Partners in India rally to stem the tide of the HIV/AIDS epidemic

Dr. Harvey Makadon leads a panel discussion in Chennai.

In the countries where the HIV/AIDS epidemic continues to ravage communities, destroy families, and stretch the resources of the health care community to the limit, avoiding the difficult facts can be a large contributor to the problem. In India, the health care professionals who are faced with the world’s second largest population of infected people are recognizing that they must meet the facts head-on if they are to stave off the kinds of catastrophic effects this epidemic has had in some countries in Africa. The facts are hard to ignore: 610,000 new HIV cases in 2002, a staggering 85 percent of cases associated with unprotected sex, and the dismal news that less than five percent of the infected Indians who need antiretroviral therapy are receiving it.

Much attention has been focused on India’s growing problem—but little good news is to be found among the findings of various organizations. India’s National AIDS Control Organization (NACO) estimates that by the end of 2002, 4.58 million people in India were infected—about 0.5 percent of the total population. Given India’s large population, a mere 0.1 percent increase in the prevalence rate could have a profound impact: half a million more HIV/AIDS sufferers in a health care system struggling already to keep up. A study conducted by the Washington, DC-based Population Reference Bureau and the Population Foundation of India found that 72 percent of Indians in rural areas had heard of HIV/AIDS, compared to about 90 percent in urban areas.

Throughout the country, however, it is becoming clear that India’s most valuable—and most reliable—resource in the effort to curb this epidemic is the commitment of the individuals and teams working to educate people about HIV/AIDS, develop an infrastructure for prevention and care services, and train more health care professionals to address the problem. The obstacles run the gamut from the medical challenges facing the health care providers to the social barriers that distort perceptions of the epidemic and make the work of physicians all the more difficult.

Sri Ramachandra Medical Center and Research Institute (SRMC-RI) has announced plans to develop a center of excellence for HIV/AIDS care in Chennai. Professor S. Thanikachalam, the SRMC-RI vice chancellor, delivered the news at the close of an HIV/AIDS education program delivered in January by a team of faculty from Harvard Medical International (HMI). Less than a year after HMI’s first HIV/AIDS workshop in Chennai, SRMC-RI is preparing to create a network of health care providers involved in clinical outpatient HIV/AIDS programs in the region.

“ By inaugurating our multi-disciplinary outpatient HIV services today, we hope to provide a referral point for care givers and patients,” said Thanikachalam.

“ Sri Ramachandra has already demonstrated its commitment to becoming a regional center for medical education,” said Dr. Harvey Makadon, HMI vice president of health systems. “Developing a robust HIV/AIDS education and treatment program, given the critical juncture of the epidemic in India, is a natural step to take it in that direction.”

A critical moment in the history of an epidemic
Makadon said the one-day program in Chennai, which was attended by 365 health care professionals, was an opportunity to present information on HIV/AIDS to a group that can directly impact the epidemic in India’s communities. “The idea is to prevent the spread of the epidemic by encouraging the spread of the latest progress in prevention and treatment. We can point to similarities between the problem in India and what occurred in Africa, and try to turn those lessons into a strong response from the health care community.”

In India, China, and Russia, the relatively low prevalence estimates have, in some areas, worked against the sense of urgency that is necessary to address the epidemic. “In many places, the prevalence of HIV is currently low, but the risk of spreading the disease is increasing. We tried to impress upon the physicians, nurses, and health care leaders in Chennai the notion that HIV/AIDS does not recognize borders,” said Makadon. “Perhaps more importantly, it does not recognize divisions between social groups, and so countries like India—as the health care community had to do in the United States—must develop health care policies that remove the stigma that keep people at risk from being willing to be tested for HIV, and that do not overlook the fact that due to a multitude of factors, this epidemic is on the move in all sectors of society.”

Dr. Jon Fuller (with microphone) and Dr. Howard Libman participate in a panel discussion.

The latest knowledge to support an enhanced response
The HIV/AIDS-related topics presented by the team from HMI form the foundation of education programs that will be developed in Chennai by SRMC-RI.

Dr. Howard Libman, an associate professor at Harvard Medical School (HMS), talked about how to prevent mother-to-child HIV transmission, and presented on the challenges of using antiretroviral therapy. “Preventing mother-to-child transmission is a complex issue that requires HIV antibody testing of pregnant women at risk for HIV infection, availability of prenatal care, implementation of peripartum strategies—for example, elective cesarean section—to decrease risk of transmission to the newborn, and the availability of antiretroviral therapy,” he said. “These antiretroviral therapy drugs are being manufactured generically in India and other resource-limited countries, and although they are much cheaper than in the U.S., their cost are still beyond the financial means of much of the population.”

The emergence of antiretroviral therapy presents a dilemma for the Indian health care community. A major benefit of the therapy is the ability to relieve the fear that contracting the virus amounts to a death sentence, and thereby remove the stigma attached to HIV positive status. But many in India worry that introducing antiretroviral therapy will encourage complacency about preventive measures, like condoms, and feed rather than curb the epidemic. Still others believe that doctors will view antiretroviral therapy as a cure-all, rather than a single component of comprehensive HIV management, which would include measures to boost the immune system, treat opportunistic infections, and build psycho-social support.

Dr. Jon Fuller answered questions about HIV from curious students at a girls’ school in Chennai.

Dr. Jon Fuller, associate professor at the Boston University School of Medicine, presented the latest on HIV’s origins and viral pathogenesis, and discussed the prevention, diagnosis, and management of opportunistic infections. “There is some difference in the spectrum of opportunistic disease being seen in India as compared to the West,” he said. “For example, we have extensive experience in the U.S. with Kaposi’s sarcoma, but this is very rare in India. On the other hand, Southeast Asia is home to Penicillium marneffei, a disseminated fungal infection that is rarely, if ever, encountered in the U.S.” Doctors in India, as in the rest of the developing world, may find that diagnosing these infections will be easier than treating them, since some drugs for opportunistic infections remain quite expensive.

Dr. Nagagopal Venna, HMS associate professor of neurology, discussed an aspect of the epidemic that is beginning to receive more attention: the neurological impact of HIV infection.

HIV/AIDS care as a model approach
The center of excellence to be based at Sri Ramachandra’s hospital will take shape in the coming months. SRMC-RI plans to develop a multidisciplinary care program that involves clinicians from multiple specialty areas. In addition, the leadership hope to develop community education programs and establish guidelines for HIV/AIDS care to support clinicians in the field. SRMC-RI already has in place a voluntary counseling and testing program, a rarity in the country.

Makadon is excited about the planned center of excellence. “We are extremely pleased that SRMC-RI, having recognized the growing HIV/AIDS problem in Chennai and the country as a whole, is set to make a real impact,” he said. “But it is important to recognize that these programs, related to both care and education, must be integrated into an infrastructure that supports its growth and development. Today that infrastructure is not fully in place, but Sri Ramachandra can certainly take a lead role in developing it.”

This systematic approach to combatting HIV/AIDS will be crucial if the Indian government follows through on its pledge to make antiretroviral therapy drugs more readily available, or if the World Health Organization’s “3 by 5” initiative—which is designed to provide antiretroviral therapy to three million people worldwide by 2005—comes to fruition in India. In addition, once the HIV/AIDS programs of Sri Ramachandra inject much needed hope into Indian society, more people are likely to come forward to be tested or treated, and the infrastructure must be prepared to deal with this.

SRMC-RI has appointed a lead clinician, Dr. J. Damodharan, who will oversee an HIV outpatient clinic. In preparation, Damodharan will visit Boston in June to go through a continuing medical education (CME) program at Beth Israel Deaconess Medical Center, where both Makadon and Libman, who is the hospital’s director of HIV medical services, are on staff. The lead clinician will observe how various HIV-related programs are conducted in Harvard-affiliated hospitals, and after returning to India will participate in monthly case discussions via videoconference with HMS faculty.

Instituting a primary care program to address the HIV/AIDS problem could have other long-term benefits for the country’s health care system, according to Makadon. “Past experience tells us that the multidisciplinary approach used to treat, diagnose, and prevent HIV can be successful. That approach, brought to the clinic in Chennai, could serve as a model for developing other primary care programs to address chronic disease problems.”