr Anne Fanning from Stop TB Canada had said to CNS during the 38th Union World Conference on Lung Health in 2007.

Factors such as social isolation, reduced access to health services, a lack of trust in the health system and lack of organized community voices exacerbate the risk of TB spreading. But by identifying these vulnerabilities to TB, control strategies can become more focussed on reaching the people most in need.

TB is transmitted more readily in conditions such as overcrowding, where there are inadequate ventilation and malnutrition. Improvements in socio-economic conditions will therefore lead to reductions in TB incidence. This should also lead to improvements in access to care, its rational use and quality of care.

About one billion people live in urban slums and over the next 30 years that number is expected to double. In the poorest countries, about 80% of the urban population lives in slums. The poor socio-economic and environmental conditions that characterize the slums facilitate the transmission of many communicable diseases including TB. The burden of TB is often far greater in these urban settings than in rural areas.

There is also increasing recognition of the fact that TB reduces people's ability to work and earn a living and that TB control programmes have the potential to reduce poverty.

Poor TB patients in developing countries are mainly dependent on daily wages or income from petty trading and have no security of income or employment. In many studies people with TB have been found to have borrowed money, used transfer payments or sold assets because of their illness.

"We have to create jobs, find income generation alternatives for those people who are on TB treatment and need financial support to sustain them through the entire treatment course," said Dr AK Jha during the TB and poverty consultative workshop in India (29-30 October 2010). The secretariat of the TB and Poverty sub-working group of Stop TB Partnership has moved now to The Union's South East Asia office in New Delhi, India since August 2010.

At this TB and poverty consultative workshop, listening to the experiences from those fighting TB on the frontlines in high burden settings like in Nepal, Thailand and India, and from five states in India, it was evident that even where Directly Observed Treatment Shortcourse (DOTS) programmes are well established, patients with TB face substantial costs prior to diagnosis. While aggregate costs for poor people tend to be lower than for those from a higher socio-economic position, the costs as a proportion of income is much higher for the poor.

Experiences from other programmes like HIV show that it was usually health-care volunteers or members from affected communities that reached the most marginalized communities, providing them with TB and HIV care and treatment services. Home-based care (HBC) experiences for people living with HIV in most hard-hit communities provide learning lessons.

Poverty has played a leading role in accelerating the spread of TB. The poor are at the greatest risk for tuberculosis because of poor housing, poor diet, poor education and risky behaviour.

Let's combat TB by addressing the barriers faced due to poverty such as infrastructural, housing, employment, educational and nutritional deficiencies.

Bobby Ramakant - CNS

Berlin 2010: TB, HIV and Lung Health: From research and innovation to solutions

The 41st Union World Conference on Lung Health will be held on 11-15 November 2010 in Berlin, Germany, and is expected to be attended by 2500 delegates from over 100 countries. The theme of this year's conference is "Tuberculosis (TB), HIV and lung health: from research and innovation to solutions." Read more

This conference is very special as it celebrates the 90th anniversary of The International Union Against Tuberculosis and Lung Disease (The Union), and marks the 100th anniversary of the death of Robert Koch who was the first person to isolate the tuberculosis bacillus in 1882 and subsequently awarded the Nobel Prize for his tuberculosis findings in 1905.

Despite recent progress, tuberculosis (TB) remains an important global public health problem. One-third of the world's population is currently infected with the tubercle bacillus, nearly 9 million new cases occur each year and close to 2 million of them die due to the disease. All countries are affected, but 85% of the cases occur in Africa (30%) and Asia(55%), with India and China alone accounting for 35% of all cases.

Pulmonary TB is contagious and spreads through the air and if not treated each person with active TB infects 10 to 15 people every year. Multidrug-resistant tuberculosis (MDR-TB) is a particularly dangerous form of drug-resistant TB and is defined as disease caused by TB bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. Rates of MDR-TB are high in some countries and, coupled with the devastating effects of TB-HIV co-infection, threaten to undermine TB control efforts worldwide.

TB is a grave health threat in India, accounting for one-fifth of the global cases of TB, killing two persons every 3 minutes. The country boasts of 2.2 million new cases every year, out of which 1 million are infectious, smear positive pulmonary cases. In fact, a recent study suggests that missed diagnosis of TB in India and China is spurring a global spread of the disease. Overcrowded living conditions combined with appalling sanitation help in the spread of this contagious disease.

DOTS was launched formally as the Revised National TB Control programme (RNTCP) in India to combat TB, in 1997. It was introduced to ensure that every TB patient completes the full six-month course of treatment, typically involving four drugs.

But this much-hyped programme, despite considerable success as reported by the WHO Global TB Control reports periodically in mitigating the impact of TB and reducing human suffering by ensuring the patients the best anti-TB medications free, has actually been less of a success than was previously assumed.

An alarming number of poor and vulnerable people who are at a high risk of TB find that benefits of DOTS are out of their reach, both economically and physically. A number of people like migrant labourers or daily wage workers do not undertake the full programme, and drop out before completing it. Such patients might develop drug-resistant TB - a deadlier form of the disease. Worse, even a single such defaulter can create a significantly large pool of infected people. Unless treatment is made convenient for patients, it will not have the desired results. In DOTS, the patient has to take anti-TB medicines in direct supervision of a health worker (or DOTS provider), or another trained person who is not a family member, at the centre. I personally know of many patients who found it very inconvenient to go to a DOTS centre everyday (or every alternate day where intermittent therapy is provided) to swallow the pills, and hence went on and off the treatment - a very dangerous step indeed, which very often results in relapse or development of drug resistant TB. Perhaps, if a family member is made responsible to administer the drugs every day, the outcome might be better. We probably have a lot to learn from home-based care (HBC) approaches in providing AIDS related treatment, care and support services. Or else the health worker should go to the patient's home to give the medicines - a seemingly impossible task in the Indian health set up which is considerably over burdened. We need to find new ways and means to monitor patients continually, until they complete the full course and recover.

While supervised treatment to ensure the right treatment given in the right way is the need of the hour, it is equally necessary that adequate standards of TB care be applied by all providers, whether public or private. The new International Standards for TB Care is a promising step in this direction.

We also need to promote the empowerment of civil society and communities in this fight against TB. The recent Patients Charter for TB Care, although a wonderful document, is yet to be adopted by national programmes. Most patients (and perhaps even doctors) in India are totally unaware of its contents.

Research on TB, neglected for decades, must be fostered to meet the increasingly pressing needs for new drugs, diagnostics and vaccines. Addressing TB/HIV and MDR-TB requires improved and rapid diagnostics and new classes of drugs. Discussions at the Open Forum 4 meet on 'Critical Path To New TB Drug Regimens' held in Ethiopia (August 2010) have brought forth new promises in this direction, and would hopefully be carried forward by this conference.

The social and economic costs of TB are enormous, as its incidence is concentrated in adults between the ages of 15 and 54, who are the primary wage earners. One estimate projects that the Thai economy will lose the equivalent of USD 7 billion by the year 2015, solely to TB sickness and death. In India, the estimated loss of economic output due to TB deaths reaches more than US$ 370 million every year. The combination of the enormous economic burden of TB and the inconsistent availability of cost-effective interventions, make TB one of the highest priorities for action in international health.

It is hoped that this 41st Union World Conference on Lung Health will greatly motivate participants to discuss the development of new diagnostics, anti TB drugs and vaccines along with further advances in HIV care, Lung Health and tobacco control, with a view to fully fund and optimally implement the revised Global Plan To Stop TB 2011-2015, which, in the words of Dr Mario Raviglione, Director, WHO Stop TB Department, "sets out the direction with renewed intensity in care and control efforts, and new approaches and tools to become available that should take us towards the achievable goal of TB elimination by 2050."

Shobha Shukla - CNS
(The author is the Editor of Citizen News Service (CNS) and also serves as the Director of CNS Stop-TB Initiative and CNS Diabetes Media Initiative (CNS-DMI). She has worked earlier with State Planning Institute, UP and teaches Physics in India's prestigious Loreto Convent College. Email: shobha@citizen-news.org, website: www.citizen-news.org)


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HIV activists help push tuberculosis awareness

Tallinn, Estonia: The call for a better, integrated approach to HIV and tuberculosis (TB) care has been getting louder worldwide in the past years. Equally, in terms of advocacy integration of the two diseases is gradually growing. People living with HIV speaking up on TB increasingly help put tuberculosis higher on the agenda. Read more


HIV and TB are the two deadliest infectious diseases globally, yet the attention given to and the awareness for the diseases remain largely unequal. Most of the spotlights are on HIV, not least because of strong activism for the disease. Advocacy for TB – though growing – remains much weaker. But TB's profile can be raised through the voices of those especially vulnerable to it: people living with HIV.

People who are HIV positive and infected with TB are 20 to 40 times more likely to develop active TB than people not infected with HIV. TB is a leading cause of death among people living with HIV, who have weakened immune systems. 
"Statistics show that especially in high burden countries people living with HIV are likely to get tuberculosis at least once in their lifetime. In some places co-infection is as high as 50% and mortality because of TB up to 60%," says Vivek Dharmaraj, project leader of Advocacy to Control TB Internationally (ACTION) Project / Global Health Advocates (GHA) India.

Engaging the HIV community is an area that ACTION/GHA has focused on. In India, they have worked extensively with the Indian Network for People living with HIV/AIDS (INP+) – a network of over 200,000 people in 24 states of India. "Advocacy is about education, empowerment and engagement," Dharmaraj explained at the sidelines of the Second Global Forum on TB Vaccines in Tallinn, Estonia, last month.

"Because this community is at such risk, they understand how serious TB is and how great the need is to have access to treatment. It is a matter of life and death," he continues. "TB is not easily diagnosed in the HIV patients; if undetected and not put on treatment early, tuberculosis can be quickly fatal in this co-infected condition. Apart from the need to know if they have TB, it becomes even more imperative that people living with HIV determine right at the start whether the tuberculosis is drug-resistant. As the community is educated and empowered in the area of tuberculosis they become engaged in advocacy. They can passionately advocate for better diagnostics tools, faster acting, less toxic drugs and vaccines."

"We have modules on TB, HIV-TB co-infection, treatment, what is freely available and then help them come to an understanding of what more is needed - diagnostics, drugs, etc," Dharmaraj says. "We encourage them to engage and advise their community, their local leaders, the politicians - who should be there for them. Not to blame but to go and share their knowledge and worries. They are often courageous and bold enough to speak up on TB as they have already taken the first step of coming out on their HIV status."

"HIV activists already deal with a lot of stigma," Claire Wingfield, TB/HIV project coordinator at TAG (Treatment Action Group) agrees. "And those with HIV/TB co-infection get the double stigma." In 2002 TAG, an HIV/AIDS research and policy think tank fighting for better treatment, a vaccine, and a cure for AIDS, included TB in its advocacy priorities because "we realized the people with HIV were at increased risk of developing and dying of TB." People living with HIV make loyal activists, Wingfield comments. "People get HIV for life, which means they are activists for life. When TB patients are cured, they are often no longer activists."

She sees the number of TB activists among people living with HIV growing. "It is great to see that for some TB is even their first issue now. They are absolutely raising the profile of TB. But it doesn’t have to be either TB or HIV. You can raise awareness for both, encourage discussion, make a difference."

Still, empowerment of TB patients has a long way to go, Wingfield stresses. "TB has such a public health approach, compared to the individual approach with HIV. There is not a lot of empowerment with information, neither among patients nor among health workers. The DOTS (Directly observed treatment, short-course) strategy is incredibly infantilizing, with people having to take medicine under observation of a healthcare worker. Where many HIV patients can exactly name their medicines, TB patients can often only say they take a yellow pill, a diamond shaped pill, etc. TB suffers from the white coat phenomenon: just take your medication because I said so."

"In India there has been some awareness among communities in the past few years. But some people still think TB is no longer a problem; that it is an old or only a poor person's disease or has even been eradicated," Dharmaraj of ACTION/GHA adds. "So a lot more has to be done to clear the air; we still need a bigger push to get the wider population involved more actively. We have to make sure to the disease is kept near the top of health agenda."

Wingfield hopes also activists from field other than HIV will increasingly address TB. "For mining communities, mother and child healthcare activists, labor unions, TB is a cross sector issue. It is important activists from other fields talk TB too."

Babs Verblackt - CNS(The author is a freelance journalist, a Fellow of CNS Writers' Bureau and Associate Communications atTuBerculosis Vaccine Initiative – TBVI) 


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