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Science Health Allied Research Education
Vijay V. Yeldandi, M.D., FACP, FCCP Secretary General Vishnu Chundi, M.D. Treasurer

SHARE Science Health Allied Research Education

MIIDRI

ICHHA International Center Human Health Advancement

APAIDSCON Andhra Pradesh AIDS Consortium supported in part by grants from United States Centers for Disease Control and Prevention (CDC) President's Emergency Plan for AIDS Relief ( PEPFAR).

PHMI Public Health Management Institute supported in part by grants from United States Centers for Diseases Control and Prevention (CDC) President's Emergency Plan for AIDS Relief ( PEPFAR).

SHARE Projects
MI PH
National level State Level

DS CO

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District Level

AP

AI

Community level

MIIDRI
 

MediCiti Immunology and Infectious Diseases Research Institute Mission:
   

To provide effective affordable comprehensive care for people with HIV/AIDS To educate and train health professionals and the community to deal with HIV/AIDS To support research using technological, social cultural tools to combat the HIV pandemic To provide a forum for international collaboration

HIV Prevalence data

Urban blood donors(data from 1997-2002) 14,185 tested 0.38% are HIV infected Rural pregnant women(data from 20012002) 1176 tested 1.19% are HIV infected More HIV infection in rural pregnant women than urban blood donors (OR 3.096: 95% CI 1.717-5.585 p< 0.001) ~ 2.5% of men between ages of 20-40 years , are HIV infected (Small non scientific sample survey)

02/10/08

HIV Risk Assessment Results

Demographics of all participants (n=5372)
  

Male: 45% ; Female: 55% Age: 18-25: 22%; 26-35:31%; 36-45:22% Marital: 82% married; 10% never married : 5% of all married participants report more than one partner after marriage – Of those reporting so, 88% were men 2% population report sexual contact in exchange for money at least once 1.5% participants report non-spousal partners as most recent sexual partner ( sex worker, friend) 98% report never using condoms with most recent partners

Sexual Behavior:

Sero-positive Individuals Total n=69 – HIV prevalence=1.28%
  

62% Male; 38% Female 84% 18-45 years of age 83% were married 12% reported 2 or more sexual partners premarriage 5% reported multiple partners after marriage 3% have had more than one partner in the past 6 months 25% of sero-positives report daily consumption of alcohol

Sexual Behavior
  

Marriage is a major risk

HIV Infection in Rural South India: A Sexual Network Analysis
JOHN A. SCHNEIDER, MD, MPH1, GURCHARAN SALUJA, MBBS2, VIJAY YELDANDI, MD, MIDC3, JOCELYN  TOLENTINO, MPH1, GANESH ORUGANTI, MD4, SRIPATHI DASS, MD2, PS REDDY, MD4, DAVID PITRAK, MD1;  1 University of Chicago, Chicago, IL,2MediCiti, Ghanpur Village, India,3Westlake Hospital, Melrose Park, IL,4MediCiti, Hyderabad,  India.
Supported in part by the International Center for Health and HIV/AIDS (ICHHA) and the University of Chicago

AIDS Care, 19:9, 1171 - 1176
BACKGROUND  The southern state of Andhra Pradesh (AP) has one of the highest  rates of HIV­1 infection in India. Recent estimates of HIV infection  in rural areas have begun to approximate the urban. Methods of  HIV transmission in rural India are poorly understood.  PURPOSE We  examined  risk  factors  for  HIV  transmission  in  a  group  of  rural      villages in AP through the use of a sexual network analysis survey ­  the Indian Health and Family Life Survey (IHFLS). MEASUREMENTS Laboratory ­ HIV­1 status retested using WHO testing strategy III with  additional Western Blot Confirmation.  RPR and hepatitis B serology  were also conducted.  Survey ­ 336 item IHFLS survey ( based upon the  National Health and Life Survey which has been validated in the US  and China) available in Telugu, English and Chinese.  17 domains  included detailed items on sociodemographics, personal health,  exposure to hypodermic needles, attitudes towards marriage and sex,  sex life, sexual partners, STIs, childhood sexual experiences,  homosexuality, sexual harassment and sexual consumption.   Conditional logistic regression models were used for all analyses.

RESULTS The sample mean age was 37 years, 22% were of a tribal caste  and 78% of a non­tribal caste. Seventy percent of the sample  earned <1000 rupees ($23) per month. When compared to  men, women were more likely to be born in another village  (87% vs. 10%; p<0.01) and less likely to have greater than  primary education (13% vs. 57%;p=0.014). Among female  respondents, none were commercial sex workers (CSW), and  there were no significant social or behavioral associations with  HIV infection. Among male respondents, 50% (5/10) of the  HIV(+) cases reported having sex with female CSW compared  to none (0/20) of the HIV(­) controls. All men who had sex  with female CSW were married, from a non­tribal caste and  did not use condoms. Men who had sex with men (MSM)  demonstrated a trend toward an increase in HIV infection  (OR=4.0;p=0.26). MSM were more likely to be tribal  (OR=16.0;p=0.042). All tribal MSM were married, had  multiple male partners, and did not use condoms. 
Figure 1. Sexual Matching Patterns of Polygamist Men, MSM and Men who Buy Sex ?
+ ? ? ? + + ? + + ? ? + + ? ?
Married Not Married Tribal Male Non-Tribal Male Non-CSW CSW ? - Unknown Caste + - HIV+

DESIGN, SETTING and PARTICIPANTS Design:  Case Control Study Setting:  38 villages in rural Ranga Reddy District, Andrhra Pradesh Participants: 60 participants (20 HIV infected and 40 controls) matched  by age, gender and village randomly selected from a Voluntary  Counseling and Testing Program.

Table 2. Selected Male Characteristics in Rural AP.
OR Personal Relationships 8.0 Marital Status (%) 3 33.3% 1 5.9% Remarried/Divorced/Widowed 6 66.7% 16 94.1% First marriage 2.7 Condom use in past year 1 12.5% 5 27.8% Yes 7 87.5% 13 72.2% No Life time sexual partners>1month 4 57.1% 17 100.0% 0-1 3 42.9% 0 0.0% 2 or more STDs 4.9 Genital Lesion in the past year (%) 2 20.0% 1 5.0% Yes 8 80.0% 19 95.0% No Sexual Consumption 0.6 Used sexually explicit media (%) 3 30.0% 8 40.0% Yes 7 70.0% 12 60.0% No Bought sex (%) 5 50.0% 0 0.0% Yes 5 50.0% 20 100.0% No Homosexuality 4.8 Homosexual feelings (%) 2 20.0% 1 5.0% Yes 8 80.0% 19 95.0% No 2.1 Sex with other men (%) 1 10.0% 1 5.0% Yes 9 90.0% 19 95.0% No *Fischer Exact test used to obtain a p-value when conditional and unconditional logistic regression models did not converge. HIV+ Cases N = 10 Matched Controls N = 20 95% CI* 0.69-92.70 0.26-27.82 p=0.03*

Table 1. Sociodemographic Characteristics (30 men and 30 women). Cases = 20 Controls = 40 OR 34.6 (12.9) 38.6 (11.2) 0.97 Age (mean, SD) 1.09 Caste (%) 3 15.0% 5 12.5% Other Caste (OC) 2 10.0% 8 20.0% Scheduled Caste (SC) 10 50.0% 19 47.5% Backwards Caste (BC) 5 25.0% 8 20.0% Scheduled Tribe (ST) 0.74 Education (%) 6 30.0% 11 27.5% >Primary 14 70.0% 29 72.5% ≤Primary 2.27* Birthplace (%) 7 35.0% 22 55.0% Outside this Village 13 65.0% 18 45.0% This Village 1.00 Occupation Type (%) 9 47.4% 19 47.5% Non-Agriculture 10 52.6% 21 52.5% Agriculture 0.80 Personal Income 7 38.9% 11 32.4% > 1000 rupees ($23) 11 61.1% 23 67.6% < 1000 rupees 1.44 Overnight travel past year Never to less than a month 16 80.0% 34 85.0% 4 20.0% 6 15.0% More than a month *Unconditional Logistic Regression

(95% CI) 0.92-1.02 0.40 - 2.99

? ? ? ? ?

0.38-60.15

0.11 - 4.90

0.13-3.25 p=0.002*

? ?

0.75 - 6.89

0.34 - 2.93

CONCLUSIONS

0.38-60.15 0.12-37.72

0.26 - 2.45

0.34 - 6.11

    In a rural south Indian sample, we did not identify specific  HIV risk factors in women. For men, both CSW and  potentially MSM play a role in dissemination of HIV infection  in identifiable subpopulations. MSM amongst tribal  individuals in rural areas may be a mechanism of HIV  transmission and warrants further study. Public health  interventions aimed at reducing HIV transmission in rural AP  should consider targeting subpopulations of men that engage  in covert MSM or CSW, as well as their at risk wives. 

Comprehensive Risk Reduction in India Strategic Partnership (CRISP)
 

 

Lowest HIV prevalence in any truck driver survey in India – 2.1% No incident cases of HIV infection of truck drivers tested more than once Acceptability of Education and Motivation Counseling Services is High Only PPP program in India Only Privately Funded Truck Driver program providing VCT in the Country

Pilot Study 2004-2006

Mean age was 30.2, 56% were from out of state, 73% spent <7days away from family per year, 58% reported consistent condom use when visiting a commercial sex worker (CSW) 2.1% (n=5) were HIV infected at baseline. Unmarried status men were more likely to be HIV-infected (OR 5.1; p=0.05). Having anal sex with a man or visiting a CSW in last six months, genital symptoms or STD diagnosis in the last 12 months and number of sex partners in the last 12 months were not associated with HIV infection (OR 0.9-2.5; p-values=0.3-1.0). The 13.5% of drivers who returned for follow-up reported increased handwashing before eating (p=0.04), were more likely to have heard of the germ theory (OR 6.3; p=0.02), and had an overall improvement in HIV knowledge (p=0.022), but did not demonstrate changes in HIV risk taking behavior. Information Motivation (IM)?
Presented at IAS 2007, Sydney Australia

Gati

Gati Community Health Center (GCHC)
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5 days a week – Inaugurated 27, March 2007 Key screening and care areas
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Diabetes, High Blood Pressure, Body Mass Index, Nutrition, Heart Disease, Vision Check, Mental Health, STD/HIV New Employee Physical Exam

Strengthening Partnership with MediCiti
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Community Medicine Faculty to Staff Clinic Medical Students to join in July

Develop Core Committee group of Transport Industry Leaders to Set HIV Policy – Led by Mr. Swarup
 

Conference September 8th and 9th, 2007 Committee Meetings Supported by Public Health Management Institute/Centers for Disease Control and Prevention Global AIDS Program

Gati Community Health Center

Gati Community Health Center

Andhra Pradesh AIDS Consortium APAIDSCON

Consortium of Private Medical Colleges and hospitals in Andhra Pradesh for HIV/AIDS related programs Bhasker Medical College, Moinabad, Ranga Reddy; Deccan College of Medical Sciences, Hyderabad; Chalmeda Ananda Rao Institute of Medical Sciences, Karimnagar; GSL Medical College, Rajamunddry, East Godavary; Kamineni Institute of Medical Sciences, Narketpally,Nalgonda; Katuri Medical College, Guntur; Konaseema Institute of Medical Sciences and Research Foundation, Amalapur; Mediciti Institute of Medical Sciences, Ghanpur, Medchal R.R.Dist; Mamata Medical College, Khammam; Maharaja's Institute of Medical Sciences,Vizianagaram; MNR Medical College, Sangareddy, Medak; NRI Academy of Sciences, Guntur; Dr Pinamaneni Siddhartha Institute of Medical Sciences & Research Foundation, Gannavaram; Sri Venkata Sai Medical College, Mahbubnagar; .ASRAMS, Eluru; SHADAN Institute of Medical Sciences, Hyderabad

Partne ring Institute s
Chalmeda
Adilabad

MNR
Nizamabad Karimnagar

Mamata

ra aga ian z Vi

m

Srikakulam

Deccan
Medak Hyderabad Khammam Warangal East Godavari West Godavari Krishna Mahabubnagar Guntur Visakhapatnam

MIMS Bhaskara SVS

Rangareddy

Nalgonda

Maharajah’s GSL

NRI
Kurnool 0.75% Prakasam

Katuri Kamineni

Ananthapur

Cuddapah

Nellore

Chittoor

APAIDSCON Aims
Opening doors for HIV/AIDS patients by 1.

2.

3.

Providing Comprehensive Care and Support services Setting up referral lab services for subsidized CD4 / Viral load testing To conduct outreach activities for awareness of HIV/AIDS among community and vulnerable groups.

Objectives - APAIDSCON

Implement and sustain a standardized approach to care and management of People Living With HIV/AIDS (PLWHA) to maintain quality of life and reduce transmission to vulnerable - women and children. Maintain the safety at work place and community from blood-borne and other infections. Improve clinical competency of the network of physicians through continuing medical education programs and capacity building. Improve private and public collaborations to expand services like counseling and testing within the communities of each member organization

Strategies
Training and Capacity building Monitoring and Support To ICTC/PPTCT

Opening doors for HIV/AIDS

Laboratory support

Outreach through Partners & Red Ribbon Clubs

Improve Public Private Partnerships

1. Capacity building (training)

Sensitization for healthcare workers – - Doctors - Nurses - Housekeeping staff - Medical students

Advanced clinical hands on trainings for - Doctors

Refresher and review meetings for -Counselors - Lab technicians

How many did we reach
Personnel trained Doctors Nurses Housekeeping staff Medical students Counselors Lab technicians State level (numbers) 90 27 30 15 15 Institution level (numbers) 507 952 956 2334 Oct 06- Sep 07

2. Monitoring and support to ICTC and PPTCT - A Public Private Partnership

15 Counselors and Laboratory technicians placed by APSACS in 9 ICTCs and 6 PPTCTs of the consortium partners

Monitoring of these 15 centers handed over by APSACS to APAIDSCON

Particulars No. of ANCs Tested No. found Positive No. of ANCs Delivered Positivity Percentage
(All data during Oct 06 – Sep 07)

Target 6000 NA 60 NA

Achieve d 20,786 159 67 0.76% Target Achieve d 19,510 1,164 5.96%

PPTCT

Particulars

No. of People Tested 12,000 No. found Positive Positivity Percentage NA NA

VCTC

3. Outreach

Red Ribbon Clubs: Run by medical students of the partnering institutions. Action at 2 levels :– 6. Individual level 7. Community level they Reach out to schools, other colleges and community

Outreach by Partnering Institutions: Partners conduct regular outreach activities through their community medicine department.

Outreach
ACTIVITY TARGET
Cumulativ A e no. achieved AB for all Partnering Institutes

6200 6200 3050

ACHIEVE D 6464 6753 6142

C

A – Abstinence

B – Being Faithful

C – Condom
(Oct 06- Sep 07)

World AIDS day rally

Street play by medical students

Pledging on the World AIDS day

Sensitization program for Doctors and Medical students

Sensitization program of Nurses

Reaching out to Schools…

Sensitizing Community level workers

Community outreach program for HIV awareness

Medical students sensitization ( HIV elective)

HIV Curriculum

John A. Schneider MD, MPH
 

Clinical Associate, Section of Infectious Diseases, University of Chicago Senior Research Fellow, Center for AIDS Research (CFAR), Brown University Associate Director, MediCiti Immunology and Infectious Diseases Research Institute, SHARE/MediCiti

Curriculum
               

For Phase I students, lectures from the curriculum will cover the material in the following MCI designated requirements: Community Medicine, - Prevention and Humanities – 1 hour For phase II students, lectures from the curriculum will be incorporated into the following MCI designated requirements: General Pathology, SI. No. 8(h) – AIDS – Integrated Teaching – 1 hour Microbiology, SI. No. 5 – General Virology AND Systemic Virology – 1 hour Microbiology Symposia and Seminars – 2 hours Pharmacology SI.No. 21 – National Programmes Including Management of AIDS – 1 hour For phase III students units will be broken into the following Theory and Practical MCI Requirement: General Medicine, SI. No. 7 – AIDS – 2 hours theory; 1 hour Practical General Medicine, SI. No. 7 – Infectious Diseases– 2 hours theory; 1 hours Practical General Medicine, SI. No. 6 – C.N.S. – 1 hour theory, 1 hour practical General Medicine, SI. No. 5 – T.B. and Chest Diseases; 2 hour theory, 1 hour practical Pediatrics, 2 Course Content - Infectious Diseases – 1 hour lecture Obstetrics and Gynaecology, Theory 24, STD and HIV – 1 hour lecture Obstetrics and Gynaecology, Family Planning 2, Contraception – 1 hour lecture Obstetrics and Gynaecology, Integrated Teaching 8, HIV complicating pregnancy – 1 hour lecture

Evaluation

Pre and Post Test

HIV Knowledge To Compare to US Medical Students For Phase Three Students Only

General Medical Student Survey
 

General Nursing Student Survey

Red Ribbon Clubs

Red Ribbon Club glimpses

Sensitization & Introduction to Red Ribbon

A Red Ribbon Club Head quarters

4. Laboratory Support

Quality CD4 testing for partners at affordable price to the patient (Rs200) Innovative mechanism of transporting samples to the lab A unique sample transport bag was prepared GATI cargo services provided support in hand delivery and surface / air transport of the sample

CD4 Sample transport bags

Vision
“A HIV-free India through enhanced public health systems, with a fullyengaged private sector and leadership of public health managers & prevention specialists.”

Mission
“Maximize Public health management and HIV prevention capacity of individuals, government bodies, and organizations (NGOs, CBOs, Private / Corporate agencies, etc.) that serve communities & individuals affected by or at risk for HIV/AIDS in India and globally”.

To develop A Public Health Movement in India – We target
•Public Health Managers, Clinicians, •Professional Social Workers, •Health Economists, Political & Administrative Bureaucrats •Media & IEC Experts, Community leaders, •Women self help groups, •Film industry, •Policy &Law makers involved in Health Care Services in India to improve and update their capacity to global standards to revitalize the HCS towards reducing the human suffering in a most cost effective manner. •Organizations currently working on HIV prevention, keen on adding • An HIV prevention component to their current work plan

Objectives

Create high quality human resources (e.g. Field level Public Health Leaders) for capacity building and systems strengthening in India Mainstreaming HIV/AIDS services. System strengthening through establishing models in Government, Private & Corporate health care services.

 

Activities of PHMI
1. Supporting Government agencies (e.g. SACS, NACO) for –
   

Management of the ICTC, M&E, Surveillance & Program management Systems strengthening through Consultants. Strengthening and developing systems to operationalize ART programs Innovative initiatives e.g. accreditation, down-referrals etc.

2. Developing CDC guided technical accreditation/certification for private labs & Private clinicians who conduct large number of HIV tests. 3. Short Public Health Management trainings in collaboration with IIHM&R 4. Developing model laboratory with HIV focus 5. Starting model Infectious Diseases Clinic. (HIV/TB/OI/ART)

Activities of PHMI contd…..
1. Setting up Diseases Surveillance Center with HIV focus 2. Supporting GHTM with the strategic management and data management systems through Tambaram Health Information System (T/HIS). 3. High quality technical Human Resource Capacity Development through Public Health Field Leaders Fellowship (PHFLF) with technical support of CDC and NASTAD 4. Organize workshops & CMEs on HIV-related information of Strategic & Technical Importance / relevance  5. Training of District AIDS Prevention and Control Units

What we did so far…

Conducted 13th International Conference on “Mainstreaming the public health response to HIVAIDS” - Attended by more than 400 delegates representing a large spectrum of stakeholders. Established a center to house model HIV Lab, ID Clinic for HIV, TB,& other infectious diseases. Lab.certification training for the 1st batch completed. Strengthened the data management system of GHTM, Tambaram. Technical support of APSACS through three

Transport Sector Working Group
XIII Annual CME NISIET Hyderabad, AP

History

First Meet in February at RTA Commissioner’s Office – Hyderabad

Vendors

    

Second Meet in March

Corporate

Third Meet in March

Vendors, mostly Gati Drivers Drivers

Fourth Meet in April

Fifth Meet in June

Sixth Meet NISIET

Drivers, Vendors, Corporate; All Separate

Health Problems in Truckers

Younger group

Less concerned about chronic disease Tension – Stress of delivering on time

Top Problems in this order

Can lead to suicide; loss of job

 

HIV/STIs – HIV/STIs not related to Tension

Pathways

    

Musculoskeletal – Aches/pains Diet – quality, quantity Sleep – quality, quantity Vision Accidents

Barriers to Accessing Health Care

Nature of the Job

Time and Money Parking not allowed Trucks not allowed Small roads Difficult to get married Difficult to get money Constant pressure from vendors and company

Lack of Accessible Services
  

No respect in society
  

Solutions
 

Take care of the entire driver ?tax breaks to “healthy” stops

Good food, water Proper Restrooms Phone minutes Sun-glasses Health clinics

Interventions
   

Greater need for corporate and vendor leadership

Measures

Measure accidents, infections, disease status at a trucker population based level Development of Clinics that Provide Full Spectrum of Services

Most only treat STIs and give education, but don’t provide HIV testing or other targeted health services

Public Health Field Leader Fellowship (PHFLF) – A unique initiative

One-year fellowship in a distance education mode, with six week of bimonthly contact sessions – started on Nov 12th 2007. Curriculum support from National Alliance of State and Territorial AIDS Directors (NASTAD) 25 fellows selected from a highly competitive and large applicant pool nationwide Concepts and practices with real-time

Public Health Field Leader

PHMI:

Fellowship Curriculum outline (for 6weeks):
Getting to know your community (and the virus) Data for decision Making IEC/BCC and Social Marketing Communications and advocacy Managerial skills Wild card (to address specific needs of trainees)

3. 4. 5. 6. 7. 8.

Public Health Field Leader Fellowship (PHFLF) Graduation Requirements:
To develop public health leaders and managers who would be seen as public health experts in the field of HIV PHMI expects minimum requirements for graduation:

 Bi-monthly on-site & residential hands-on training that will be technical and managerial (total of 6 weeks per year) Full participation and attendance

PHMI:

 self learning as a strong method of the-job trainings and skill development (with continuous ongoing mentoring)  completion of a final project (which is closely linked to the output of your daily work and job responsibilities)

Batch- 1 PHFLF/PHMI

The agenda ahead….
 

Technical support to NACO with 3 ART Consultants and 3 NACO Coordinators to SACS. To strengthen AP Chest Hospital on par with GHTM and Gandhi Hospital, Hyderabad. Health System Management trainings for Government and Private Medical College Hospitals. Protocol based treatment & Soft skills hands on trainings for clinicians and health managers. Diseases Surveillance & MIS trainings for Data Managers Cost effective management, effective implementation of NRHM, NUHM, HSD, Costing & Budgeting of Health Systems in India for Public Health Officers of line depts. Establishing effective Public – Private Partnership in

New Strategies for HIV Prevention
 

Decrease Substance Abuse Non-condom prevention interventions? Targeting high-risk groups

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