India

This program is run by the Jeevan Jyoti Health Service Society based at Jeevan Jyoti Hospital, a 100-bed tertiary care facility with three ORs and a blood bank. In four towns of Jhabua district counselors run Voluntary Confidential Counseling and Testing Centers (VCCTCs) from where they refer individuals. The program creates HIV awareness in schools and villages with the help of counsellors and 500 self-help groups, ie. more than 6,000 village women.

Background

India is sometimes projected to have as many as 25 million HIV/AIDS cases by the year 2010, outnumbering all other countries.¹ More than five million people in India are already infected with HIV while the epidemic is now reaching the rural communities and the National AIDS Control Organization (NACO) is only gradually upgrading its Voluntary Counseling and Testing program.²

In the Western-most part of Madhya Pradesh, a state in Central India which is still regarded to have a low-prevalence, Jhabua district with its 85% tribal population, presents with among the lowest literacy rates of the country.³ 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.⁴

In 2002, Gujarat saw an HIV prevalence of more than five percent among high-risk groups, while Maharashtra was regarded as a high-prevalence state since more than one percent of pregnant women were infected with HIV.⁵ Working as migrant laborers in urban areas, the tribal illiterate migrant workers of Jhabua are exposed to a number of risk factors to acquire HIV/AIDS including sexual exploitation and contact with commercial sex workers. In Jhabua district, the only AIDS cell is currently staffed by a half-time employed counselor at the district hospital, which is not reachable from several pockets of the district because transportation is either lacking, time-consuming or expensive.Fabian Toegel, a physician from Germany and honorary Country Director for India of Real Medicine Foundation initiated a program to increase capacity of the Government's voluntary confidential counseling and testing center (VCCTC) in the district headquarter in Jhabua. He recruited the former Government HIV officer, Dr. Rathore, as program director and employed the Government's HIV counselor, Shashank Nagar, to work part-time for the project. In addition, he recruited two male counselors with Master of Social Work degrees, to work at three strategically located Government clinics in the district while a female counselor would perform counseling of female patients and pregnant women at the district hospital. While full confidentiality will be maintained and guaranteed, the Madhya Pradesh AIDS Control Society's (MPSACS) District Nodal Officer in Jhabua will be overlooking the activities and document and report the cases according to rules and regulations of the Government of India and the National AIDS Control Organization. The local implementing agency is Jeevan Jyoti Health Service Society which runs a 100-bed mission hospital in the Northern part of the district and which handles all money transactions. Individuals who will be found to be HIV positive will 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.

Training of counselors is conducted by Wockhardt-Harvard Medical International HIV/AIDS Education and Research Foundation (WHARF) in Mumbai or Jhabua at three-month intervals. While the counselors had received their first one-week training in Mumbai in September 2005⁶, WHARF faculty Dr. Rachna Bharadwaj and Program Coordinator Rakhi Nair visited the counselors in their workplaces in January of 2006.

The World Health Organization advocates the "right to know" in that every individual is entitled to know his or her HIV status and this in turn calls for an expansion of HIV testing under the Voluntary Counseling and Testing program.⁷ The world has seen increased resources that are available for combating the epidemic and an increased emphasis on treatment supported by many countries including the G8. ⁸ An expansion of testing under the Government's program in Jhabua district will therefore grant access to its inhabitants at a larger scale. The Government represented by the District Nodal Officer of the Madhya Pradesh State AIDS Control Society (MPSACS) and the Chief Medical and Health Officer have agreed to a private public partnership with RMF's partner organization Jeevan Jyoti Health Service Society (JJHSS) to expand the VCT Program in Jhabua District.

¹National Intelligence Council. The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China. Intelligence Community Assessment, September 2002.

²Fears over India rural HIV rate. BBC News, UK version. 30 November 2005. http://news.bbc.co.uk/1/hi/world/south_asia/4486568.stm

³Education for All, India. 2003. http://www.educationforallinindia.com/page157.html

⁴Jhabua: Statistical profile. National Informatics Centre, Madhya Pradesh. 2005.

⁵UNAIDS India, 2006. HIV Epidemic in India, Maps 2002.

⁶Jhabua Counselors Orientation Program: A Report from WHARF.

Goal

The World Health Organization advocates the "right to know" in that every individual is entitled to know his or her HIV status and this in turn calls for an expansion of HIV testing under the Voluntary Counseling and Testing program.⁷ The world has seen increased resources that are available for combating the epidemic and an increased emphasis on treatment supported by many countries including the G8. ⁸ An expansion of testing under the Government's program in Jhabua district will therefore grant access to its inhabitants at a larger scale. The Government represented by the District Nodal Officer of the Madhya Pradesh State AIDS Control Society (MPSACS) and the Chief Medical and Health Officer have agreed to a private public partnership with RMF's partner organization Jeevan Jyoti Health Service Society (JJHSS) to expand the VCT Program in Jhabua District.

⁷Right to know. World Health Organization. Geneva, 2003.

⁸De Cock, K et al. Unfinished Business ? Expanding HIV Testing in Developing Countries. N Engl J Med. 2006 Feb 2;354(5):440-2

Objectives

The program aims to gain an understanding of the magnitude of the epidemic in Jhabua by testing patients and pregnant women visiting the clinics while providing care and treatment at Jeevan Jyoti Hospital for the persons living with HIV/AIDS. Given the high vulnerability of the tribal population due to poverty, illiteracy, tribal customs and migration to high prevalence states, the prevalence in Jhabua may very well be higher than the Government alleges for the rest of the state. While the Government in the form of the Madhya Pradesh AIDS Control Society (MPSACS) provides the legal frame in which this program operates, the Real Medicine Foundation?s initiative provides consistent supply of funds, permanent monitoring from the donor's side, and continuous training of counselors.

Other places in India have fully implemented HIV prevention, care and treatment programs run by the Government such as Calicut Medical College which Dr. Toegel had recently visited during a field trip to Kerala in January of 2006. These are well-coordinated programs which rely on the collaboration between the State AIDS Control Society, different hospital departments and NGOs. Given their mission, NACO and MPSACS are expected to upscale their commitment to the fight HIV/AIDS in Jhabua and support this public-private partnership with human and financial resources. For rural areas, this public-private partnership is a pilot project which has the potential to be a model for fighting HIV/AIDS in underdeveloped regions.

Components

• Running Four Voluntary Confidential Counseling and Testing Centers

1. Jhabua: At the district headquarter, 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, another counselor with a Master of Social Work (MSW) degree, who counsels women and expecting mothers. Recently, the Government has introduced incentives for pregnant women to deliver at the newly built Mother and Child Wards of the hospital. This incentives 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 Parent-to-child transmission of HIV.
2. Alirajpur: This town is an administrative head-quarter 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 the counselor.
3. Petlawad: This administrative sub-unit in the North-Eastern part of the district is the site of another VCCTC where the counselor Mr. Chandrapal Singh Rathore, MSW works with at the Primary Health Center in collaboration with the Petlawad's Block Medical Officer.
4. Meghnagar: This town half-way between Jhabua and Petlawad is the site of the Jeevan Jyoti Hospital, where the Jeevan Jyoti Health Service Society has been running this institution for over ten years. It 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 both VCT services are offered and patients will be cared for and treated if individuals are found to be positive. The hospital is about to become affiliated with one of the top-ten medical schools in India, St. John's Medical College in Bangalore, for training and research purposes.

• HIV Prevention and Education Initiatives in villages and at schools

A survey conducted by WHARF in 2004 in which 500 tribal villagers were interviewed showed that more than 80% of men and more than 90% of women were not aware what HIV was, while only 29% of men and 13% of women had heard of AIDS. Most of the persons interviewed were not aware how HIV is transmitted while they thought that kissing or hugging, eating or shaking hands or being in the same place with an HIV positive individual could cause 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, who in turn teach other village members. During the school summer vacation (April through June) education programs and workshops for high school students across the district will teach them about adolescent health and HIV.

• Capacity building of the members of the community

All members of the tribal community once educated or trained, can tell and teach the other members of the community about HIV in order to raise awareness. Their contributions to spreading awareness about HIV and the testing facilities as well as the right to know about one's HIV status will be awarded through incentives.

Implications

The Government of Madhya Pradesh has been seeking public-private partnerships in the form of the ?Patient Welfare Societies? which run all 45 district hospitals in the state and local NGOs which are in charge of certain Primary Health Centers.⁹ The public-private collaboration to run the existing VCCTC and open new ones in Jhabua, is an option that should be financially supported by private and public institutions, the Government, corporations, as well as international donor agencies.

According to the prevalence rate determined by this program, different prevention and care strategies can be designed. Persons including pregnant women testing positive will be counseled, cared for and treated at the Jeevan Jyoti Mission Hospital. Treatment protocols will follow the guidelines of institutions such as Calicut Medical College including those of the Prevention of Parent-to-Child Transmission (PPTCT) program.

⁹Ministry of Health and Family Welfare, Government of India, in collaboration with the World Health Organization Country Office India. Health Sector Reforms in India: Initiatives from Nine States. No year available. 37-49

Monitoring and evaluation

Jeevan Jyoti Health Service Society will be sending monthly reports to the donors regarding all activities including financial transactions. WHARF will be an independent agency to monitor and evaluate the program.