The district hospital ward for kala-azar had exactly eight beds and one occupant, and he was a chance discovery for the doctors. The 47-year-old farmer had walked in to the Antiretroviral Therapy (ART) centre in the hospital with a high fever. When the blood work came back, it showed a potentially dangerous cocktail of diseases – HIV, tuberculosis and kala-azar.
Kala-azar belongs to the Neglected Tropical Disease (NTD) family of diseases which affect the poorest populations, persist under conditions of poverty and are concentrated almost exclusively in the developing world. The hallmark of an NTD is the lack of reliable statistics.
Kala-azar, also known as Visceral Leishmaniasis (VL), is a parasitic disease transmitted by the sand fly and characterised by irregular bouts of high fever, substantial weight loss, and enlargement of the spleen and liver.
Families living in close proximity to livestock and the humid conditions along the southern banks of the Ganga make Bihar a perfect hunting ground for the sand fly, and indeed the state is the global epicentre of kala-azar.
On a war footing
Humanitarian aid organisation Médecins Sans Frontières (MSF), which is known for its work in conflict zones, has been on a war footing collecting data, standardising treatment protocol and, most significantly, diagnosing patients with kala-azar and HIV coinfection. The situation is so dire that the government pays Rs. 7,100 for every kala-azar patient who completes treatment.
“When we started our project in Bihar, our priority was to standardise treatment – every doctor was treating the disease differently. We brought in our experiences from East Africa and helped the State government with a single day-single dose treatment. We kept seeing unfavourable responses to treatment and frequent relapses, and it took us a while to realise why that was happening,” said Dr. Ravinder Singh Rishi, field coordinator at MSF’s kala-azar project in Bihar. “They had HIV too,” he said, snapping his fingers as if he had just figured it out.
MSF is initiating a study on HIV and kala-azar coinfection along with the Rajendra Memorial Research Institute of Medical Sciences (RMRIMS)
“Scarce data is available regarding the magnitude of the co-infection,” noted Dr. Rishi, adding that MSF hoped to generate more evidence on treatments in India. “When we initially started the kala-azar project, it was to use our experiences in African countries to develop a treatment protocol,” he said.
The government of India has a kala-azar elimination target of 2017.
According to MSF, there are between 2,00,000 and 4,00,000 new cases a year, about 50 per cent of which are in India. And 70 per cent of the cases in India come from Bihar alone. Of the 38 districts of Bihar, 33 are affected. The population at risk is 34.65 million, in approximately 12,000 villages spread over 426 blocks.
Dr. Rishi says the State government has instructed all ART centres to screen patients for kala-azar if they display symptoms, and recommended that all kala-azar patients be screened for HIV.
“We are hoping the MSF/RMRIMS trial will give us more data to act on the co-infections,” he said.
In addition to not having data, the HIV-kala-azar coinfection presents another problem for the authorities: they cannot go into the community with Information, Education, and Communication activities as it might cause panic.
Therefore the government and MSF are relying on health centres to catch the patients, such as the one that got screened at the ART centre and referred to Hajipur district hospital. Unfortunately only one in eight kala-azar cases gets caught in official surveillance data, according to a study conducted in 2006.
The silver lining is that even for patients walking in with a deadly cocktail of diseases, the afflictions are manageable if diagnosed in time.
Skewed presence of Neglected Tropical Diseases in poorer sections leads to under-investment in research.This is the fifth part of the series, Malady Nation, on India's multi-dimensional healthcare crisis. This part outlines the cost of neglected tropical diseases and underscores the urgent need for funding.