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.
United States of America
Rural HealthCARE Project Manager
March – July 2013