Community-based VCT demanded

Civil society networks, United Nations agencies and other partners in Asia and the Pacific are urging a rapid increase of voluntary confidential community-based HIV testing and counselling for key populations at higher risk in the region – including men who have sex with men, transgender people, sex workers and people who use drugs – to help ensure more people in need are able to access life-saving antiretroviral treatment.

Low levels of access to HIV testing and counselling for key populations remains a serious cause for concern in Asia and the Pacific. Across the region, less than half of the key populations know their HIV status, which can lead to late diagnosis, late initiation to care and treatment services, and can result in unnecessarily high morbidity and mortality for people living with HIV. This also means the benefits of the prevention impact of antiretroviral therapy (ART) are not being fully maximized.

Although countries have made significant strides to expand coverage of ART in recent years, in 2012 only around half of people eligible for ART were receiving it. If access to antiretroviral treatment is to be increased, there is an urgent need to change current approaches to HIV testing and counselling. This can only be achieved by ministries of health partnering with community organizations who are trusted by their peers to provide life-saving HIV prevention, care and support, and who understand how to deliver services that are ethical, convenient, acceptable and effective.

Access to HIV testing of any kind has been low among key populations in Indonesia, for example. Between a third of female sex workers and three quarters of transgender people have tested. Earlier this year, the Minister of Health signed a circular distributed to health departments in all provinces and districts in the country, as well to the directors of every hospital. The circular recommended that people from key populations living with HIV should be started on ART regardless of their CD4 cell count. This is “Test and Treat” for key populations; a major step forward in increasing access to treatment. Even the most conservative estimates for Indonesian key populations are 800,000 people. A major barrier to them exercising their right to health was removed with the stroke of the Minister’s pen.

Giving drug users a path

By Sumita Thapar

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Oral substitution therapy (OST) saves lives, improves quality of life, and helps people who use drugs to lead functional lives, advocates say. It is like “insulin for a diabetic,” argues Dr M Suresh Kumar, a psychiatrist from Chennai, India, who has worked on substance use disorder for over 30 years. Beneficiaries of OST agree that it turns drug use into a chronic condition, which can be managed with medical and psychosocial help. “By taking care of withdrawal, it saves them from doing ‘desperate’ things.”

OST involves replacing a short acting opioid such as heroin with a long acting substitute drug – methadone or buprenorphine. Taken orally once a day in a clinical setting, dose and adherence are critical to effectiveness. By taking care of withdrawal it helps users to lead functional lives. Drug users living with are also able to adhere better to long-term treatments for HIV, tuberculosis or hepatitis. It reduces the risk of acquiring new infections by doing away with injecting.

Though OST is offered in South Asian countries (except Sri Lanka), the coverage is low. While pilots have been done in Afghanistan and Pakistan, Bangladesh has just a small intervention restricted to Dhaka. In India, OST is going from pilot to scale, with the next phase of the national programme in 2014 and aiming for a coverage of 40%.

Project ORCHID has done pioneering work on harm reduction and OST in Manipur and Nagaland in North-East India for over 10 years. Lessons from the project are now being used in the national programme.

“Equity in service delivery is a major challenge since beneficiaries must visit the centre every day to receive the dosage,” says Melody Lalmuanpuii, Project ORCHID. “The population is dispersed, there are a large number of users in rural areas, and women drug users are hidden since they are stigmatized more.”

Although buprenorphine costs over 10 times more than methadone, countries such as India use it because it does not carry any risk of overdose. Advocates of OST say beneficiaries can be on OST as long as they need to, and this can vary considerably between users.

Glimpses of the HIV picture in the PICTS

By Shobha Shukla

Beginning with the Lord’s Prayer, HE Ratu Epeli Nailatikau, President of Fiji began the ‘Pacific Islands Voyage’ with a celebration of the united efforts of the 22 countries comprising the Pacific Island Countries and territories (PICTS) in response to HIV and other sexually-transmitted infections (STIs).

With a population of around 10 million, the region is home to one third’s of the world languages and a rich cultural diversity. PICTS has a low HIV prevalence rate of < 0.1% (with the exception of Papua New Guinea, which has prevalence of 0.9%) with three countries reporting no HIV at all.

However, STIs rates are among the highest in the world and an estimated 25% of the Pacific Islanders below the age of 25 suffer from an STI.

“Gender inequality and traditional gender roles in the region adversely impact the sexual and reproductive health of women. Condom use is inconsistent and alcohol consumption and drug use are other risky behaviours increasing the individual’s risk to STIs and HIV,” the President conceded. “Also many countries have legislation that is discriminatory against sex workers, MSMs, TGs and PLHIV.”

And yet, the responses towards HIV/STI have improved tremendously over the past few years. A Rapid Diagnostics of HIV Testing Algorithm has been rolled out in countries. Specimens were previously shipped to Australia or New Zealand for testing. These rapid tests have reduced the turnaround time from > 4 weeks to less than 48 hours. This has increased the number of people tested, with some countries testing >50% of their population.

A five-country study (in Fiji, Guam, Kiribati, Samoa and Solomon Islands) revealed that more than 50% of the respondents on ARTs had stopped treatment at least once. Poverty, stigma and discrimination, little knowledge about treatment, and lack of family support are major barriers to adherence and often result in PLHIVs quitting treatment. Some are also overwhelmed with the side-effects. In many cases the simple gesture of being reminded by a family member to take the medicine was enough incentive to continue treatment.

Rebecca Kubu Navanua of the Pacific Positive Group of Women felt that PLHIV, who are trained as community and outreach workers, play an important role by way of community outreach, advocacy and governance. They facilitate education sessions in the community focusing on safe sex, the need for acceptance and love from family and friends, ensuring that people can live normal lives on treatment and can have children free of HIV. The outreach workers also give inputs in drafting HIV laws/policies; work with church leaders; and do training on human rights including right to treatment without discrimination so that people with HIV get the respect they deserve. They have meaningful involvement in governance as members of several decision-making bodies like national AIDS committees, national HIV boards and national networks.

Dr Moale Kariko, of the PNG National AIDS Council Secretariat, summed up the way forward. Since 2011, access to testing, treatment and information on HIV has improved considerably. HIV is now concentrated in certain geographical regions and in key populations such as sex workers. However risk factors exist with the potential for the virus to spread more widely. Rates of STIs are very high and gender inequality, stigma and discrimination add fuel to fire. 26% of those in need of ART are still not accessing it, loss-to-follow up is high and condom use is low. More investment is required for prevention interventions in most at risk populations.

Innovation is crucial in HIV fight

By Swapna Majumdar

India has the world’s third-largest population of people living with HIV – 2.4 million. Nevertheless, it has been able to make significant progress in recent years – by thinking out of the box. Over the past decade, this has led to a 50% decline in the number of new infections. For a country that was once feared could eventually house the largest number of people living with HIV in the world, this is no mean feat.

One such innovative programme is the ‘link worker scheme’ (LWS) designed to bridge the gaps in rural India caused by a lack of awareness of the infection, reduce stigma and discrimination associated with HIV and link people to quality health care services.

Realizing that greater attention was required in the rural areas where many of the 120,000 new people diagnosed as HIV-positive in 2011 live, the National AIDS Control Organisation (NACO) initiated the LWS to reach marginalized groups in districts across the 18 states known to be hot spots of the epidemic.

One male and one female link worker work together as a team. Pairs are responsible for a cluster of five vulnerable villages, each with a population of over 5,000, including people living with HIV and sex workers practicing sex work in the village. It was the strategy to choose link workers from the community, many of who are themselves living with HIV, that has helped bring change at the grassroots level.

Bihar State, which is home to over 100,000 HIV-positive people, is rapidly emerging as one of the high HIV prevalence states in the country. High rates of migration for work from tribal and poor communities combine with low levels of literacy and skill in this hot spot of the epidemic. A number of studies have documented that migrants encounter more HIV risk through sexual behaviour than non-migrants, potentially spreading HIV from high prevalence areas to lower ones.

All these factors coupled with high percentage of early marriage, little or no awareness of HIV, unsafe sexual practices, a poor health care system and gender inequality, have made rural Bihar highly vulnerable to the epidemic. The link workers are therefore crucial in the government’s bid to prevent HIV transmission as well as creating an enabling environment for people living with HIV to seek treatment and other care services.

Sitamarhi is one of the five districts where the LWS has been launched in Bihar State. It has the highest HIV prevalence rate in the state (3.7%), shares its borders with Nepal and five other high risk districts in Bihar. The presence of a red-light area has increased its vulnerability to cross border and inter-state trafficking. Reaching out to sex workers, primarily female, is critical. One of the facts behind the LWS was conclusive evidence of a strong presence of sex work in rural areas, and the need to reach out to them.

This is where the women link workers are making a difference. Mostly in their mid-twenties and from the same communities where the programmes are launched, they are creating awareness about HIV-related risks. Although difficult to discuss sex and sexuality in relatively conservative Bihar, the persistence and commitment of the link workers has paid off.

They have won the trust of sex workers. Rama, a sex worker in Radhaur said that a specific link worker helped her to understand the importance of protecting herself. “I make sure that the condoms she gives me are used by the clients. I also got myself tested after she convinced me that treatment would enable me to lead a normal life, in case I had acquired HIV. Thankfully, I tested negative. At least now I don’t have to live in fear. I am happy that I listened to her.”

Understanding the specific needs of affected women and girls different communities, whether housewives or sex workers, is key to combating HIV. This concern has been overcome by the cadre of link workers in Bihar, who have managed to increase the number of referrals to testing centres by adopting inventive ways of convincing vulnerable communities to access treatment.

Five things you need to know about naloxone

By Naloxone Ninja

NN_postcard1You 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.

You can help too. Here are the five main things you need to know about naloxone:

1. Used in emergency rooms for decades, naloxone saves lives and should be available at the scene of any overdose. Naloxone is extremely safe, cheap and easy to use. With overdose as a leading cause of death for drug users around the world making naloxone easily available to them and those around them is a no-brainer.

2. Naloxone attracts participants to other life-saving public health services, including HIV treatment and harm reduction programmes. For many people who use drugs, overdose is a much more immediate problem than HIV or hepatitis. By offering drug users what they need – i.e. naloxone – programmes find that they often are able to engage new people in their other services, like HIV testing and treatment.

3. Naloxone is empowering. People who rescue friends using naloxone can feel an increased sense of self-efficacy and pride. This may translate into people taking better care of their own health.

4. Advocates for HIV and hepatitis C prevention and treatment should be advocates for naloxone. People who use drugs have a 74 percent greater risk of overdose if they are HIV-positive. One Australian study found that 72 percent of deaths among subjects with hepatitis C were from drug overdose or suicide—not from advanced liver disease as a result of hepatitis. Naloxone is especially vital as a safety net for drug users living with these viruses.

5. You can start your own naloxone programme. In fact, naloxone is probably already legal in your country, and used in most operating rooms and emergency departments. To learn more, and to get the tools you need to start distributing naloxone to drug users, visit naloxoneinfo.org.

Getting to Zero: Country perspectives

By Nenet Ortega

“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.

At ICAAP on Wednesday, three countries shared different approaches in getting to a specific zero: deaths among positive clients attending treatment care and support in their facilities. A medical team in Yunnan (China) initiated scaling up of antiretroviral therapy. The team worked collaboratively with a community heavily affected by the epidemic. In 2010, only 5,000 people were on antiretroviral therapy (ART) and by end of 2011 it rose to more than 7,000. Part of the ‘zero deaths’ treatment package is counselling to make sure that clients understand what it is to initiate and enrol on ART, its benefits and potential side-effects. The community is a constant partner in providing the psychosocial services and family members are trained on provision of home-based care support services to assist family member on ART. Clients on ART are constantly followed up to monitor the health and have tests to make sure that they are responding to the treatment. By the end of 2012, clients on ART increased to about 38,000. Average CD4 counts have increased from 200–250 to 650. In six months time, average viral load reduction was 70%. Annual deaths were reduced to 3 per 100. This is a two-year pilot initiative with a potential of larger roll-out if and when resources are made available.

A similar initiative was implemented in Karnetaka, in South India. Intensifying AIDS-related care and support at the community level, involving families and community support systems proved to be beneficial to clients initiated on ART, as well as treatment for opportunistic infections. Mortality due to opportunistic infections was reduced.

Thailand, known for its progressive and pro-active approach to providing comprehensive care through a government financing scheme, embarked on detecting early warning signs of ARV resistance, which could potentially lead to avoidable deaths.

A related initiative has been rolled out in Indonesia focusing on prevention ART stock-outs, ensuring that clients on ART get sustained supplies of medication. Skipping ARV doses may lead to resistant virus. Indonesia previously obtained their supplies from the national health office. This mechanism delayed drug distribution, leaving provincial ART hubs without timely supplies for distribution. To avoid stock outs, ART provision was decentralized to the provincial level directly. Numbers of clients lost to follow up because of lack of ART availability was reduced by almost 90%. CD4 counts increased and improvements in the health status of clients were achieved.

These are three different approaches for providing treatment and care services that lead to improved lives and adherence, better prognosis and fewer deaths. Three different countries with different approaches of contributing to zero deaths, all engaged families and communities, with services provided holistically.

Each of these countries recognize that in order to achieve zero deaths, treatment, care and support must be addressed by a team approach, including medical staff, families and community support systems.

Intensified information and education within the community, and engaging community support systems, creates an enabling environment that leads towards zero discrimination. These actions, coupled with scaled-up treatment, care and support ultimately leads to zero new infections.

ICAAP 12: Will it happen? Should it happen?

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.

The slated 2015 host country sees it slightly differently: Bangladesh is speeding its preparations. They have a substantial delegation here in Bangkok, and have a booth brimming with attractive information and promotional materials. The country is clearly taking the current conference as the best opportunity to introduce itself as the destination of the 12th ICAAP.

“We are all ready. Our Prime Minister, Government and Congress are so committed to the successful organization of ICAAP 12,” said Professor Dr. A.K.M. Nurun Nabi, Vice Chancellor of Begun Rokeya Univeristy in Rangpur, Bangladesh. “The next ICAAP in Bangladesh will be very exciting and unique as we focus on the young leaders, the next generations of cultures. It should be the hub for every culture to gather and share with each other, and together we could fight and win against AIDS”.

Some are not convinced it will happen. Sipping cups of coffee, some delegates let out long sighs and lament that this may be the last in a long line of ICAAPs. They fear Bangladesh may be preparing for a conference that will never take place.

The overlap with the upcoming International AIDS Conference (IAC) is being raised as a specific reason to question if an ICAAP is needed in 2015.

“Why do we need a bi-annual Asia-Pacific meeting while at the same time we have an annual worldwide conference about the same subject here?” one delegate asked.

The ‘Future of ICAAP’ satellite was one of the most open and intense sessions this week, with the audience asking presenters some tough questions. After 11 ICAAPs, questions remain unanswered regarding the costs and use of resources around the event. Can anyone assess whether funds are wisely invested in ICAAP when the budget is still opaque?

One comment from Rico Gustav of the Asia Pacific Network of People Living with HIV (APN+) was applauded by most in the room, when he proposed there should be no more ICAAPs until those accounts were made clear.

Professor Nurun Nabi strongly objected to the whole idea, saying that Asia-Pacific is the largest region in the world, and affected most seriously by HIV – and that it is also easily neglected when we put our problems into the same pot with other continents.

“So ICAAP 12 – the congress about and for our Asia-Pacific – must go on,” he said.

The responsibility for ICAAP’s fate presumably lies with the conference convenors and organizing partners – and ultimately with the sponsors who provide the money required to organize such an event.

Putting questions about the overlap with next year’s IAC and calls for budget transparency aside, a contradiction exists between ICAAP hesitations and calls made here for “no more business as usual”: How can those with a future – the new generation of young people, activists and committed key affected populations – take over and drive the regional AIDS response without a venue like ICAAP where they can learn from the mistakes of the coffee lounge lizards?

(Session coverage by Le Nguyen)