Apollo Blood Services & Free HIV Testing Clinic (May 31)

This is a backlog of what we did yesterday--by the end of the day we were so beat we just barely finished dinner before collapsing at around 8:30.

Dr. Raina, an immunologist (and anti-religionist!) gave us a tour of the blood services at the Sarita Villar Apollo. Apollo Hospitals are a corporate group with 40,000 beds in India. It's a paid service, although 10% of the beds are government-sponsored, and the private revenues pay for services for those who can't afford Apollo's "luxury" care.

Interesting what constitutes luxury. This is not a primary care hospital--it's a referral hospital. Got a rare disease? You'll find your superspecialist here. There are 450 doctors in this hospital, and 2,500 staff. They offer the best care you'll find anywhere in the world.

Almost. At first it seemed odd that Dr. Raina would bring us to this posh area (read: central A/C) to tell us about the disease burden of HIV/AIDS and how it's infiltrating the blood supply. I thought we were at Apollo to talk about success in the health care arena for a change.

About 10 years ago, blood donation legislation changed in India. Instead of getting paid donors to donate, lawmakers banned compensation for donation and decided that patients should rely on family members and, in case of no ready family members, voluntary donors. 60-70% of blood donated comes from family members of a patient. The rest comes from unpaid donation.

However, there is a significant black market in India for blood. There is quite a shortage, according to Dr. Raina. The country uses 6-7 billion units, but it only gets about 5 million units each year. This leads to a massive shortage, which fuels a black market that attracts not healthy people's blood, but the blood of drug users and other high risk populations.

What is the consequence of having a population with a higher burden of HIV/AIDS, Hepatitis B, HPV and other STDs regularly donating blood? The consequence is that the transmission risk for HIV/AIDS in India is 202-50 fold higher than in other countries. This is NOT because of bad testing (1 of every 40,000 will transmit HIV AFTER standard screening, which translates into a profound number in a country with 1 billion people), but because of the population load of the virus. And to get more specific, it's because of the sort of people who are donating. Dr. Raina pointed out that this problem would be solved not by focusing on the black market, but by encouraging healthy people to do their part and donate their good blood.

This is not the only issue. There are two types of screening tests: testing for antibody presence, and testing for viral load. The nucleic acid testing (NAT) is very expensive and new. It is neither required by the Indian government, nor affordable to the general population (at Apollo, however, it is required). Thus, the vast majority of screening relies on ELISA--the antibody test. Antibodies are bigger than nucleic acids, so the test is easier, cheaper, and older. However, it is not so sensitive as doing the two in combination. In the United States, of course, both antibody and viral testing is done. Dr. Raina stressed that if this precaution is needed anywhere, it is needed in India. The situation is compounded by the fact that a high percentage of donors are repeat donors, so if the tests do not detect their seropositivity the first time, they will continue to be cleared for donation again and again. Their donated unit of blood will infect not only one other person, but three or four. Dr. Raina says that the fact that there is no national ID system in India, and no HIV registry, make it much harder to keep the blood supply clean. In the clinics, we have met two patients, both young, who contracted HIV through blood transfusions.

The second part of our day was spent near a huge truck stop at a free HIV testing clinic run by SPYM (correction from the previous blog: SPYM stands for society for the promotion of youth and MASSES!). We met with health workers who do outreach work serving 1,000 people in the community, including female sex workers, MSM, injected-drug users, and truck drivers. The health workers there indicated that MSM were the most at-risk for HIV due to their sexual practices and risky use of condoms that has a higher rate of breakage. The center gives free HIV testing (antibody testing, rapid assay--25 minutes). Many people don't come back for their results. The clinic gets government funding for all its laboratory equipment, and also receives NGO funding that trickles down from larger national anti-AIDS programs.

We gained some insight into the lives of MSM there. For instance, they may be married and have kids. Some are openly MSM and have no other life, others live a normal life (they may have been pressured to get married despite their desire for a different lifestyle). Many who test HIV positive don't tell their wives about their status. They often don't know how it is spread. One of the health workers, Narendra, said that many think having sex with a donkey or a virgin will actually cure them (this was hard to believe, but he was serious). It's hard for health workers to spread awareness because many of their target populations think that having sex is the only way to get the disease; therefore, from the beginning, they are aware of the stigma associated with it and are not open to discussing it. Many are more worried about STDs, and Narendra said that his biggest challenge was convincing them that STDs were not a bigger threat than HIV, but the other way around.

Another highlight of our HOT afternoon was talking to Ammaji, a peer educator for female sex workers. She is a peer not because she herself is a sex worker but because she lives among them. She is older, and has a very strong spirit. She is committed to the women she serves. She said she has sat outside while sex workers are meeting with clients, in order to track them down and educate them. If a client refuses to wear a condom, she openly counsels/scolds/stands up to him, and has empowered the community to say no to clients who bully them not to use condoms. It was interesting; she was able to do what she does successfully because of her position as a strong, wise, older woman.

Trafficking is a big problem in Delhi. Not across borders, but within the country. Women are trafficked from other states into the capital city to work in the sex trade. Men come to Delhi looking for work, and fall into MSM as work because it pays more than other jobs. One of the men we met on Monday afternoon at the Sahara transgender clinic was an example of this. He came to Delhi looking for work, and is an MSM sex worker. He has a girlfriend, and plans to go back to his village and live out the rest of his life there once he's made enough money. This was interesting too.

Ammaji had more insight into the life of the female sex worker: there's drugs, alcohol, and husbands to cover, too. Some husbands of female CSWs accept their work because it brings in much-needed income; others don't even know what their wives do for a living. Some husbands are addicted to smack, or alcohol, and waste away money needed to feed, clothe and school their children. Children of CSWs who live on the street are likely to follow their parent into the trade; those that live in houses have a better chance at a normal life.

A typical CSW has about 10 clients a day (according to Ammaji) and makes anywhere from 50 to 4,000 rupees.