Sharing what

SHARE does
Science Health Allied Research
Education
Vijay V. Yeldandi, M.D., FACP, FCCP
Secretary General
Vishnu Chundi, M.D.
Treasurer
 SHARE
Science Health Allied Research Education

MIIDRI

ICHHA
International Center Human Health Advancement

APAIDSCON
Andhra Pradesh AIDS Consortium
supported in part
by grants from United States Centers
for Disease Control and Prevention (CDC)
President's Emergency Plan for AIDS Relief
( PEPFAR).
PHMI
Public Health Management
Institute
supported in part by grants from
United States Centers for Diseases
Control and Prevention (CDC)
President's Emergency Plan for
AIDS Relief ( PEPFAR).
 SHARE Projects

PH
National

MI
level

State Level
N
CO

District Level
DS
AI
AP

Community level
 MIIDRI

 MediCiti Immunology and Infectious Diseases Research

Institute
 Mission:
 To provide effective affordable comprehensive care for
people with HIV/AIDS
 To educate and train health professionals and the
community to deal with HIV/AIDS
 To support research using technological, social cultural
tools to combat the HIV pandemic
 To provide a forum for international collaboration
 HIV Prevalence data
 Urban blood donors(data from 1997-2002)
14,185 tested 0.38% are HIV infected
 Rural pregnant women(data from 2001-
2002) 1176 tested 1.19% are HIV infected
 More HIV infection in rural pregnant
women than urban blood donors (OR
3.096: 95% CI 1.717-5.585 p< 0.001)
 ~ 2.5% of men between ages of 20-40
years , are HIV infected (Small non
scientific sample survey)

02/10/08
 HIV Risk Assessment
Results
 Demographics of all participants (n=5372)
 Male: 45% ; Female: 55%
 Age: 18-25: 22%; 26-35:31%; 36-45:22%
 Marital: 82% married; 10% never married :
 Sexual Behavior:
 5% of all married participants report more than one
partner after marriage – Of those reporting so, 88% were
men
 2% population report sexual contact in exchange for
money at least once
 1.5% participants report non-spousal partners as most
recent sexual partner ( sex worker, friend)
 98% report never using condoms with most recent
partners
 Sero-positive
 Individuals
Total n=69 – HIV prevalence=1.28%
 62% Male; 38% Female
 84% 18-45 years of age
 83% were married
 Sexual Behavior
 12% reported 2 or more sexual partners pre-
marriage
 5% reported multiple partners after marriage
 3% have had more than one partner in the past 6
months
 25% of sero-positives report daily consumption of
alcohol

Marriage is a major risk

 HIV Infection in Rural South India: A Sexual Network Analysis
JOHN A. SCHNEIDER, MD, MPH1, GURCHARAN SALUJA, MBBS2, VIJAY YELDANDI, MD, MIDC3, JOCELYN 
TOLENTINO, MPH1, GANESH ORUGANTI, MD4, SRIPATHI DASS, MD2, PS REDDY, MD4, DAVID PITRAK, MD1; 
1
University of Chicago, Chicago, IL,2MediCiti, Ghanpur Village, India,3Westlake Hospital, Melrose Park, IL,4MediCiti, Hyderabad, 
India.
Supported in part by the International Center for Health and HIV/AIDS (ICHHA) and the University of Chicago

AIDS Care, 19:9, 1171 - 1176

BACKGROUND MEASUREMENTS RESULTS

 The southern state of Andhra Pradesh (AP) has one of the highest  Laboratory ­ HIV­1 status retested using WHO testing strategy III with  The sample mean age was 37 years, 22% were of a tribal caste 

rates of HIV­1 infection in India. Recent estimates of HIV infection  additional Western Blot Confirmation.  RPR and hepatitis B serology  and 78% of a non­tribal caste. Seventy percent of the sample 
in rural areas have begun to approximate the urban. Methods of  were also conducted.  Survey ­ 336 item IHFLS survey ( based upon the  earned <1000 rupees ($23) per month. When compared to 
HIV transmission in rural India are poorly understood.  National Health and Life Survey which has been validated in the US  men, women were more likely to be born in another village 
and China) available in Telugu, English and Chinese.  17 domains  (87% vs. 10%; p<0.01) and less likely to have greater than 
PURPOSE
included detailed items on sociodemographics, personal health,  primary education (13% vs. 57%;p=0.014). Among female 
We  examined  risk  factors  for  HIV  transmission  in  a  group  of  rural  exposure to hypodermic needles, attitudes towards marriage and sex,  respondents, none were commercial sex workers (CSW), and 
    villages in AP through the use of a sexual network analysis survey ­  sex life, sexual partners, STIs, childhood sexual experiences,  there were no significant social or behavioral associations with 
the Indian Health and Family Life Survey (IHFLS). homosexuality, sexual harassment and sexual consumption.   HIV infection. Among male respondents, 50% (5/10) of the 
Conditional logistic regression models were used for all analyses. HIV(+) cases reported having sex with female CSW compared 
to none (0/20) of the HIV(­) controls. All men who had sex 
with female CSW were married, from a non­tribal caste and 
did not use condoms. Men who had sex with men (MSM) 
DESIGN, SETTING and PARTICIPANTS Table 2. Selected Male Characteristics in Rural AP. demonstrated a trend toward an increase in HIV infection 
Design:  Case Control Study HIV+ Cases Matched Controls (OR=4.0;p=0.26). MSM were more likely to be tribal 
N = 10 N = 20 OR 95% CI* (OR=16.0;p=0.042). All tribal MSM were married, had 
Setting:  38 villages in rural Ranga Reddy District, Andrhra Pradesh Personal Relationships multiple male partners, and did not use condoms. 
Participants: 60 participants (20 HIV infected and 40 controls) matched  Marital Status (%) 8.0 0.69-92.70
by age, gender and village randomly selected from a Voluntary  Remarried/Divorced/Widowed 3 33.3% 1 5.9% Figure 1. Sexual Matching Patterns of Polygamist Men, MSM and
First marriage 6 66.7% 16 94.1%
Counseling and Testing Program. Men who Buy Sex ?
Condom use in past year 2.7 0.26-27.82
?
Yes 1 12.5% 5 27.8% +
?
No 7 87.5% 13 72.2%
?
Table 1. Sociodemographic Characteristics (30 men and 30 women). Life time sexual partners>1month p=0.03*
Cases = 20 Controls = 40 OR (95% CI) 0-1 4 57.1% 17 100.0% + ?
?
Age (mean, SD) 34.6 (12.9) 38.6 (11.2) 0.97 0.92-1.02 2 or more 3 42.9% 0 0.0%
Caste (%) 1.09 0.40 - 2.99 STDs ?
+ ?
Other Caste (OC) 3 15.0% 5 12.5% Genital Lesion in the past year (%) 4.9 0.38-60.15 ?
Scheduled Caste (SC) 2 10.0% 8 20.0% Yes 2 20.0% 1 5.0% ?
+
Backwards Caste (BC) 10 50.0% 19 47.5% No 8 80.0% 19 95.0% ?
+
Scheduled Tribe (ST) 5 25.0% 8 20.0%
Sexual Consumption
Education (%) 0.74 0.11 - 4.90 ? ?
Used sexually explicit media (%) 0.6 0.13-3.25
>Primary 6 30.0% 11 27.5% +
Yes 3 30.0% 8 40.0% ? ?
≤Primary 14 70.0% 29 72.5% +
No 7 70.0% 12 60.0% ?
Birthplace (%) 2.27* 0.75 - 6.89 Married Tribal Male Non-CSW ? - Unknown Caste
7 35.0% 22 55.0%
Bought sex (%) p=0.002*
Outside this Village Not Married Non-Tribal Male CSW + - HIV+
Yes 5 50.0% 0 0.0%
This Village 13 65.0% 18 45.0% CONCLUSIONS
Occupation Type (%) 1.00 0.34 - 2.93 No 5 50.0% 20 100.0%
Non-Agriculture 9 47.4% 19 47.5% Homosexuality     In a rural south Indian sample, we did not identify specific 
Agriculture 10 52.6% 21 52.5% Homosexual feelings (%) 4.8 0.38-60.15 HIV risk factors in women. For men, both CSW and 
Personal Income 0.80 0.26 - 2.45 Yes 2 20.0% 1 5.0% potentially MSM play a role in dissemination of HIV infection 
> 1000 rupees ($23) 7 38.9% 11 32.4% No 8 80.0% 19 95.0% in identifiable subpopulations. MSM amongst tribal 
< 1000 rupees 11 61.1% 23 67.6% Sex with other men (%) 2.1 0.12-37.72 individuals in rural areas may be a mechanism of HIV 
Overnight travel past year 1.44 0.34 - 6.11 Yes 1 10.0% 1 5.0% transmission and warrants further study. Public health 
Never to less than a month 16 80.0% 34 85.0% No 9 90.0% 19 95.0% interventions aimed at reducing HIV transmission in rural AP 
More than a month 4 20.0% 6 15.0% *Fischer Exact test used to obtain a p-value when conditional and unconditional logistic should consider targeting subpopulations of men that engage 
*Unconditional Logistic Regression regression models did not converge. in covert MSM or CSW, as well as their at risk wives. 
Comprehensive Risk Reduction
in India Strategic Partnership
(CRISP)
 Lowest HIV prevalence in any truck driver
survey in India – 2.1%
 No incident cases of HIV infection of truck
drivers tested more than once
 Acceptability of Education and Motivation
Counseling Services is High
 Only PPP program in India
 Only Privately Funded Truck Driver
program providing VCT in the Country
 Pilot Study 2004-2006
 Mean age was 30.2, 56% were from out of state, 73% spent
<7days away from family per year, 58% reported consistent
condom use when visiting a commercial sex worker (CSW)

 2.1% (n=5) were HIV infected at baseline.

 Unmarried status men were more likely to be HIV-infected (OR 5.1;

p=0.05). Having anal sex with a man or visiting a CSW in last six
months, genital symptoms or STD diagnosis in the last 12 months
and number of sex partners in the last 12 months were not
associated with HIV infection (OR 0.9-2.5; p-values=0.3-1.0).

 The 13.5% of drivers who returned for follow-up reported

increased handwashing before eating (p=0.04), were more likely
to have heard of the germ theory (OR 6.3; p=0.02), and had an
overall improvement in HIV knowledge (p=0.022), but did not
demonstrate changes in HIV risk taking behavior.

 Information Motivation (IM)?

Presented at IAS 2007, Sydney Australia
 Gati
 Gati Community Health Center (GCHC)
 5 days a week – Inaugurated 27, March 2007
 Key screening and care areas
 Diabetes, High Blood Pressure, Body Mass Index, Nutrition,
Heart Disease, Vision Check, Mental Health, STD/HIV
 New Employee Physical Exam
 Strengthening Partnership with MediCiti
 Community Medicine Faculty to Staff Clinic
 Medical Students to join in July
 Develop Core Committee group of Transport
Industry Leaders to Set HIV Policy – Led by Mr.
Swarup
 Conference September 8th and 9th, 2007
 Committee Meetings Supported by Public Health
Management Institute/Centers for Disease Control and
Prevention Global AIDS Program
Gati Community Health
Center
Gati Community Health
Center
 Andhra Pradesh AIDS
Consortium APAIDSCON
 Consortium of Private Medical Colleges and hospitals in Andhra Pradesh for
HIV/AIDS related programs
 Bhasker Medical College, Moinabad, Ranga Reddy; Deccan College of Medical
Sciences, Hyderabad; Chalmeda Ananda Rao Institute of Medical Sciences,
Karimnagar; GSL Medical College, Rajamunddry, East Godavary; Kamineni
Institute of Medical Sciences, Narketpally,Nalgonda; Katuri Medical College,
Guntur; Konaseema Institute of Medical Sciences and Research Foundation,
Amalapur; Mediciti Institute of Medical Sciences, Ghanpur, Medchal R.R.Dist;
Mamata Medical College, Khammam; Maharaja's Institute of Medical
Sciences,Vizianagaram; MNR Medical College, Sangareddy, Medak; NRI
Academy of Sciences, Guntur; Dr Pinamaneni Siddhartha Institute of Medical
Sciences & Research Foundation, Gannavaram; Sri Venkata Sai Medical
College, Mahbubnagar; .ASRAMS, Eluru; SHADAN Institute of Medical Sciences,
Hyderabad
 Partnering Institutes
Chalmeda
Adilabad

MNR m
ara
Mamata ia nag
z
Nizamabad Karimnagar Vi Srikakulam

Deccan
Medak Warangal
Visakhapatnam
Hyderabad East
Khammam Godavari
Rangareddy Maharajah’s
MIMS Nalgonda West
Godavari
Bhaskara Krishna
Mahabubnagar
Guntur
GSL
SVS
NRI
Prakasam
Kurnool
0.75%
Katuri
Kamineni
Ananthapur Cuddapah Nellore

Chittoor
 APAIDSCON Aims
Opening doors for HIV/AIDS patients by -
1. Providing Comprehensive Care and
Support services
2. Setting up referral lab services for
subsidized CD4 / Viral load testing
3. To conduct outreach activities for
awareness of HIV/AIDS among community
and vulnerable groups.
 Objectives - APAIDSCON
 Implement and sustain a standardized approach to care
and management of People Living With HIV/AIDS (PLWHA)
to maintain quality of life and reduce transmission to
vulnerable - women and children.
 Maintain the safety at work place and community from
blood-borne and other infections.
 Improve clinical competency of the network of physicians
through continuing medical education programs and
capacity building.
 Improve private and public collaborations to expand
services like counseling and testing within the communities
of each member organization
 Strategies
Training and Monitoring and Support
Capacity building To ICTC/PPTCT

Opening doors for

HIV/AIDS

Outreach through
Laboratory support Partners &
Red Ribbon Clubs

Improve Public
Private Partnerships
 1. Capacity building (training)

Sensitization
Refresher and
for Advanced clinical
review meetings
healthcare workers – hands on trainings
for
- Doctors for
-Counselors
- Nurses - Doctors
- Lab technicians
- Housekeeping staff
- Medical students
 How many did we reach
Personnel State level Institution
trained (numbers) level
Doctors 90 (numbers)
507
Nurses 27 952
Housekeeping 30 956
staff
Medical - 2334
students
Counselors 15 -
Lab 15 -
technicians Oct 06- Sep 07
2. Monitoring and support to ICTC and PPTCT
- A Public Private Partnership

15 Counselors and
Monitoring of these
Laboratory technicians
placed by APSACS 15 centers handed
in 9 ICTCs and over by APSACS
6 PPTCTs of to APAIDSCON
the consortium partners
Particulars Target Achieve
No. of ANCs Tested 6000 d
20,786

No. found Positive NA 159

No. of ANCs 60 67
PPTCT
Delivered
Positivity NA 0.76%
Percentage
(All data during Particulars Target Achieve
Oct 06 – Sep 07) d
No. of People Tested 12,000 19,510

No. found Positive NA 1,164

VCTC
Positivity NA 5.96%
Percentage
 3. Outreach

Red Ribbon Clubs: Outreach by

Run by medical Partnering
students Institutions:
of the partnering Partners conduct
institutions. regular outreach
Action at 2 levels :– activities through
6. Individual level their community
7. Community level medicine
they department.
Reach out to schools,
other colleges and
community
 Outreach

ACTIVITY TARGET ACHIEVE

D
Cumulativ A 6200 6464
e no.
achieved
for all AB 6200 6753
Partnering
Institutes
C 3050 6142

A – Abstinence B – Being Faithful C – Condom

(Oct 06- Sep 07)
World AIDS day rally Street play by medical students

Pledging on the World AIDS day

Sensitization program for Doctors and Medical students

Sensitization program of Nurses

 Reaching out to Schools…

Sensitizing Community level workers

Community outreach program for HIV awareness

Medical students sensitization ( HIV elective)

 HIV Curriculum
 John A. Schneider MD, MPH
 Clinical Associate, Section of Infectious
Diseases, University of Chicago
 Senior Research Fellow, Center for AIDS
Research (CFAR), Brown University
 Associate Director, MediCiti Immunology
and Infectious Diseases Research
Institute, SHARE/MediCiti
 Curriculum
 For Phase I students, lectures from the curriculum will cover the material
in the following MCI designated requirements:
 Community Medicine, - Prevention and Humanities – 1 hour
 For phase II students, lectures from the curriculum will be incorporated
into the following MCI designated requirements:
 General Pathology, SI. No. 8(h) – AIDS – Integrated Teaching – 1 hour
 Microbiology, SI. No. 5 – General Virology AND Systemic Virology – 1 hour
 Microbiology Symposia and Seminars – 2 hours
 Pharmacology SI.No. 21 – National Programmes Including Management of
AIDS – 1 hour
 For phase III students units will be broken into the following Theory and
Practical MCI Requirement:
 General Medicine, SI. No. 7 – AIDS – 2 hours theory; 1 hour Practical
 General Medicine, SI. No. 7 – Infectious Diseases– 2 hours theory; 1 hours
Practical
 General Medicine, SI. No. 6 – C.N.S. – 1 hour theory, 1 hour practical
 General Medicine, SI. No. 5 – T.B. and Chest Diseases; 2 hour theory, 1
hour practical
 Pediatrics, 2 Course Content - Infectious Diseases – 1 hour lecture
 Obstetrics and Gynaecology, Theory 24, STD and HIV – 1 hour lecture
 Obstetrics and Gynaecology, Family Planning 2, Contraception – 1 hour
lecture
 Obstetrics and Gynaecology, Integrated Teaching 8, HIV complicating
pregnancy – 1 hour lecture
 Evaluation
 Pre and Post Test
 HIV Knowledge
 General Medical Student Survey
 To Compare to US Medical Students
 For Phase Three Students Only
 General Nursing Student Survey
Red Ribbon Clubs
 Red Ribbon Club glimpses

Sensitization & Introduction to Red Ribbon

A Red Ribbon Club Head quarters
 4. Laboratory Support
 Quality CD4 testing for partners at
affordable
price to the patient (Rs200)
 Innovative mechanism of transporting
samples to the lab
 A unique sample transport bag was
prepared
 GATI cargo services provided support in
hand delivery and surface / air transport of
the sample

CD4 Sample transport bags
 Vision
“A HIV-free India through enhanced
public health systems, with a fully-
engaged private sector and
leadership of public health managers
& prevention specialists.”
 Mission

“Maximize Public health

management and HIV prevention
capacity of individuals, government
bodies, and organizations (NGOs,
CBOs, Private / Corporate agencies,
etc.) that serve communities &
individuals affected by or at risk for
HIV/AIDS in India and globally”.
To develop A Public Health
Movement in India – We target
•Public Health Managers, Clinicians,
•Professional Social Workers,
•Health Economists, Political & Administrative Bureaucrats
•Media & IEC Experts, Community leaders,
•Women self help groups,
•Film industry,
•Policy &Law makers involved in Health Care Services in India to
improve and update their capacity to global standards to revitalize
the HCS towards reducing the human suffering in a most cost
effective manner.
•Organizations currently working on HIV prevention, keen on adding
• An HIV prevention component to their current work plan
 Objectives
 Create high quality human resources (e.g.
Field level Public Health Leaders) for
capacity building and systems
strengthening in India
 Mainstreaming HIV/AIDS services.
 System strengthening through
establishing models in Government,
Private & Corporate health care services.
 Activities of PHMI
1. Supporting Government agencies (e.g. SACS, NACO) for –
 Management of the ICTC, M&E, Surveillance & Program
management
 Systems strengthening through Consultants.
 Strengthening and developing systems to operationalize ART
programs
 Innovative initiatives e.g. accreditation, down-referrals etc.

2. Developing CDC guided technical

accreditation/certification for private labs & Private
clinicians who conduct large number of HIV tests.

3. Short Public Health Management trainings in collaboration

with IIHM&R

4. Developing model laboratory with HIV focus

5. Starting model Infectious Diseases Clinic. (HIV/TB/OI/ART)

 Activities of PHMI contd…..
1. Setting up Diseases Surveillance Center with HIV focus
2. Supporting GHTM with the strategic management and
data management systems through Tambaram Health
Information System (T/HIS).
3. High quality technical Human Resource Capacity
Development through Public Health Field Leaders
Fellowship (PHFLF) with technical support of CDC and
NASTAD
4. Organize workshops & CMEs on HIV-related information of
Strategic & Technical Importance / relevance 
5. Training of District AIDS Prevention and Control Units
 What we did so far…
 Conducted 13th International Conference on
“Mainstreaming the public health response to HIV-
AIDS” - Attended by more than 400 delegates
representing a large spectrum of stakeholders.

 Established a center to house model HIV Lab, ID

Clinic for HIV, TB,& other infectious diseases.

 Lab.certification training for the 1st batch completed.

 Strengthened the data management system of

GHTM, Tambaram.

 Technical support of APSACS through three

Transport Sector Working
Group

XIII Annual CME

NISIET
Hyderabad, AP
 History
 First Meet in February at RTA Commissioner’s
Office – Hyderabad
 Vendors
 Second Meet in March
 Corporate
 Third Meet in March
 Vendors, mostly Gati
 Fourth Meet in April
 Drivers
 Fifth Meet in June
 Drivers
 Sixth Meet NISIET
 Drivers, Vendors, Corporate; All Separate
Health Problems in Truckers
 Younger group
 Less concerned about chronic disease
 Top Problems in this order
 Tension – Stress of delivering on time
 Can lead to suicide; loss of job
 HIV/STIs –
 HIV/STIs not related to Tension
 Pathways
 Musculoskeletal – Aches/pains
 Diet – quality, quantity
 Sleep – quality, quantity
 Vision
 Accidents
 Barriers to Accessing Health
Care
 Nature of the Job
 Time and Money
 Lack of Accessible Services
 Parking not allowed
 Trucks not allowed
 Small roads
 No respect in society
 Difficult to get married
 Difficult to get money
 Constant pressure from vendors and company
 Solutions
 Take care of the entire driver
 ?tax breaks to “healthy” stops
 Good food, water
 Interventions
 Proper Restrooms
 Phone minutes
 Sun-glasses
 Health clinics
 Greater need for corporate and vendor
leadership
 Measures
 Measure accidents, infections,
disease status at a trucker
population based level

 Development of Clinics that Provide

Full Spectrum of Services
 Most only treat STIs and give education,
but don’t provide HIV testing or other
targeted health services
 Public Health Field Leader
Fellowship
(PHFLF) – A unique initiative
 One-year fellowship in a distance
education mode, with six week of bi-
monthly contact sessions – started on Nov
12th 2007.
 Curriculum support from National Alliance
of State and Territorial AIDS Directors
(NASTAD)
 25 fellows selected from a highly
competitive and large applicant pool
nationwide
 Concepts and practices with real-time
 PHMI:
Public Health Field Leader
Fellowship
 Curriculum outline (for 6-
weeks):

3. Getting to know your community (and the

virus)
4. Data for decision Making
5. IEC/BCC and Social Marketing
6. Communications and advocacy
7. Managerial skills
8. Wild card (to address specific needs of
trainees)
 PHMI:
Public Health Field Leader
Fellowship (PHFLF)
Graduation Requirements:
To develop public health leaders and managers who would
be seen as public health experts in the field of HIV
PHMI expects minimum requirements for graduation:
 Bi-monthly on-site & residential hands-on training that will be
technical and managerial (total of 6 weeks per year)

 Full participation and attendance

 self learning as a strong method of the-job trainings and skill

development (with continuous ongoing mentoring)

 completion of a final project (which is closely linked to the output of your

daily work and job responsibilities)
Batch- 1 PHFLF/PHMI
 The agenda ahead….
 Technical support to NACO with 3 ART Consultants
and 3 NACO Coordinators to SACS.
 To strengthen AP Chest Hospital on par with GHTM
and Gandhi Hospital, Hyderabad.
 Health System Management trainings for
Government and Private Medical College Hospitals.
 Protocol based treatment & Soft skills hands on
trainings for clinicians and health managers.
 Diseases Surveillance & MIS trainings for Data
Managers
 Cost effective management, effective
implementation of NRHM, NUHM, HSD, Costing &
Budgeting of Health Systems in India for Public
Health Officers of line depts.
 Establishing effective Public – Private Partnership in
 New Strategies for HIV
Prevention
 Decrease Substance Abuse
 Non-condom prevention
interventions?
 Targeting high-risk groups