Monday, March 23, 2015
This week’s field visit brings Pallavi and I to the dermatology department at Sion hospital, which specializes in STI (Sexually Transmitted Infections) treatment.
We are supposed to meet an MSM client who has been HIV+ since last January and has now been diagnosed with syphilis. We wait all morning. He never shows. The counsellor, Harish, tells us that this is the 3rd visit his client has missed this month. Proof that you can bring a horse to water, but you can’t force it to drink. Apparently, the man is also addicted to MDMA, and Harish suspects his absenteeism is linked to his substance abuse.
I count approximately thirty people waiting outside the office. Men, women, and children, all sitting uncomfortably on wooden benches, clutching their registration sheets. As I look up from the doctor’s desk, I notice the clock in the upper left corner of the room has stopped, as will all the others I notice that day. Beside it, there is a placard with the name of the doctors who work in the office, and a mention of the NGO. Only the sign reads “Hum Safer Trust”, instead of Humsafar. It makes for a strangely appropriate typo.
The Suraksha (prevention) clinic opened in 1999, as a joint initiative between HST and the hospital, and currently treats 80 people, at an average of 6 or 7 patients a day.
Harish gets a call on his mobile from a young man who wants to come in for preventive treatment, his Saturday night date having turned into a disaster on account of a broken condom, but mostly because the status of his partner is unknown. The patient will be ingesting his second dose of Azithromycin (1mg) before breakfast, and Cefixime (400mg) after lunch. This treatment kit is part of NACO’s prevention initiative, and apparently cures the symptoms of Gonorrhoea and Chlamydia within 4 or 5 hours, even if the latent infections can still be transmitted to another person for a period of 7-10 days following the initial dose. Harish tells us that most of his clients will use condoms when having anal sex, but rarely for oral. This increases the risk of infection because some of these diseases can be passed on through bacteria in the throat.
In other news, Hepatitis C, which had not been reported since January 2014, has resurfaced amid 4 new cases, all of which were MSM who interacted with multiple partners while taking part in orgies.
The hospital also houses an HIV-care clinic, operating according to NACO’s guidelines, which keeps track of the antiretroviral treatments taken by every patient. The centre also offers treatment for secondary ailments like jaundice or tuberculosis, which can be tricky to get rid of once your immune system is shot.
More than 40,000 people walk through these doors every year, and I wonder how many of them keep making it out. I can’t help but stare at a young mother, mid-twenties, as she holds fast her toddler while reaching for her registration sheet with the other hand. I wonder about the future of these people who, despite the fact that we have stabilized AIDS in a North American context, will probably never be given anything else than the generic versions of the drugs they desperately need to keep them alive.
Back in the early days hospitals used to identify HIV+ patients with special plates above their beds. This was seen as a controversial matter because families are still often kept in the dark. It was also seen as an open invitation for discrimination. When I enquire about end-of-life care facilities, and I am told that there are 2 NGOs in the greater Mumbai area who deal with terminal HIV patients. The counsellor, however, is sceptical about the quality of the care provided by these establishments and he tells me that, mostly, “no one takes care of them.”
Confidentiality is paramount in this business, as most of the clients still aren’t out to their families, despite being infected. “They usually find my contact info on the Humsafar Trust website,” says Harish.
It isn’t until a client’s white blood cell count falls below 300 (the normal range being between 4,000 and 11,000 per cubic millimeter of blood) that families are notified, either through an invitation to attend the clinic or a home visit. Harish affirms that with a healthy and balanced lifestyle, most patients can expect to live another twenty years following a positive diagnosis. I am told, however, that Indians don’t have a big pharmaceutical culture, and that getting patients to abide religiously by their posology is problematic. Nevertheless, most meds at government hospitals are distributed freely, which minimizes the risk of patients being given drugs that don’t suit them, at least for the likely few who could afford them.
Luckily, the super strain of the HIV virus (H2) has not yet spread in India, with only 6 or 7 cases being reported in the last 5 years. Harish believes most of these patients contracted the disease overseas, in Saudi Arabia or the UK.
Still, there are other, more personal, considerations to address, like a self-conscious transgender woman who is shy about meeting a doctor alone and needs to be attended to. Harish tells us that most hijras only show up for treatment when they have reached an advanced stage and can no longer manage on their own. Usually part of a community, or a hijra house, these ailing patients are often handed a one-way bus ticket by their gurus, and told to go back to their families to die.
Patient reactions range from dispassionate composure, blaming it on fate and what has been marked as inevitable in your stars, to utter and total emotional distress. Others just get angry, flush their meds down the toilet, and drown their sorrows in bouts of alcoholism, which weakens their immune systems even further. And yet getting people’s info to do follow-ups remains the clinic’s main challenge. I am told that between the fake addresses, temporary phone numbers, photo-less registration cards, and people who seem to vanish overnight, keeping an accurate track-record of the walking dead is a grim prospect at best.
A survey done by the HST revealed that the 18-28 demographic currently has the highest rate of infection. Perhaps this is because there is a misconception that people you meet online are cleaner, more honest. Even more distressing than this belief is the tendency among resentful MSM HIV+ patients to start recruiting younger partners and convince them to have unprotected sex. “No one made me aware before they infected me,” they argue, “so why should I?” With empathy and compassion so alarmingly depleted, the vicious circle continues, and steadily keeps on growing.
To illustrate this point, we are given the example of a 21-year-old who got tangled up with an older gay couple. For several months they would get the youth liquored up every Saturday night and reassure him into having unprotected sex. When a few of his friends decided to go for a routine test, he tagged along, only to discover that he was now HIV+. He claims the couple were the only two sexual partners he ever had. I think of all the wasted lives, and it makes me angry.
Out of desperation, I ask the counsellor how he gets through to his clients, when the odds seem so clearly stacked against him. He tells me he has this technique he favours, which consists of putting a condom on his two forefingers and sweeping it across his desk. He then shows it to the client and says, “See, you thought this desk was clean, but look at all this dust I’ve picked up – still, my fingers are protected.” Perhaps it isn’t the most hard-hitting of metaphors, but a big part of me sure hopes it drives the point across, for everyone’s sake.
#SundayFriends...too bad we're Monday I guess.