Putting people at the centre of TB, HIV and hepatitis treatment in Manipur

When Thongsei Lupho, 44, first started feeling unwell, he suspected he had contracted tuberculosis (TB). He visited Médecins Sans Frontières’ (MSF) clinic in Moreh, on the India-Myanmar border, where was diagnosed with HIV.

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. Having put his drug use behind him once he married, his diagnosis came as a shock.

At first, he was afraid of discrimination and felt unable to mingle with others in public. He also worried about his children, some of whom were also diagnosed with HIV. His eldest daughter feels ashamed of her diagnosis and hides it from her friends and classmates.

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.

Intravenous drug use is not uncommon in Manipur and, according to the Manipur State Aids Society, it has contributed significantly to the spread of HIV and hepatitis C in India’s northeastern states.

Tuberculosis is likewise highly prevalent but in Manipur, which has experienced years of low-intensity conflict, state infrastructure has been unable to cope with the high number of HIV-positive and TB patients, particularly people with drug-resistant TB (DR-TB). This can have dire outcomes: in cases of co-infection, each disease speeds up the progress of the other, making the patient more vulnerable and their treatment more difficult.

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

Houses on the side of the hills in Churachandpur, Manipur, India, where MSF has a clinic that provides treatment to people for HIV, TB and hepatitis C.

MSF started providing specialised care for HIV and TB in Manipur in 2005 and 2007, respectively. At our three clinics in Chakpikarong, Churachandpur and Moreh, we provide screening, diagnosis and treatment for HIV, TB, hepatitis C and co-infections of the three diseases.

We are the only international NGO in Manipur treating the three diseases and have a patient-focused model of care at the heart of our operations in order to improve outcomes and minimise the spread of the diseases.

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.

“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 the family house,” says Nicolotti. “This greatly minimises the risk of transmission to others but keeps the patient close enough to maintain normal family interaction.”

MSF has built nine such houses during 2018 and 2019. We also send a nurse to the patient’s house every day to carry out tests and ensure they are adhering to their treatment, which involves a challenging cocktail of drugs to be taken 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.

Along with treating partners of co-infected patients, we also treat mono-infected hepatitis C patients at an opioid substitution therapy 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. We support the district hospital in Churachandpur by treating people living with HIV for hepatitis C.

Since January 2019, 120 new people were started on antiretroviral drugs to treat HIV; 36 HIV-hepatitis C co-infected patients are being treated for hepatitis C, and 133 patients were started on treatment for drug-sensitive or drug-resistant TB.

In 2018, MSF started using a new drug, bedaquiline, in the treatment of patients with drug-resistant forms of TB. Currently, three multidrug-resistant TB patients are on new, shorter treatment regimens using the newest drugs bedaquiline and delamanid, with the remaining patients on the two-year regimen.

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