(This is just an outline of what i thought would be useful. will need more discussions about feasibility and we will need to research other programs like this to improve programmatic aspects and, of course, leave enough flexibility so people on the ground can improve it further. if interested to assist in developing this program, email: bibhav(at)nyayahealth.org)

HIV control in Migrant Workers

Objective: To minimize risk of acquiring HIV among migrants that travel to India from Achham and to minimize transmission from those that are infected. 

Rationale: Our target region has the highest number of new HIV infections in Nepal. Migrant workers acquire HIV in India and very often do not know their status. After they return, their wives and other sex partners get infected. We should not only provide treament for those who are infected but also control the epidemic by working proactively to prevent infection and transmission of HIV among migrant workers. The Saphebagar Primary Health Center is located very close to the bus station which is the transportation hub of all migrant workers from Achham (and possibly Bajura as well). We are in a strategic position, technically and geographically, to intervene right before the migrant workers leave and right after they arrive from India.

Program:

The HIV Control in Migrant Workers will be a two-fold program:

(i) Prevention of acquiring HIV

   1. Investigate the sources of HIV infection among migrants who travel to India from Achham: 

We will interview returnees who may or may not be HIV positive and research any literature available on this particular population to map the regions that are frequented by our target population, learn about their risk-behavior and gain better understanding of the potential sources of infection that include unprotected sex with sex workers, MSMs or sharing needles.

    2. Pre-departure health program:

Work with the transportation union and the local community to recruit people who will be going to India to work into our health program. Instead of focusing exclusively on HIV (which may be a deterrent for many clients) we will provide health package that will include other health education programs. We will then focus on HIV and use what we learned from step 1 to inform migrant workers about risk behavior, minimizing risk and places near their workpalce where they can receive help. We could distribute condoms, show correct use etc. Should not be longer than an hour and we can decide on including incentives or not based on how things go. We may want to train returnees to help run these pre-departure programs.

    3. Follow-up:

As of yet, this appears to be the least feasible. (Look at note following this section). We can explore several options to follow-up with migrant workers while they are in India: identifying and partnering with organizations or clinics near their worksites. Working with migrants' families to reinforce the importance of reducing risk when they are in touch.

Note: We may be able to find students (from college or med/eph) who can do this as a research project.  They can research risk patterns, learn about services available in india and then travel there to help us form partnerships. If we can develop this a little further, I am 90% sure we can get a student from haverford to do it. there is a huge grant that funds projects like these. only downside would be we'll have to wait until the summer. 

(ii) Screening returnees and HIV treatment and support

    Most of the clinical aspects of this program will be already in place. Will just need to establish an effective outreach method to capture all returnees.

1. Rapid test upon return:

Not sure about feasibility (uncertainty in arrival times of the buses and just resistance in general) but this is obviously extremely important. Since many will presumably be in a rush to head back, we should try to use rapid testing. We will work with the bus companies, drivers/conductors who can direct passengers to the clinic. Could package it with a completely voluntary health screening program for returnees with the option to opt out of specific tests as well.

    2. Counseling and referral of positives

Those who test positive will be fed into our HIV care system. Will receive treatment if eligible. If not, will learn about prevention of transmission etc.

    3. Follow-up and support services

Again, part of the regular HIV treatment and support system.

 Thanks Duncan for posting the following.  This piece can help in developing the program:

Here's an grant RFA that we had sent to CIRA but didn't get very far:

Identifying Structural Factors that may Impact

Antiretroviral Treatment Expansion to Rural Western Nepal

The HIV epidemic in South Asia has exacted a devastating toll on the subcontinent. While several countries in this region are currently rolling out antiretrovirals (ARVs) to treat the growing numbers of patients in need, few studies have determined the specific structural factors that may hinder the effective inclusion of rural patients in ARV programs.  Nepal, the poorest and least developed country of the subcontinent, has a particularly acute need to address HIV among its rural citizens, who constitute 90% of the country, three quarters of the HIV cases, and less than a quarter of individuals receiving ART. 

The epidemic of HIV in Nepal is very much entwined with that of neighboring India.  In some communities, 80% of adult males migrate seasonally to India for work, and these individuals form the largest population of people living with HIV in Nepal.  The second largest population of infected individuals is believed to be the migrants’ wives and partners.  Many of these migrants live in the rural, remote western part of the country where there has been virtually no access to HIV care.  The ARV rollout in Nepal faces some shared challenges with that of India, but also many that are unique to its context.

The rural western districts of Achham and Doti, which have the highest known prevalence of HIV among migrants in the country (8-10%), have been slated for ARV expansion in mid 2007; however, the rollout faces potential structural barriers to care, including profound poverty, lack of basic health services, frequent migration, gender roles and female economic disempowerment, and poor transportation infrastructure in the mountainous terrain.   Specific anticipated issues include the difficulty of male migrants adhering to an ARV program that depends on travel to one clinical site throughout the year and their wives’ difficulty in accessing services due to their economic and cultural disempowerment within the household.  Successful ARV program expansion to this area may therefore be very difficult unless the specific structural factors that hinder effective expansion are clearly characterized, and interventions to address them are tested.

            To meet the acute need for research, we will investigate structural factors impacting ARV care at the new clinical site in Achham—the site slated for ARV delivery to the region and the first rural ART site in the country.  We will work with the public charity Nyaya Health, which is collaborating with the Ministry of Health to revitalize the district hospital and revamp primary care, HIV, maternal, and TB clinical services in the region.  The first part of our research will be a field survey addressing barriers to seeking care to those men and women agreeing to voluntary counseling and testing patients at the district hospital and the mobile testing unit in Achham and Doti. Through follow-up participatory ethnographic interviews with those patients testing positive, we will then seek to further characterize the potential barriers and facilitators to subjects’ participation and continuation in ARV programs. We will characterize the context of migration, poverty, and health for men in rural far western Nepal; for women, we will assess the social, cultural, and economic structural factors impacting their health and healthcare.   In general, we will identify structural factors in the framework of understanding accessibility, availability, and acceptability.

            We believe this research is timely and innovative. It seeks to identify key structural barriers to ARV program expansion just prior to the Nepalese roll-out of ARVs in a setting of extreme poverty and geographical remoteness, and addresses the factors of migration and women’s empowerment in a manner that is participatory. The project addresses structural barriers to ARV program expansion and does so rigorously—using ethnographic field methods to determine subjects’ own perceptions of barriers and how interventions may alter them. The proposal is also designed for expansion into a larger, externally-funded study that will involve controlled trials of structural interventions to improve access to ARV care in this difficult context, including the development of a coordinated pair of clinics cross-border that will enable migrants to receive care while in India and at home in Nepal.  We anticipate that this research will continue to be interdisciplinary, crossing the boundaries between epidemiology, ethnography and clinical medicine.