One of the current projects under Rural HealthCARE is an
evaluation of injecting drug use (IDU) and the associated communicable
diseases, such as HIV/AIDS, in the area.
Two of EduCARE’s centers are located in Punjab where IDU runs rampant,
in about one third of every household.
Consequently, HIV/AIDS is on the rise in Punjab, infecting over 21% of
users in the state (according to the Times of India). For a little perspective, the national
average is between 7 and 9%.
The Project Director believes this trend is slowly moving
across the border into Himachal Pradesh, particularly within the migrant
communities. And furthermore, the
tourism in the state makes Himachal Pradesh even more vulnerable. According to statistics however, Himachal
Pradesh has little IDU and the lowest prevalence rate of HIV/AIDS in the
country at .03% (as of 2007, reported by the Himachal Pradesh State AIDS
Control Society). There are only 4,374
HIV positive cases and only 885 AIDS cases (HPSACS). Nevertheless, due to its proximity to Punjab
and its tourism, Himachal Pradesh may be at risk, and therefore, we must assess
this risk in the communities EduCARE works in.
Research began in Mcleodganj (the tourist hub down the mountain
from Naddi) at a small substance abuse center called Kunphen. The Tibetan NGO is run by a former addict
named Neema, who believes drug abuse is increasing in the community. He explains that Mcleodganj is a safe place
for drug users, who can survive off of the tourists – friendly foreigners who
share meals and sometimes, often the women, beds. The hippy culture of the area doesn’t
help. Cannabis is the most common. But in 1985, the Narcotic Drugs and
Psychotropic Substances Act made cannabis illegal, and other drugs began to
penetrate, such as pharmaceuticals. Kunphen
offers counseling to drug users and conducts school visits as part of a drug
awareness and education campaign, but because of limited resources, it cannot
offer any HIV/AIDS education or resources.
Instead, we took our questions to Choice, an HIV/AIDS initiative in
Mcleodganj.
Choice conducts workshops on HIV/AIDS education in all
different locations – monasteries, nunneries, army bases, schools… And they have partnered with the Dali Lama to
create a campaign video, which forced the Tibetan community to listen even
though the topic (sex) was taboo. In
2010, the organization created an initiative in which rich Tibetan families financially
support poor Tibetans with HIV/AIDS.
Another initiative supports children of HIV positive parents and sends
them to boarding school to help them avoid stigma. And lastly, Choice established a network of
HIV positive people in Tibetan settlements across India. This network creates a system of support and
allows for antiretroviral drugs (which are often only available in big cities)
to be picked up and delivered. Although
based in Mcleodganj, the Choice staff must travels all over India to ensure
these programs are running smoothly.
Like Kunphen, Choice is a Tibetan NGO, and therefore could
provide little information on the prevalence of HIV/AIDS in the population
beyond Tibetans. In order to get this
information, we travelled to the Zonal Hospital in Dharamshala to visit the
ICTC – Integrated Counseling and Testing Centre.
The Zonal hospital is a huge cement building in the middle
of Dharmashala, standing out in a coat of bright green paint. The parking lot is full of makeshift Jeep
ambulances and people waiting – on benches, on the street for the bus, in line
for the three chemists (pharmacies) that surround the hospital. With a referral from Choice, we went looking
for Dr. Sood, the District AIDS Program Officer.
Soft spoken and polite, Dr. Sood answered all of the
questions the Project Director and I asked from behind his spotless desk, his
hands folded over his lap. The ICTC in
Dharamshala is one of 27 centers in Himachal Pradesh, serving over 45,000
people in the Kangradistrict, (the district Dharamshala, Mcleodganj, and Rajol
are in), which has over one quarter of Himachal Pradesh’s AIDS population. The ICTC consists of lab technicians and counselors. People can visit the center to get tested for
HIV, but the center (and its staff of seven counselors) also reaches out –
visiting villages once per week to dispel myths, create demand for testing, and
conducttesting camps (if 50 or more people in a village want to get
tested). In this community outreach, the
ICTC works through the Integrated Child Development Services, another
government health scheme.
When trying to convince people to get tested, Dr. Sood
creates a dialogue around the idea that anyone can get AIDS, regardless of
risky behavior. “No one will admit to
high-risk behavior,” he explains.
Instead Dr. Sood says to them, “Have you had a dental procedure? Are you sure the dental instruments were
boiled before your procedure? Did you
see them boiled?” By creating this fear
of infection, most members of the community consent to testing, and the few
hesitant ones are then peer pressured by the rest. Then, perhaps to counter the stigma that fear
creates, the counselors of the ICTC (and the ICDS) work with the women of
village self help groups to promote interaction with and income generation for
HIV positive women in the community.
Additionally, the ICTC heads multiple HIV/AIDS
initiatives. One initiative provides
financial incentives for the educational needs of 40-50 children in the
district with HIV positive parents. The center has previously organized and
funded social events with these children as well, such as a morale-building
painting competition. Due to a
reallocation of their limited resources, there are no more events like these,
but Dr. Sood seemed very open to working with EduCARE on this. Another ICTC initiative is the Red Ribbon
youth program. Through this program
there are four workshops every year with college students and trained “peer
educators” who encourage safe behavior (such as saying no to drugs).
In order to reach out and test as many at-risk people as
possible, the ICTC has a network of linkages and referrals, such as with TB
clinics, (TB being the most common opportunistic infection of HIV positive
people). They run seven STI clinics in
the district, which provide symptom management, free medications, and
testing. And they also partner with four
NGOs in “targeted intervention” – outreach and testing of high-risk groups such
as sex workers, drug users, and homosexuals.
Through these targeted intervention centers, peer educators provide
counseling, testing, and medical examinations.
These high-risk communities also have two mobile vans dedicated to
outreach, testing, and care.
For those with HIV/AIDS (about 6,500 people in Himachal
Pradesh and 1,800 people in the Kangra district, according to Dr. Sood), the
ICTC also facilitates universal access to antiretroviral therapy by reimbursing
bus fare to the ART center in Kangra.
First line ART is free, but second line therapy is not as available;
people must travel to Chandigarh to get it, which is about 7 hours away by
bus.
When we asked Dr. Sood about the cause of the rising number
of HIV cases in Himachal Pradesh, curious about the Project Director’s theory
of IDU spreading across the border from Punjab, Dr. Sood said IDU was not a
major cause. He estimated that there are
only 400 injecting drug users in the whole district, most of them in
Mcleodganj. “Ninety percent of
transmission is heterosexual behavior,” he said. (He seemed uncomfortable with the word “sex”,
ironically). The major cause is
migration. Due to limited livelihood
opportunities, men leave their families to work for 6 months or more and many
visit sex workers while they are away.
In terms of risk, Dr. Sood ranks these migrants in between the high-risk
groups and the normal population.
And Dr. Sood’s ranking of risk is important because the ICTC
is currently out of testing kits, and only high-risk people are encouraged to
get tested. When a low risk person comes
in for testing, the ICTC counselor talks to him about safe behavior and tells
him testing is not necessary. Dr. Sood
explained that he has to save the few testing kits he has left for the
high-risk groups… What else can you
do? He calls it a crisis situation. They have been out of tests for a month and a
half, having already tested 45,500 people this year.
Despite their current lack of resources, the ICTC seems to
be running successful outreach programs and Dr. Sood seems dedicated to ending
the AIDS epidemic. If any of our
communities in Himachal Pradesh desire HIV/AIDS education, testing, or
treatment, then Dr. Sood will be
our greatest resource.
Betsy Hinchey
United States of America
Rural HealthCARE Project Manager
March – July 2013
For the migrants in Punjab high nitrate
levels is consequently a three fold issue.
High nitrate levels has been shown to be an issue of concern in Punjab
due to heavy use of pesticides as a consequence of the farming practices
created during the Green revolution. The Green revolution was implemented by
the India government in the 1960s-1970s in order to increase food production. A
second issue in particular with the Hariana camp is an accumulation of nitrate
from the trash dump which located just below the camps tents. The camp also has
about 30 pigs or so, this is a third potential source of nitrate in particular
because of the disposal of animal waste.
