Day 9: Epidemiology of HIV

Objectives and the need of the programme in District based on statistics (prevalence, incidence or other rates etc.) for the districts.

HIV/AIDS Section of the DHO’s Objectives
1. Reducing the spread of HIV.
2. Reducing the transmission from mother-to-child.
3. Prevention of HIV with NGOs

Issues Identified in the State Plan of Action 2011
1. Poor coverage of Harm Reduction in KKs
2. Need to increase coverage of the Methadone Substitution Clinic to the KKs under the DHO
3. Increased HIV infections through sexual contact

Issues in Sik
1. Ignorance
2. Lack of activities (idle mind is a devil’s workshop)

Statistics

The PPKP was new to the department and had not yet accessed the data. Of hand he says the cases here do not extend beyond 15/year and last year’s mortality were 3 individuals. The prevalence is concentrated on men and individuals above 40 especially among odd-job workers and rubber tappers. The PPKP suspects a clinical iceberg exists especially among migrant workers especially illegal ones but there is no budget provision to test them. Common high risk behaviors here include IDU and sexual contact (heterosexual and MSM).

The strategies of this programme

Existing programmes (DHO)
1. National AIDS Strategy [PROSTAR, methadone clinic, condom distribution, organizing health campaigns and screening in high risk areas: Voluntary anonymous screening (IC, phone number, address)]

WE GO TO THEM
2. Pre-marriage HIV testing
3. Handling AIDS Corpses

Under State Health Plan of Action 2011
1. NSEP in KKs in all DHOs (at least 1 KK/DHO)
2. Methadone clinic (2 KKs/district)
3. Improve HIV screening among husbands of pregnant mothers, high risk groups – from prepregnancy care, positive STI, transgendered individuals, sex workers, men-who-have-sex-with-men (MSM), GROs and their partners.

Personnel involved and their responsibilities (organization set up/ duties and responsibilities) DHO

1. PPKP Jamalul Hayat: Manages the HIV/AIDS as well as STI programme (campaigns/collaborating with KKs) in the district, PROSTAR, contact tracing handles AIDS corpses.

MOH: Diagnosis, treatment, counseling, treatment defaulter tracing
1. FMS/MO
2. Lab staff
3. KK – SN/MA in charge of the programme in their health facility

Implementation of activities from District to peripheral level PPKP coordinates with MOH people (through staff in charge in the KKs)

1. Collaboration with NGOs, RISDA, UMNO, AADK, PLKN, schools (HM/HEM)
2. Innovative HIV screening- to know the high risk village first before conducting screening (going in guise of working to know the population e.g. Mat Rempit, targeting screening)
3. Methadone clinic
4. Outreach – Brochure/souvenir with prior explanation at public places, cooking activities
5. PROSTAR – Schools
6. PLKN – Sex education: Using a condom properly
Maintenance of records and reports ( flow of information from peripheral to Ministry level) Open Case  e-notifikasi by PPKPK  MOH
(refer Health Infrastructure)

Budget provision
> HIV/AIDS STI programme: RM 40 000

> Methadone Clinic: RM 30 000

> Programme monitoring and evaluation (challenges/remedies/future programmes) Indicators of State Health Plan 2011 with targets:

1. Improving coverage of Harm Reduction in KKs
a. Number of registered clients (100/KK)
b. Percentage of regular clients (>70%)
c. Percentage of needles returned (>70%)
d. Percentage of clients screened for HIV/TPHA/Hep B/Hep C (100%)
e. Percentage of clients testing positive for HIV/TPHA/Hep B/Hep C (>10%)
f. Percentage of clients receiving advice on safe sex (100%)
g. Percentage of clients receiving condoms (100%)
h. Number of Harm Reduction training sessions conducted (1/year)
2. Methadone clinic (MMT) coverage
a. Number of KKs with MMT (2/DHO)
b. Cumulative registered clients (100 – 150/KK)
c. Percentage of regular clients (>70%)
d. Percentage of clients screened for HIV/TPHA/Hep B/Hep C (100%)
e. Percentage of clients testing positive for HIV/TPHA/Hep B/Hep C (>10%)
f. Percentage of clients receiving advice on safe sex (100%)
g. Percentage of clients receiving condoms (100%)
3. Increasing HIV screening among high risk groups
a. Percentage of pregnant mothers screened for HIV (>50%)
b. Percentage of HIV screening among partners with an MMT client (100%)
c. Percentage of STI cases confirmed for HIV (100%)
d. Percentage of IDU & partners screened for HIV under AADK monitoring
e. Number of activities with transgendered individuals, MSMs, sex workers and other high risk groups (2/year) and their percentage of HIV screening (100%)

Problems
1. Lack of cooperation due to stigma (fear of sending to prison for IDUs)
2. Asymptomatic phase
3. Screening for high risk groups only
4. No funding for illegal immigrants
5. Defaulting treatment (a cumbersome process: KD census and tracing all pseudonyms)
6. Contact tracing/defaulter tracing because of fake addresses and phone numbers
7. NSEP in KK Jeniang had to be postponed – IDUs found problems with the needles offered as they were too big and had to be returned to PharmaNiaga
8. Ineffective PROSTAR – youths indulging in high risk behavior because of the lack of activities

Future Plans
1. Opening a PROSTAR centre equipped with CC/gym/jamming room/karaoke/kitchen
2. HIV/AIDS specific campaign in Kampung Siam at the Wat with a Siamese IK to overcome language barrier

HIV Diagnostic Protocol in Kedah


>Rapid test
---->Non-reactive : F/U 3/12, 6/12
---->Reactive : ELISA/EIA/EA
:a. Positive:
> Repeat
> Confirmed and open case
:b. Negative: STI screen



Managing a HIV Case

1. Open case
   
2. e-notifikasi
   
3. Appointment with FMS at the nearest KK (WE GO TO THEM POLICY): Date, time, caregiver, contacts must be brought along  Counseling and Treatment  F/U by MOs (Clinical side)

**AIDS Corpse Handling Need to inform PPKP/PKD/KD/KK/Hospital. An offense under CDC Act if not done so.

1. Disinfectant used: Sodium hypochlorite/detergent
2. PPKP wears double layered PPE.

Principle: DO NOT INTERFERE WITH CEREMONIAL RITES. Just add on.

Muslim:
Body  Kain kapan with disinfectant  Thick plastic sheet  6 layers of cloth without disinfectant (Corpse becomes big and stigma ensues)

Non-muslim:
Cremation: Clothes soaked with disinfectant and all orifices covered with cotton soaked with disinfectant to prevent fluids leaking out.

Unclaimed bodies are handled by PPKP.

Methadone Substitution Clinic Started in 15/11/2008
Under DHO (Dr. Ishak), FMS (Dr. Amilene), SN Zahrah, Senior MA, KJK, JM.

• Aims to reduce HIV infection among IDUs.

**Only targeted at IDUs (heroin).

Two objectives:
1. Methadone Substitution (2 years)
2. Social integration (Kelab Kembali Bersinar): Getting them a job, helping them start a business, preventing relapse (For life)

Once enrolled, a participant is subjected to blood investigations (LFT, HBV, HCV, TPHA, VDRL, HIV screening) and is referred to the FMS. A date is given for induction. Participant has to bring next-of-kin to the induction. Methadone is a red syrup given at a special room by the Pharmacy Officer who also counsels. After induction, participant is allowed to rest at the facility for 3 – 4 hours and is accompanied back home by kin. Methadone is started at 20 mg and raised to 70 mg and under the FMS’s advice is tapered down.

Other activities in this clinic: safe sex education, screening for STIs, condom distribution

Expulsion from programme (6/64):
a. Urine test is done after 1 week after therapy (If +ve 3 times thrown out of the programme)
b. Poor attendance
Problem initially: Gaining acceptance from the community.

Achievements in the programme in Sik:
1. Businesses started (Agriculture, car workshop, chips business, landscaping, gravediggers, artwork)
2. Community treats the community (Peer recruitment and counseling)
3. Acceptance


RavivarmaRao