Train Ride to Khammam

When I was 20 years old, I traveled a lot through India by myself. I took train rides and bus rides by myself. I even took an ill-advised walk through desolate streets of Bombay by myself. I was not particularly intimidated by the travails I faced. Now that I am a decade and a half older, though, I am significantly less confident. So when my father-in-law informed me that I would be taking the train to Khammam myself, I became vaguely apprehensive. When the taxi/autorickshaw strike (called for by the Communist Party of India (CPI)) began 36 hours before my trip, I became agitated. When Vishwanath suggested to me at the train station that he would just drop me off rather than accompany me inside, I nearly had a stroke.

A word on Vishwanath: There is a phenomenon that I suspect occurs in many places outside the US. I have seen it for myself in Colombia and have heard about it in other countries from friends. It has to do with the blurring of family and friends. It certainly happens in India all the time. Vishwanath belongs to a poor family in a different part of Andhra Pradesh. I am told he was brought up in a small village, in a rural setting. Not sure what his parents do for a living. Not sure how my aunt heard about him, but she did. When he was around 16 years old. She heard about a good kid who was from a poor family; smart, but not doing well in school. Could use some extra money to help out his family. So she took him in. The plan was that he would help out around the house and she would get him to college. It didn’t work out quite like that. This had more to do with Vishwanath’s interests than my aunt’s efforts. She actually has a track record of doing something like this very successfully in the past, but was unable to get V to focus on his studies. He turned out great, though. He has a job with a local IT company, doing packing, delivering, and some computer trouble-shooting. He is also married (a pretty funny story) and has a beautiful 8-year old boy. Whenever my uncles and aunts need stuff done, for example, someone to take their 35-year old baby nephew to the train station at 6AM, V is there. He is a rock.

We went to the station on V’s scooter. As he pulled in , he suggested that he would drop me at the entrance and that I would be fine from there on. After some silent blinking, I told him he would park his scooter and come with me to my seat. With some difficulty, we found my compartment and I got good and settled in my seat before dismissing him. I am still convinced that I would not have made the train if I had let him just drop me off at the entrance to the Secunderabad Station.

Traveling by train is by far the best way to see India. Looking out the train window is one of my top 5 things to do in this world. This did not happen on this 5 hour voyage. The exhaustion set in, and I slept nearly the entire time. The neurologist sitting next to me tried valiantly to strike up conversation, but I was having none of it. When we got close to Khammam, I called my father-in-law, who told me he would be waiting outside the station in his car. I disembarked and headed down the platform looking for the exit. My father-in-law had told me to just follow the crowds, so I found the biggest crowd I could and got ensconced within it. It was an enthusiastic bunch, I observed, and they were exiting the station with much more determination than I was used to seeing. Many of the members were also brandishing some sort of cloth on a stick. Closer inspection revealed this to be a white hammer and sickle on a red flag. Once we hit the exit, there was much bellowing amongst by my new leftist brothers and this turned into yelling with gusto as I was swept by convection down the front steps and into the parking lot. Out of the corner of my eye, I saw my father-in-law sitting in his car peering toward the exit that I had long left behind. I extricated myself from the communist demonstration and made my way to his car. Not without some fervor of my own. Welcome to Khammam, he said to me as I got in.

APSACS

The government rollout of ART in India is led by NACO, which works through the state AIDS contol societies. In Andhra Pradesh, this is done by APSACS. The ART Centres include Osmania General Hospital, Gandhi Hospital, Niloufer, and the Chest Hospital. Here, patients who have CD4 counts less than 200 receive free first line ART. As I have discussed previously, the patient load at each of these centers is immense. Last year, Dr. Emmanuel from the Osmania center told me that he had registered 13,000 unique patients there and had started some 4000 on ART. This includes, interestingly enough, some 100 patients with HIV-2. The large patient numbers at these centers makes them, theoretically, an excellent place to do HIV outcomes research; however, government approval is necessary. There’s the rub.

When I mentioned my interest in working with these centers to Dr. Hrishikesh, he was kind enough to call the Additional Project Director at APSACS, Dr. Kalidas, an old student of his. Dr. Kalidas agreed to meet me in his office Tuesday morning at 9. The APSACS headquarters is in a part of Hyderabad called Sultan Bazaar. I remember going there in 2004 with my wife’s uncle to meet with the then head of APSACS about a speaking engagement. Today, I went to a different building. It was early, and I saw no employees as I entered. The lights had not yet been turned on, so the natural lighting that filtered through the hallway was all I had as I made my way down a long corridor to Dr. Kalidas’ office. I sat down at a bench and started jotting down an agenda. A superfluous move, I was soon to realize.

Dr. Kalidas came down the hall at 9:25, talking animatedly on his cell phone. He looked at me as he unlocked his door and did a double take. I introduced myself and he, cordially, showed me in. We had a discussion about my efforts and my research interests. I was mostly on the receiving end and spoke occasionally. I was struck by three things in the course of the conversation:

1. Dr. Kalidas does not spend much of his time meeting with low-level persons such as me. So thanks Dr. Hrishikesh for making this possible.

2. Dr. Kalidas has an excellent command of the issues surrounding ART in AP. So often, not just in India, the people in charge are out of touch with the realities on the ground. Dr. Kalidas has an excellent appreciation for the key issues surrounding ART delivery. I spoke of resistance; he was already aware of the magnitude of the problem. I spoke of adherence and he quickly demonstrated to me that he has a deep understanding of the various aspects of adherence and non-adherence.

3. If I am to collaborate with ART Centres in Hyderabad, or anywhere else, for that matter, I will need permission from the highest levels of NACO in New Delhi. This will probably not come by the end of my 10 day trip (sarcasm alert).

Dr. Kalidas concluded his remarks to me by highlighting one project that he thinks is critical for somebody (like me) to underatke: the development and testing of scientific, culturally-based interventions to promote adherence to ART.

I left his office feeling a mixture of admiration, frustration, and despondency/despair. In time, I am sure I will get over all of these feelings. Headed next to one of the ART Centres that I will apparently not be working with any time soon.

Back at NIMS

Tara and I left SRH for NIMS in one of the SRH vehicles. The traffic in Hyderabad is somehow better than what I remember back in September. It only took half an hour to get to NIMS. On the way, I saw the reconstruction of the flyover that collapsed the day CIT1 left Hyderabad.

At NIMS, we met with Dr. Subbalaxmi, Assistant Professor of Internal Medicine. She is one of the principal HIV providers there, and is my co-investigator. Seeing her, going to the Acute Medical Care conference room, and seeing other faculty and even residents with whom I had interacted brought back a lot of memories and made me feel at home.

I tried to install the database software this afternoon. The instructions are a six page document, and I managed to get stuck at the halfway point of the first page. Nice. Other than that, we caught up on the goings on in each other’s career and called it a day. I called a cab, dropped Tara off back in Kukatpally, and went home. So far, things are going as well as can be expected.

HIV at SRH, Part 2

After our meeting with Dr. Reddy, we proceeded to the HIV wards at SRH. This has become one of my favorite activities when I visit Hyderabad. The HIV wards consist of four adjacent rooms in a one-story building near the north end of the campus. Across the dirt road is another one story building, which houses the mess hall for the patients and the visitors. The medical officer in charge of adult HIV care is Dr. Suguna, and every time I go to SRH, I have the privilege of making rounds with her and hearing about all the cases. At any given time, there are about 10 women and 10 men hospitalized there.

Today Dr. Suguna was eagerly anticipating our arrival and had prepared a powerpoint summary of the ward activities since the inception of the Care and Support Centre in March 2006. They have had some 800 admissions in that time, and the complexity of the patients has steadily increased. We heard about the spectrum of opportunistic infections they have seen, the relatively steady mortality rates, and the challenges they have faced in terms of making firm diagnoses. There was visiting infectious diseases fellow from Vellore Christian Medical College. She was rotating through to get experience in inpatient HIV and was also helping to improve their methods to identify diarrheal pathogens.

Diarrhea is an important complication of HIV, ranking just behind TB here in India. Determining the cause of diarrhea can be tough with limited resources; bacterial, viral, and protozoal pathogens are all common. There is a small lab area in the building with the capability to do CBC, BUN, creatinine, and some microscopy. Other tests need to be referred to outside labs. For CD4 cell counts, as well as for initiation of ART, patients are taken to a local government-sponsored ART Centre, usually at the Chest Hospital. I hope that the lab capacity at SRH can increase, since it would clearly benefits the inpatients immensely.

The Care and Support Centre was recently upgraded to Community Care Centre. It looks like this is going to be a new model for HIV primary care in these parts. The patient population, and potentially the complications of HIV, will likely be different than those seen in tertiary care centers. Dr. Suguna, Tara, and I decided to discuss the current literature on HIV inpatients in India on Thursday morning, to put the SRH experience in context.

HIV at SRH, Part 1

Tara arrived over the weekend and today was her first day at SRH. I hired a taxi and picked her up near Bashir Bagh, at her uncle’s house. We made the one hour trip to SRH uneventfully and were taken immediately to the guest house, where she and Akanksha will be staying. The accommodations are great there. She gets a one bedroom apartment with a fridge, gas range, and bathroom with western style toilets. They brought in two large plastic bags full of mineral water bottles and we got a tour of the mess hall where she and the other visiting students will have their meals. All in all, they thought of everything.

Dr. Hrishikesh arrived at 9:30 and took us to his office, where we were joined by Dr. Venkat Reddy. Dr. Reddy is in charge of the DOTS program at SRH, and is temporarily in charge of the PPTCT program until they find a permanent person. The PPTCT program (prevention of parent to child transmission; widely known as PMTCT in most of the world) was started at the behest of APSACS in October. The catchment area for SRH is actually based 50 km away, in a town called Sangareddi, in the rural, highly impoverished Medhak district. The staff includes 9 outreach workers, all living with HIV themselves, and a social worker. Their job is to link HIV positive mothers-to-be with appropriate prenatal care, encourage them to use designated facilities during labor, and to do follow-up, postnatal visits for 18 months.

Testing for HIV is an important part of the program, obviously. The standard method for testing is at government-sponsored centers called VCTCs – Voluntary Testing and Counseling Centres. These are present in more densely populated areas of districts, however, and are not readily available to the rural populations. Thus, SRH runs testing camps periodically in more remote areas. The overall positivity rate has been between 1.0-1.5%, which is the expected rate in this part of the state. When women test positive, they are scheduled for home visits by one of the outreach workers. In addition, women who test positive at the VCTCs are also referred to the SRH outreach workers.

The primary method of preventing MTCT here is administration of single-dose nevirapine once to the woman, with the onset of labor and once to the infant, within 72h of birth. This is a very commonly used strategy throughout the developing world, and though highly effective, has its drawbacks. Getting the women to the main hospital is a major challenge of the program. The standard of care in the US for PMTCT is administration of combination ART. This is not currently an option here unless the mother has a CD4 cell count less than 200.

The postnatal visits serve a few functions. It is a way to continue to follow the mother’s health and make sure she stays linked to primary HIV care. As a point of clarification: the SRH program does not provide this care, they facilitate the patients’ access to care and support centers. The postnatal period also is an opportunity to provide reinforcement on proper care of the child. Breastfeeding is another potential mode of HIV transmission, so counseling is done in this regard as well. Finally, the infant is tested for HIV at 18 months, when the antibody test result is likely to be correct. Earlier diagnosis is possible with viral lead measurement, but this is expensive and not currently available to these types of programs.

The program is still new, and the details are still being ironed out, but the usual superb quality of care provided by SRH is clearly there already. Tara is going to get to know the program even better and report back to us on it in the near future.

Access

My aunt is a retired women’s health specialist, but still maintains a part-time practice at a small, nearby hospital (“nursing home”; not in the American sense). She has only been there a few weeks, and prior to this, she worked at a charity hospital. She told me an interested story about HIV and access to care.

She was visited by a couple from Nizamabad, some 200km away from Hyderabad, after they both tested positive for HIV. The woman seemed, clinically, in early stage disease, but the man was clearly wasted and probably needed antiretroviral therapy on that basis. I am not clear on their socioeconomic background, but is likely that they do not have many resources, as the story involves seeking care at government hospitals. They came to see her because they had made multiple attempts at getting ART at various facilities both in their hometown and here in the capital, but met with no success. They first tried to get care at Nizamabad, where they were told that the ART centre did not have the proper kits (I presume this means CD4 count kits). Per NACO guidelines, there needs to be a documented CD4 count less than 200 for a person to qualify for free medications. They came to Hyderabad to see the larger clinics here. Apparently, they were turned away at two of them because of the large waiting lines. I believe this readily, since I have spoken to the man who essentially runs the largest clinic in town (and in AP) and have seen that he often sees 150 patients a day.

So it is nice that first line regimens are available for free for persons with AIDS. It is unfortunate that the available regimens are fairly toxic and have a low threshold for the development of drug resistance. It is really terrible that access to care is so bad, if this anecdote is accurate and happens with any frequency. Clearly, there needs to be an increase in the number of places equipped to care for person living with HIV/AIDS. It is not reasonable to expect that a place like Osmania will be able to physically handle 150 patients a day. According to my reckoning, there are some 8 to 10 million persons living in Hyderabad. If there is a prevalence in the general population of 0.7% (this is the prevalence in antenatal clinics here and it is felt that the prevalence in AP is definitely over 0.5%, if not 1%) then we are looking at up to 70,000 persons in the city that are HIV infected. The only reason that the system has not been overwhelmed is the fact that the vast majority of these persons do not know their status. Hopefully, the rumors of the epidemic slowing down in India are true (not the opinion of HIV providers I have spoken to here), or there is going to be big trouble.

Niloufer

I went to Niloufer Children’s Hospital today, saw the ART Centre, and spoke to the superintendent. It was a different experience for me, being an internist, but one that definitely made me think a bit.

Niloufer is a government hospital, much like Osmania General Hospital and Gandhi Hospital here in Hyderabad. It is fairly close to NIMS, but not really connected to a main road, like the other hospitals are. It turns out the my wife’s uncle was the superintendent (the equivalent of a Chief of Staff at a US hospital) of Niloufer in the 1980s. The outer gate is guarded half-heartedly by a man who offered little resistance as Dr. Lakshmi and I pushed through. The inner gate, representing the main entrance to the main building, was guarded more vigorously. Yet, we were able to pass with no problems and perhaps a 10 second delay. Most of the delay was related to negotiating past the mass of humanity that was trying to gain entry.

Once in, we proceeded to the lab, where we learned that the person with whom Dr. Lakshmi wanted to meet was still off site. We were offered the chance to go to the ART Centre, to which we agreed readily, and were led outside, again past the throngs (where a gipsy-like lady was being manhandled by the security guard for trying to get through. As an aside, it is still not clear to me why people were not allowed to pass. It seemed that they were there to visit a sick, pediatric relative. Anyway.) On our way out, I caught a glimpse of a sick infant in the TB area; a fairly effective reminder as to why I did not go into pediatrics. I was bad enough with the concept of sick kids before I became a father. Now it is even harder for me to see them.

We went to an adjacent building and climbed a flight of stairs to the “first” floor. At the top of the stairs was a long hallway going off to either side. Just in front of us was a door leading to the ART Centre. In stark contrast to the rest of the hallway, painted in the usual pale yellow I have grown accustomed to seeing in Indian hospitals, there was a painting of Baloo, Mowgli, and other Jungle Book characters. It was a nice touch, and a bit unexpected for me, I admit.

Upon entering, we met the junior medical officer, who led us to her office/exam area. I launched into my introduction, explaining that I am an HIV specialist from the States and that I am interested in learning about HIV care in AP. As the doctor began to describe the center, the power went out. She continued to speak for another two minutes, in near total darkness, before suggesting that we adjourn to the naturally lit hallway outside the pharmacy. After giving me the background on the Niloufer ART Centre, she gave me a tour of the pharmacy (an adjoining room with one shelf) and we chatted a bit more informally about HIV care, research, and the like.

Niloufer just opened their ART Centre two months ago. They have 29 patients registered there (all, by definition of eligibility less than 15 years of age); 21 on co-trimoxazole alone and 8 on antiretroviral therapy. CD4 cell percentages are used in the toddlers to determine who needs ART, as one would expect. For the kids over 4 years old, a CD4 cell count of 200 is the threshold, as it is in all ART centres in India for persons age 15 years and older. Kids on ART are seen monthly, given medications in one month supplies, and have CD4 cell monitoring, along with CBC and chemistries, every 6 months. The kids that are not yet on ART are seen twice a year. The patient population is the poorest of the poor (nobody with any money would go to a government hospital in India) and all live on less than US$1/day. About half the kids are urban, from Hyderabad, and half rural. Although the rural kids are usually from surrounding areas, there are occasionally families that come from remote parts of the state because they do not want to be seen in their towns going to an HIV clinic. Apparently, some 8 years ago, almost all the cases were in Hindu families, but this disparity no longer exists. Half the kids at the Niloufer ART Centre are Muslim, mirroring the population of Hyderabad itself.

The clinic provides first line regimens in the form of fixed-dose combinations (FDC). There are three different FDCs of stavudine/lamivudine, with or without nevirapine. Zidovudine/lamivudine is available for non-anemic children and efarienz is available as a suspension. Viral loads are not measured; treatment success is measured only by CD4 numbers. This means that virological failure probably happens months before clinical failure is apparent. While this would be considered a disaster in my practice, it is really not that bad here, when one considers that there are no second line regimens available. Failing first-line therapy means hospice care for these kids.

The JMO is not convinced that adherence is very good. Some of the families have asked her to give their child (actually, not their own offspring, since the majority of the 8 kids on ART are orphans) a pill to [kill] them. So adherence is probably not a big priority for some of these families at home. Overall, there are about 373 kids in Hyderabad on ART, spread out between this facility, Osmania, Gandhi, and the Chest Hospital. It is anticipated that many of these children will eventually get their care from Niloufer, once things are up and running.

Data on pediatric HIV in India are lacking. A place like Niloufer could contribute a lot to our understanding of the pediatric epidemic here.  The overseeing authority is the Andhra Pradesh State AIDS Control Society (APSACS), so any outcomes work would probably have to go through them.

Shamshabad

The new airport in Hyderabad is nice. I don’t know how old the old one was, but it was small, dirty, and inconvenient for the high flow there in recent years. With the development of the IT sector in Hyderabad (“Cyberabad“), the city desparately needed a larger airport. The new Rajiv Gandhi International Airport opened some 2 months ago, and is really well organized. My companion in the seat next to me (who, incidentally, lives right near SRH) told me that it is only 25-30% completed. I navigated the immigration and customs with ease. This is more than I can say for my new friend, who ended up paying a small “service charge” to the security officers just before the exit for his bottle of Chivas Regal.

They best way to get to your final destination from the Shamshabad airport, in my experience (n=1) is to use the Radio Taxi. This is the airport-approved service and goes strictly by the meter. I was charged about Rs. 750 (~$18.50) for the 40km trip to Sikh Village in Secunderabad. Plus he gave me a computerized receipt, which always looks better than the usual scrawlings I have been handed before from other taxi companies.

The weather promises to be unbearably hot, with temps on the 39-40 degree (centigrade – 104 F for those keeping score at home) range. The mosquitoes have begun feasting on me, so I had to DEET up early.

Schiphol

The upgrade to first class on the CLE-DTW leg was nice, for 26 minutes. I wonder what it takes to get upgraded on an international flight? Probably doesn’t happen, since I seem to remember empty seats in past trips. The Amsterdam Airport Schiphol is becoming a second home to me. This is the first time in 3 trips that I am here by myself. There was a bit of CIT1 nostalgia as I went through the shops.

I perused a Request For Applications from the NIH on the way here. Actually, it is a joint announcement from NIH and ICMR. It is focused on maternal and child health, including PMTCT of HIV. Too bad it expires this year. If Tara’s project takes off, it could feed nicely into something like this. Will keep my eyes open next year, I guess.

Even though it is 5:30AM Gopal time right now, and I couldn’t sleep for more than an hour or so, I am not doing bad. It is the next leg that is going to exhaust me.

Quickie

The night before my 10 trip to India. I am actually mostly packed, which surprises me. I still don’t have a clear idea of my schedule, but I know most of what I want to accomplish:

1. Install database

2. Get my student situated at SRH for the summer

3. Assess the SRH slum and PPTCT projects, since these are new for me since the last time I was in India

4. Explore new opportunities for CaseIndiaTrips experiences

My first challenge is going to be getting a decent cell phone. Apparently, if one knows what they are doing, one can use the cell phone for internet access for one’s laptop. Of course, this can clearly be done here in the USA as well, but my understanding is that in India it does not cost an arm and a leg. Not only do I not know how to rig this, but I don’t even know who to talk to about it.

I am excited to be flying KLM again. Am interested to see the new airport in Hyderabad, but not enthused about the huge distance from this airport to my family’s place. The old airport was just 15 minutes away. This one is an hour away under the best circumstances, I am told. Plus it costs Rs. 1000 ($25).