Tribal communities

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• Tribal communities HIV
• Fabian Tögel, MD, MPH
• Aktionsgemeinschaft Partner Indiens,
  e.V.
• Munich, Germany
• November 11th, 2006

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• Half of the worlds indigenous people live in
  India (89 million, equivalent to the current
  population of the State of Bihar or the
  Philippines)
• Tribal identity differs from caste identity in
  terms of language, social organization,
  religious affiliation, economic patterns,
  geographic location and self-identification
• Primitive Tribes - low literacy
• - pre-agricultural technology
• - stagnant/diminishing population

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• 8.1 of the population (89 million)
• Protected under constitutional schedules 5th
  (areas in Central India with gt50 tribal
  population) and 6th (in the Northeast)
• Tribal sub-plans under Integrated Tribal
  Development Agency (ITDA)
• Article 46 (promotion of interests, protection
  from exploitation), Article 47 (improve
  standard of living, promote public health)
• National Health Policy, 2002 (equitable access
  to health services) with reference to tribals

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Social Assessment of HIV/AIDS among Tribal People
in India

• A report submitted to the National AIDS Control
  Programme Phase 3 (NACP-III) Planning Team, New
  Delhi (May 2006)
• Data collection from one district each in Andhra
  Pradesh, Chhattisgarh, Maharashtra, Manipur, and
  West Bengal
• Review of social dimensions of other project
  preparation studies
• Consultations with tribal stakeholders and other
  participating agencies

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Key findings of Social Assessment

• Low awareness and knowledge of HIV/AIDS and STIs
• Wide variation in sexual and marital practices
• Very low access to modern health facilities
  (especially women face social, physical and
  economic barriers to seeking healthcare)
• High use of traditional healers or unqualified
  practitioners
• High vulnerability among youth and those who come
  in contact with non-tribal populations (eg.
  migrants, women engaging in sex work)

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Contact with high-risk groups (HRGs)

• Women Truckers, contractors, tourists, defence
  personnel
• Men CSW during migration
• Acting as HRGs
• CSW, MSM or IDU (in Northeast)
• Other ways of acquiring HIV
• Pre- and extramarital unprotected sex, unsafe
  injection and tattooing practices

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• NACP-3 Tribal Strategy Action Plan 2006-2011
• Classification of districts based on prevalence

Level A High prevalence district Level B
Concentrated epidemic Level C Vulnerable
population Level D Low prevalence, low/unknown
vulnerability Accordingly, the district will see
varying numbers of services including ICT, PPTCT,
STI/OI care, ART, presence of link workers.
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Implementation of Tribal Action Plan

• Mapping of vulnerable populations in
  collaboration with the Integrated Tribal
  Development Authorities (IDTAs)
• Translation of IEC material by Tribal Research
  Institutes for behavior change communication,
  condom promotion referral to ICTC and ART
  services
• Compensation for travel and related expenses
• Targeted interventions for migrant workers
• Involvement of CBOs/NGOs

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Challenges

• Mainstreaming Collaboration with the Ministry of
  Tribal Affairs, Ministry of Social Justice
  Empowerment, Ministry of Human Resource
  Development (Education)
• Integration into National Rural Health Mission
  (NRHM), Reproductive Child Health Phase 2
  (RCH-2), Revised National TB Control Programm
  (RNTCP)

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NGO initiatives to prevent HIV among tribals in
Jhabua district, Madhya Pradesh

• District profile
• Borders with Rajasthan, Gujarat, Maharashtra
• Population 1.4 million (2001 Census)
• Tribal population gt 85 (1.2 million belonging
  to Bhil tribe)
• Below poverty line 47
• Literacy 37 (4 among women lowest literacy
  in the country in the 1991 Census)
• Lowest Human Development Index of all 45
  districts in the State (2002)
• Out-migration 65 on average during last decade
  
• Low HIV/AIDS awareness (WHARF survey during July
  2004 workshop)

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Current scenario of Madhya Pradesh (since
inception 2001), MPSACS
Jhabua district with the VCT centers at
Jhabua, Alirajpur and Jeevan Jyoti
Hospital/Meghnagar
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Jhabua district HIV prevention program
Germany
WHARF Mumbai/Boston

Funding
Technical support
Jeevan Jyoti Health Service Society, Jhabua
(operating a 100-bed mission hospital)
Medical supervisor
Project Manager
Counselors
Patients
Coordination with district administration higher
secondary and college HIV education programme
Services in 3 voluntary counseling testing
centres across the district (Jhabua, Alirajpur,
Meghnagar)
Coordination of 582 Self-help groups in 180
villages across the district IEC activities
including linkage with voluntary counseling
testing centres
Clients
Referral
Government institutions Community Health
Centres ART Centres in Indore/ Ahmedabad
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Voluntary Counseling and Testing at Three Centres
in Jhabua district
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Characteristics of 68 clients tested in the
period of August through October 2006
Clients largely from tribal community
More than 2/3 of clients were women
Almost half of clients were illiterate
40 of clients had TB, 45 had an STI
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Scaling up the programme

• Since prevalence (1.88) still low
• Increase service uptake through direct referral
  from village self-help groups, TB and antenatal
  care programs, other NGOs
• Collaborate with medical officers on STI care
• Establish two additional VCT centres at Pelawad
  (Northeast corner of the district) and Pitol
  (truckers stop at the border with Gujarat)
• Extension into other districts with NGO
  presence Ratlam, Neemuch, Mandsaur (prevalence
  3!)
• Establish linkage with ART Centres at Indore and
  Ahmedabad

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Recommendations

• Rally for local support, community involvement
• Public-private partnership direct Government
  support under NACP-3
• Support from abroad (financial, experts)
• Large scale-funding to conduct
  behavioral studies, targeted interventions,
  condom promotion
• Engage stakeholders in discussion on
  circumcision and stigma reduction
• Formalize linkages with RNTCP, NRHM, RCH-2

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Thank you!