The story of an anti-HIV/AIDS programme in Tamil Nadu's Namakkal district may hold many lessons for the health professional and policy-planner.
National leaders have often urged institutions of learning to be involved in programmes that would have an impact on the lives of India's villagers. The efforts of a medical university in Tamil Nadu have a particular resonance in this context.
The Tamilnadu Dr. M.G.R. Medical University is a relatively young affiliating university. It is committed to prioritising health care delivery to the masses and providing medical education to achieve this objective. Though the university is the second of its kind in India (the first being the Dr. NTR University of Health Sciences in Andhra Pradesh), it is considered the mother university among health sciences universities.
The Department of Experimental Medicine (DEM) was the first department to be started at the university, in 1993. It was the brainchild of Dr. Lalitha Kameswaran, its first Vice-Chancellor. After several brain-storming sessions, it was decided to focus on HIV/AIDS, tuberculosis and malnutrition as the thrust areas for research and education.
At that point in time, the prevalence of HIV/AIDS was on the rise in Tamil Nadu, and the need for educational programmes and diagnostic and clinical services in the field was felt. After each teaching session, participants would ask how to treat patients with HIV/AIDS. There were no simple answers to this question. Antiretroviral drugs were prohibitively expensive and had to be imported, and they were beyond the reach of a majority of the patients, particularly those from the rural areas. Zidovudine is an anti-retroviral drug, which, when administered by itself for AIDS therapy, developed resistance. However, in 1995 a group of U.S. researchers showed that the use of the drug prevented the transmission of the virus from mother to infant. This was an exciting discovery and the beginning of ‘prevention science.' Pregnant women in Chennai were offered this drug and the initial results were encouraging. Physicians in the urban and rural districts were encountering in their clinical practice a growing number of HIV infections. They wished to learn about the new disease, its diagnosis and management.
The story of the initiation of an anti-HIV/AIDS programme in Tamil Nadu's Namakkal district to provide counselling to pregnant women, diagnostic services and the consequent research and training may hold many lessons for the committed health professional and policy-planner.
After receiving calls from many physicians in Namakkal, a team from the university, including this writer, visited Namakkal to assess the seroprevalence of HIV-1 among pregnant women coming to the District Hospital. Six per cent of pregnant women was found to be seropositive. Results of the pilot study were reviewed with Dr. K. Anandakannan, Vice-Chancellor. He directed the department to conduct further studies in Namakkal. This was the beginning of the first rural-based Prevention of Mother-to-Child Transmission (PMTCT) centre in a public sector hospital in India.
The team travelled from Chennai to Namakkal along with students to set up counselling and testing facilities. It was the sheer commitment of the group-members that made them travel regularly to Namakkal. The hospital authorities were supportive and provided two rooms in the tuberculosis treatment building to set up the laboratory and for confidential counselling sessions. Pregnant women attending the antenatal clinic were group counselled, and after obtaining informed consent were tested for HIV. Individual counselling was provided to seropositive women.
The women perceived themselves at risk as most of their partners were long-distance truck drivers. Some 85 per cent of them returned to collect their test results after four days. This was an encouraging sign.
Initially there was some resistance from both the staff members and other patients, but its decline over time was palpable. It was the leadership of the hospital that made the difference for the decline of feelings of stigma and discrimination among health care providers. From June 2000 to September 2009, the total number of pregnant women counselled stood at 45,700. And the number who consented to be tested was 45,443 (99.4 per cent). Exactly 827 women were detected to be HIV-positive.
The efforts to prevent mother-to-child transmission attracted international attention. A team from the National Institutes of Health (NIH), U.S., led by Dr. Jennifer Read, visited the PMTCT centre in Namakkal and satellite centres in Rasipuram, Tiruchengode and Paramathi Velur.
It was decided to conduct a joint study to administer an efficacious prophylactic regimen to pregnant women to prevent mother-to-infant transmission. The Namakkal and Rasipuram government hospitals were selected by the NIH, the Indian Council of Medical Research (ICMR) and the National AIDS Control Organisation (NACO) to undertake research and provide clinical facilities. PMTCT centres with facilities for confidential patient-counselling were set up in the hospitals by the NIH. Nutrition, replacement and exclusive breast-feeding facilities were provided. Laboratories were set up to provide diagnostic tools and facilities to store blood samples.
Staff members were appointed for each centre: a medical officer was the team leader. Training was provided by international experts on counselling, electronic records maintenance, administration of drugs and infection control. Couriers were trained to transport blood within 24 hours to laboratories in Chennai for additional tests. The NIH trained members of the community advisory board and the Data and Safety and Monitoring Board (DSMB). The collaboration with the NIH led to the publication of 10 publications.
This writer was introduced to Lisa Frenkel in Chicago at the CROI conference, the annual conference sponsored by the Foundation for Retrovirology and Human Health in collaboration with the Centres for Disease Control. She was from the University Children's Hospital of the University of Washington (WU), Seattle. Dr. Frenkel accepted an invitation to visit the university in Chennai and seek collaborative programmes in research and education. It soon resulted in an exchange programme of students and residents from WU to Namakkal. In return, staff members from the Department of Experimental Medicine went to attend research methodology courses and skill-building at the WU. The visiting students spent six weeks in Namakkal, undertook research and learnt about infectious diseases. They went to the villages, interacted with patients and participated in conducting deliveries. They attended ward rounds with medical officers and assisted duty medical officers in the clinical evaluation of patients. The collaboration resulted in three publications.
This was a unique experience. The students and residents made friends with local individuals. The six-week stay exposed them to the diverse Indian culture and hospitality, as also to clinical medicine. It was an eye-opener for them.
The setting up of PMTCT services and the establishment of a CD4/CD8 laboratory by the Department of Experimental Medicine in Namakkal, made NACO sanction the first anti retroviral therapy (ART) centre in a rural district hospital in India. Training programmes for medical doctors in PMTCT, paediatric AIDS and ART were conducted. APAC (the AIDS Prevention and Control project) used the facilities to conduct a certificate course for private practitioners. The structured courses on PMTCT were attended by doctors from all parts. The faculty was drawn from Christian Medical College, Vellore; the All India Institute of Medical Sciences, New Delhi; St. John's Hospital, Bangalore; the University of Washington; the University of London, the University of Regensburg, to name a few. The training programmes for doctors, nurses and counsellors, including village health nurses, were remarkable.
Due to the availability of training courses in a rural environment, physicians and other health care providers from urban settings who otherwise would not get to visit rural districts for training did not hesitate to spend up to two weeks for the purpose.
The focus is on women and children. It was the felt need of the team that children with HIV needed to be studied further and that the evolution of the HIV condition required more attention in the Indian setting.
With the already existing infrastructure in Rasipuram hospital, a rural paediatric AIDS centre was set up in 2006.
The team provided extensive awareness and counselling programmes to the rural communities in their own settings. The training offered to ‘opinion and community leaders' had an impact on the stigma and discrimination that had prevailed. However, there is lot more to be done in this area. HIV/AIDS is still considered a new disease and it will take a long time to remove the stigma and discrimination. There are brave individuals who have put aside societal pressures and are making progress in coping with the stigma and discrimination.
The spin-offs of the programme include its impact on the control of tuberculosis and the adherence to DOTS, or Directly Observed Treatment, Short Course; on exclusive breast feeding and avoidance of culturally accepted forms of first infant feeds; on family planning and spacing of children. The prevalence of mother-to-child transmission is down to 1.8 per cent.
Continued research and the implementation of prevention programmes against mother-to-child transmission are required. The eagerness to pursue scientific research and training in urban settings needs to change. Institutes of learning have a responsibility to the villages, and this should go beyond tokenism.
(Professor Dr. N.M. Samuel was Head of the Department of Experimental Medicine, Tamilnadu Dr. M.G.R. Medical University, from 1993 to 2007 .)