الهند | المرضى في قلب برنامج علاج السل وفيروس نقص المناعة والتهاب الكبد

حالما بدأ يشعر تونغساي لوفو البالغ من العمر 44 عامًا بالمرض، اشتبه في أنّه مصاب بالسل. وعندما زار عيادة منظّمة أطباء بلا حدود في مدينة موريه الواقعة على الحدود الهندية الميانمارية، تم تشخيص إصابته بفيروس نقص المناعة البشري.

كان لوفو يستخدم المخدرات في السابق لكي يحظى على تقبّل آخرين في مجتمعه، إذ أنّه يعيش في منطقة عزّزت فيها التوترات القبلية بيئة من عدم الثقة بين أعضائها. غير أنّه توقف عن ذلك عندما تزوّج وتفاجئ كثيرًا عند تشخيص مرضه.

في البداية، كان يخشى أن يقع ضحية التمييز وشعر أنّه لا يريد الاختلاط بالآخرين في الأماكن العامة. كما أنّه أحس بالقلق على أطفاله حيث أنّه تم تشخيص إصابة بعضهم بفيروس نقص المناعة البشرية. وتشعر ابنته الكبرى بالخجل من تشخيصها وتخفي حقيقة الأمر عن أصدقائها وزملائها في المدرسة.

Thongsei Lupho (44) and his wife Mary have seven children. Thongsei is HIV positive and has been a patient at the MSF Clinic in Moreh since 2012.
Thongsei used to work in charcoal and cultivation. Since he contracted HIV, his health has deteriorated and he is no longer able to do manual labour. He has seven children; the oldest is 17 years old and the youngest one 14 months old. Mary takes care of the children. Thongsei contracted HIV through drug use: Lupho had used drugs in the past to gain social acceptance in an area where tribal tensions had fostered a lack of trust amongst people. He stopped taking drugs when he got married. He first visited the MSF clinic because he thought he had TB, but his diagnosis was that he was HIV-positive. His failing strength meant he was no longer able to work. He was afraid of discrimination and isolated himself. He thought he could no longer mingle with other people in public spaces. His eldest daughter, Lamknohat, and several of his other children are also HIV-postive. Lamknohat feels ashamed and doesn’t want other people to know. — Thongsei Lupho (44) and his wife Mary have seven children. Thongsei is HIV positive and has been a patient at the MSF Clinic in Moreh since 2012. Thongsei used to work in charcoal and cultivation. Since he contracted HIV, his health has deteriorated and he is no longer able to do manual labour. He has seven children; the oldest is 17 years old and the youngest one 14 months old. Mary takes care of the children. Thongsei contracted HIV through drug use: Lupho had used drugs in the past to gain social acceptance in an area where tribal tensions had fostered a lack of trust amongst people. He stopped taking drugs when he got married. He first visited the MSF clinic because he thought he had TB, but his diagnosis was that he was HIV-positive. His failing strength meant he was no longer able to work. He was afraid of discrimination and isolated himself. He thought he could no longer mingle with other people in public spaces. His eldest daughter, Lamknohat, and several of his other children are also HIV-postive. Lamknohat feels ashamed and doesn’t want other people to know.

Thongsei Lupho (44) and his wife Mary have seven children. Thongsei is HIV-positive and has been a patient at the MSF clinic in Moreh since 2012. Some of his children are also HIV-positive. Thongsei and his son are going to the "jungle", the nearby forest, to fix the waterpipes that provide water to the village. Even though Thongsei can't work easily as a HIV patient, he does his best to be active in his community. His son is also HIV-positive and receives treatment from the MSF clinic in Moreh.

Thongsei Lupho (44) is at the MSF clinic in Moreh for a check-up. He has been a patient here since 2012, receives his medicines from the clinic and is being followed closely.

يعتبر استخدام المخدرات عن طريق الإبر شائعًا في مانيبور وفقًا لجمعية مكافحة الإيدز بولاية مانيبور، ما يساهم بشكل كبير في انتشار الإصابة بفيروس نقص المناعية البشري وفيروس التهاب الكبد C في ولايات الهند الشمالية الشرقية، كما ينتشر مرض السلّ بشكل كبير.

غير أنّ مانيبور التي شهدت سنوات من النزاع المنخفض الحدة لا تملك البنى التحتية الحكومية القادرة على تلبية احتياجات العدد الكبير من المصابين بفيروس نقص المناعة البشري ومرضى السل، وخاصة المصابين بالسل المقاوم للأدوية. وقد ينتج عن هذا العجز عواقب وخيمة، ففي الحالات التي يصاب فيها شخص بأكثر من واحدة من هذه الأمراض، يسرّع كل مرض من تفاقم الآخر ما يجعل المريض أكثر عرضة للخطر ويزيد من صعوبة معالجته.

View of the surroundings of Churachandpur. Many people live in the hills.

منازل تقع على تلال تشوراشاندبور في مانيبور في الهند حيث تقدّم أطباء بلا حدود في عيادتها العلاج للمصابين بفيروس نقص المناعة البشرية والسل والتهاب الكبد C.

بدأت منظّمة أطباء بلا حدود بتقديم الرعاية المتخصّصة في مانيبور لعلاج المرضى المصابين بفيروس نقص المناعة البشري في العام 2005، ثم لعلاج أولئك المصابين بالسل في العام 2007. تتوفّر في عياداتنا في تشاكبيكارونغ وتشوراشاندبور وموريه خدمات فحص الكشف عن الإصابة بفيروس نقص المناعة البشري والسل والتهاب الكبد C كما نقدم في حال تأكيد الإصابة بهذه الأمراض العلاج اللازم في العيادات.

نحن المنظّمة غير الحكومية الدولية الوحيدة التي تقدّم في مانيبور العلاج لهذه الأمراض الثلاثة في نموذج للرعاية يتمحور حول المريض بغية تحسين نتائج العلاج وخفض مدى انتشار هذه الأمراض.

Gracy Chingnuamkin, 21 years old, is a MDR-TB patient from Churachandpur who receives home-based
Care from MSF. She sputum negative, meaning she has reduced risk of transmitting TB to others, and is half way through her treatment. MDR-TB patients usually have to stay at home for two years during their treatment. This is to both reduce the risk of transmitting the disease but also because the treatment regime can have severe side effects.

During this home visit, an MSF nurse ensures Gracy is taking all the required pills and therefore properly adhering to her treatment. Gracy has to take 15 tablets per day. She started treatment on 1 June 2018.

MSF started providing specialised care for HIV and TB in Manipur in 2005 and 2007, respectively. At its three clinics in Chakpikarong, Churachandpur and Moreh, MSF provides screening, diagnosis and treatment for HIV, TB, Hepatitis C and co-infections. MSF, which is the only international NGO in Manipur, has put a patient-focused model of care at the heart of its operations in order to improve outcomes and minimise the spread of the diseases.

“One of the simple ways we’ve tried to reduce the spread of drug-resistant strains of tuberculosis is to bring care to the patient, instead of making them come to us,” says Edoardo Nicolotti, MSF Project Coordinator. “When someone is newly diagnosed, we visit them at home to carry out an infection prevention and control assessment. If they live with family, we offer to build a simple house for them near to the house. This greatly minimises the risk of transmission to others but keeps the patient close enough to maintain normal interaction.” MSF has built nine such houses in 2018- 2019. MSF also sends a nurse to the patient’s house every day to carry out tests and ensure they are sticking to their treatment, which involves a challenging cocktail of drugs over roughly two years. Since DR-TB medication causes significant side effects, making it difficult for patients to complete treatment, MSF also provides counselling to encourage better outcomes. — Gracy Chingnuamkin, 21 years old, is a MDR-TB patient from Churachandpur who receives home-based Care from MSF. She sputum negative, meaning she has reduced risk of transmitting TB to others, and is half way through her treatment. MDR-TB patients usually have to stay at home for two years during their treatment. This is to both reduce the risk of transmitting the disease but also because the treatment regime can have severe side effects. During this home visit, an MSF nurse ensures Gracy is taking all the required pills and therefore properly adhering to her treatment. Gracy has to take 15 tablets per day. She started treatment on 1 June 2018. MSF started providing specialised care for HIV and TB in Manipur in 2005 and 2007, respectively. At its three clinics in Chakpikarong, Churachandpur and Moreh, MSF provides screening, diagnosis and treatment for HIV, TB, Hepatitis C and co-infections. MSF, which is the only international NGO in Manipur, has put a patient-focused model of care at the heart of its operations in order to improve outcomes and minimise the spread of the diseases. “One of the simple ways we’ve tried to reduce the spread of drug-resistant strains of tuberculosis is to bring care to the patient, instead of making them come to us,” says Edoardo Nicolotti, MSF Project Coordinator. “When someone is newly diagnosed, we visit them at home to carry out an infection prevention and control assessment. If they live with family, we offer to build a simple house for them near to the house. This greatly minimises the risk of transmission to others but keeps the patient close enough to maintain normal interaction.” MSF has built nine such houses in 2018- 2019. MSF also sends a nurse to the patient’s house every day to carry out tests and ensure they are sticking to their treatment, which involves a challenging cocktail of drugs over roughly two years. Since DR-TB medication causes significant side effects, making it difficult for patients to complete treatment, MSF also provides counselling to encourage better outcomes.

S. Thangkhoshin Hookip is an MDR-TB patient in Churachandpur. Every day, a DOTS nurse visits him to administer an injection and watch him take all the medicine he has to take daily (15 pills in total). The home-based treatment normally lasts around two years.

A patient at MSF’s Churachandpur clinic during a consultation with Dr Dwaragesh Natarajan and his translator.

Sanomani, who has advanced HIV, sits on his bed at Shalom IPD. He was under OST (Opioid substitution therapy) for a while. MSF started providing specialised care for HIV and TB in Manipur in 2005 and 2007, respectively. At its three clinics in Chakpikarong, Churachandpur and Moreh, MSF provides screening, diagnosis and treatment for HIV, TB, Hepatitis C and co-infections. MSF, which is the only international NGO in Manipur, has put a patient-focused model of care at the heart of its operations in order to improve outcomes and minimise the spread of the diseases. Along with treating partners of co-infected patients, MSF also treats hepatitis C patients who are mono-infected in an opioid substitution therapy (OST) centre in Churachandpur. At the same clinic, people who inject drugs can pick up clean needles and turn in their used ones, helping to reduce the risk of needle-sharing and further infection.
Additionally, MSF supports the district hospital in Churachandpur by treating the HIV cohort for hepatitis C. — Sanomani, who has advanced HIV, sits on his bed at Shalom IPD. He was under OST (Opioid substitution therapy) for a while. MSF started providing specialised care for HIV and TB in Manipur in 2005 and 2007, respectively. At its three clinics in Chakpikarong, Churachandpur and Moreh, MSF provides screening, diagnosis and treatment for HIV, TB, Hepatitis C and co-infections. MSF, which is the only international NGO in Manipur, has put a patient-focused model of care at the heart of its operations in order to improve outcomes and minimise the spread of the diseases. Along with treating partners of co-infected patients, MSF also treats hepatitis C patients who are mono-infected in an opioid substitution therapy (OST) centre in Churachandpur. At the same clinic, people who inject drugs can pick up clean needles and turn in their used ones, helping to reduce the risk of needle-sharing and further infection. Additionally, MSF supports the district hospital in Churachandpur by treating the HIV cohort for hepatitis C.

Singruwng Bejoy Anal (35 years old) receives treatment for Hepatitis C under MSF supervision at the Shalom IPD (inpatient department) in Churachandpur. He is supervised for two months in order to ensure he properly adheres to treatment. MSF funds the Shalom IPD to care for patients with advanced HIV.

ويقول منسّق مشروع منظّمة أطباء بلا حدود إدواردو نيكولوتي، "اعتمدنا في المنظمة زيارة المرضى بأنفسنا بدلًا من مجيئهم إلينا ويشكّل ذلك طريقة بسيطة للغاية حاولنا تطبيقها لخفض انتشار أشكال السل المقاومة للأدوية. عندما يتم تشخيص إصابة أحدهم بالسل، نذهب لزيارته في منزله لإجراء تقييم الوقاية من العدوى ومكافحتها".

ويضيف نيكولوتي، "إذا كانوا يعيشون في المنزل مع عائلتهم، نقترح عليهم أن نعمّر لهم منزلًا بسيطًا لهم قرب منزل العائلة. إذ يقلّل ذلك بشكل كبير من خطر انتقال العدوى إلى الآخرين لكن يسمح للمريض بالبقاء قرب عائلته لكي لا يتوقف عن رؤيتهم".

في هذا الإطار، بنت منظّمة أطباء بلا حدود تسعة من هذه البيوت خلال العامين 2018 و2019 . كما أنّنا نرسل ممرضًا إلى منزل المريض لكي يجرى الفحوص اللازمة ويتأكّد من التزام المريض بالعلاج كما ينبغي حيث أنّه يتطلّب تناول عدد كبير من الأدوية المختلفة طوال مدة قد تصل إلى السنتين.

تنتج عن الأدوية التي تستخدم لعلاج السل المقاوم للأدوية عوارض جانبية مزعجة ما يجعل التزام المريض بالعلاج إلى حين استكماله صعبًا. لذلك، تقدّم منظمة أطباء بلا حدود للمرضى جلسات إرشاد تهدف إلى مساعدة المريض على الالتزام بتناول الدواء للحصول على النتائج المرجوة.

وإلى جانب تقديم العلاج لشريك حياة المصاب بأكثر من واحدة من بين هذه الأمراض، نعالج أيضًا المرضى المصابين بفيروس التهاب الكبد C في مركز للعلاج البديل بشبائه الأفيون في تشوراشاندبور. وفي العيادة نفسها، يمكن للأشخاص الذين يتلقون العلاج البديل بحقن الإبر تبديل الإبر المستخدمة بإبر جديدة، ما يساعد على التقليل من مشاركة الإبر ونشر العدوى. ونقدّم الدعم لمستشفى الولاية في تشوراشاندبور من خلال علاج المصابين بفيروس نقص المناعة البشرية من التهاب الكبد C.

منذ شهر كانون الثاني 2019، بدأ 120 مريضًا بتلقي الأدوية المضادة للفيروسات القهقرية لعلاج إصابتهم بفيروس نقص المناعة البشرية، ويتلقى 36 من المصابين بفيروس نقص المناعة البشرية والتهاب الكبد C معًا العلاج من التهاب الكبد C، وبدأ 133 مريضًا بتلقي علاج السلّ المتجاوب للعلاج والسل المقاوم للأدوية.

في العام 2018، بدأت منظّمة أطباء بلا حدود باستعمال دواء جديد يدعى بيداكويلين ضمن العلاج المقدّم لأشكال السل المقاومة للعلاج. في الوقت الحالي، يتلقى ثلاثة مرضى مصابين بالسل المقاوم للأدوية العلاج وفق نظام جديد أقصر باستخدام أحدث العقاقير أي البيداكويلين والدلامانيد، بينما يستمر بقية المرضى في اتباع نظام العلاج المحدّد لمدة سنتين.

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الهند | المرضى في قلب برنامج علاج السل وفيروس نقص المناعة والتهاب الكبد في مانيبور

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