No DOT(ted) lines for them…HIV vs TB

Not just homes, but hopes were razed on June 14, 2004. Further pushed into a life of poverty, added with their high risk behaviour, have made commercial sex workers fall easy prey to TB and HIV. PREETU NAIR walks through the narrow lanes of Baina to understand the extent of the problem.When earthmovers and bulldozers tore through, brutally and indiscriminately obliterating Shenaz's home in Baina in the western state of Goa, India on June 14, 2004, she didn't breakdown. She didn't cry even when she had to push her minor daughter into commercial sex work to pay the house rent. After all, she had learnt to tackle poverty and live with the little opportunities and choices that life bestowed on her.

Now, Shenaz is in total despair. She finds herself in a vicious circle of stigma, economic hardship and discrimination, aggravated by the fact that she was detected with TB in February. "Life has changed for me. I have lost weight, feel weak and easily tired," said Shenaz. Being detected with TB and put on DOTS was just the beginning of her woes.

Recalling the happenings of the past few months, Shenaz said that she was asked to take medicines for six months from the local STD clinic at Baina. "I got medicines for a week. Later, when I went to the clinic, I was insulted and denied medicines because there was no doctor or nurse on duty. This went on for more than a week and my condition deteriorated and I had to be hospitalised," she revealed.Shehnaz's first time to the STD clinic was a bitter experience. She says, "I am going to the STD clinic because I get medicines free of cost."

Policy makers claim that the DOTS strategy is based on the availability of free, quality anti-TB drugs for all actively infected patients through the public health network, the reality is quite different. People like Shehnaz are denied easy access to treatment because they belong to a stigmatised group in Baina.

However, officials at the Goa State Tuberculosis Control Society (GSTCS) blame the failing primary health system and shortage of doctors in the health centres for such goof-ups. "At present, there is no doctor at the Baina STD clinic. We are trying to cover up for it with the help of auxiliary workers and they are doing good work, but there is an obvious lack of doctor, which shows," explained Dr VR Muralidharan, District TB Officer, North Goa.

However, Shenaz doesn't understand these arguments. All she knows is that her health deteriorated because she, a single breadwinner, didn't get medicines on time. "It is really difficult times for us. Each time I have fought to rebuild my life. Now I am tired," she added.

OUT OF REACH
Dr Maryam Shahmanesh, Clinical Research Fellow and Clinical epidemiologist for EFA, University College London, reveals that their studies have shown that the forced eviction of Baina has made the women much more mobile than before. "If they had TB it would have been very difficult for them to access DOT services and even more difficult for services and NGOs to find them. An additional factor is that the demolition led to a further erosion of the women's trust towards both public health services as well as NGOs for the Baina women felt let down by these services/agencies," she said.

Although there are no accurate estimates of TB in Baina, Dr Maryam believes that given the high prevalence of HIV amongst the Baina "sex workers" and the higher vulnerability to TB and HIV, it is very likely that the prevalence of TB in the women of Baina would have been much higher than the general population.

Arun Pandey, Director, ARZ, an NGO working with trafficked victims in Baina admits that many women in Baina didn't get the benefits of the Revised National Tuberculosis Control Programme because it started in Goa in September 2004, a few months after the Baina demolition. "Now it is also difficult for NGO's to have access to TB patients, as the trafficked victims have spread around. Their behavioural pattern, fear of discrimination and stigma make it difficult for them to come for treatment," said Arun.

NO DATE WITH DOTS
When a physically weak Rupa was taken for a sputum test at the Cottage hospital at Chicalim, she was sent to the TB hospital at Margao. At the TB hospital, she was tested sputum positive. The doctor advised her to be admitted for monitoring. However, the condition placed on her was: She should arrange for someone to stay with her at the hospital.
"Often patients are dumped at the TB hospital for months together because no one is ready to take them back home due to stigma. We wanted to fix responsibility and therefore we insist that someone should accompany the patient to the TB hospital and stay with them. This ensures family support and takes care of patient's needs besides the nursing part," added Dr Muralidharan.
"As no one was ready to stay with me, I made an excuse that my little child was alone at home and as there is no one to look after him, I would prefer to stay at home," she said. The doctors agreed and put her on DOTS. A month later, she went on a date (that's outstation trips for a period of 10 or 15 days for commercial sex work) during which she stopped the treatment. Now back in Goa, she is admitted in the TB hospital, struggling hard to survive.

"When you have the strong medicines to cure TB you need to have nutritious food and vitamin supplements. For this, they have to prostitute and to prostitute they drink alcohol. Alcoholism added with the kind of job they indulge in, ensures that they have no discipline in life. Further they are stressed out, depressed and have suicidal tendencies as they have no expectation from life, so it is difficult to convince them to continue with the medicines", observed Pandey.

Officials at GSTCS admit that dropouts are high amongst these vulnerable sections. "Sometimes they don't reveal their proper address. Neither do they inform us when they go out of station. This is the case with many here. Stopping the medicines abruptly and re-starting has resulted in many cases of drug resistance in Baina," admitted Dr Bidan Das, State TB Officer, GSTCS.

HIV V/S TB
In a late night raid at Baina on July 24, 2006, Laxmi was rescued and produced by the police before the Mormugao Deputy Collector and SDM, who remanded her to protective custody. The next day, the SDM ordered the police to take her to GMC for medical examination, which was delayed.
On July 27, the SDM learned from an NGO that Laxmi was receiving DOTS treatment and she had missed the medicines because she was sent to the State Protective Home at Merces, and immediately passed an order stating that Laxmi be allowed to take any medical treatment. Few days later, the in-charge of Protective Home wrote to the SDM stating that Laxmi has revealed that she has TB and HIV and is bleeding, which is risky for others and there is no medical staff to give her medicines nor any vehicle to transport her to the hospital in case of an emergency.

"With this case I was put in a peculiar situation. Immediate medical check-up is essential under section 15 (5)(A) of ITPA and I had asked for her to be sent for medical check-up. Had we got the reports on time, there wouldn't have been any problem. Further, I was in a fix once the State Protective Home in-charge expressed their inability to keep her and so I had to seek the help of an NGO ASRO," stated SDM Levinson Martins.

Despite the HIV pandemic presenting a massive challenge to the control of TB at all levels, there is no joint effort between various agencies to decrease the burden of TB and HIV especially amongst the vulnerable section and ensure timely treatment. At the moment, the only joint effort in Goa is between Goa State AIDS Control Society and GSTCS, but their role is also very limited.

(Few names have been changed to protect the identities of the individuals)
The article appeared in Gomantak Times, Panjim Edition dated April 13, 2007This article is written with the support of PANOS STOP Media Fellowship