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.