A Conversation with Johns Hopkins Medical and Public Health Researchers in India
>>Good morning. Good afternoon. Good evening, depending on where you are in the world. Thank you for joining us for the Hopkins at Home livestream co-hosted today by the Johns Hopkins India Institute. My name is Bob Bollinger. I'm the Raj and Kamla Gupta Professor of Infectious Diseases at the Johns Hopkins School of Medicine with joint appointments in the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins School of Nursing. I've had the great pleasure to have worked with colleagues in India for the last 40 years and so I'm really looking forward today to today's session, which is our fourth in a series co-hosted by the Johns Hopkins India Institute, highlighting some of the tremendous work that Hopkins is doing with their great partners in India.
The establishment of the Johns Hopkins India Institute is designed to unite the researchers, educators, clinicians, and at Hopkins with our partners in India and to help us expand on our many, many decades of work in India. And so today you're going to hear from four of the outstanding Hopkins faculty who are working with their colleagues in India. There'll be describing their research. We have four great speakers. And so the format will be have each of them give an overview of some of the research and then we'll open it up for questions from, from the audience. So without further ado, our first speaker is Dr. Shruti Mehta. She's a Professor and Deputy Chair in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. Her research focuses on hard-to-reach populations and understanding the epidemiology
natural history and treatment of hepatitis C virus, HIV, and HIV HCV co-infections. In addition to being a professor at Hopkins School of Public Health, we're happy to say that Dr. Mehta is also an alumnus of Johns Hopkins and she's gotten her MPH and her PhD from the Bloomberg School of Public Health. So without further ado, Dr. Mehta welcome. >>Thank you. Thank you, Bob. And I want to thank the Johns Hopkins India Institute for inviting me to participate today. Full disclosure, I actually got my start working in India with Dr. Bob Ballinger. So everything that I have learned from him. So I'm going to talk about some of the work that we've been doing in
India with vulnerable populations in HIV. So we began this work in 2006 in collaboration with a non-governmental organization, YRG care in Chennai. But as you can see from the map here, over the years we've expanded to pretty all parts of India. A number of groups are considered vulnerable or key populations with respect to HIV in India and that is because they face an increased burden relative to the general population. But our focus has been on people who inject drugs and men who have sex with men. And these two groups face many common barriers when it comes to engaging in HIV testing and treatment. First of all, all of the services that they need,
things like HIV testing treatment, other preventive services are available in India, most free of charge, but they're in different centers. So people have to go one place for HIV testing, another for treatment. Second, most of the services are delivered in government settings. And so these particular populations face a lot of stigma and discrimination when visiting these centers. Additionally, a lot of the services, they don't specifically cater to these groups, but
cater to the population at large. So then there's issues with crowding and distance and accessing these services. All of our work in India has led us to the conclusion that really structural changes are needed to improve HIV outcomes across India in these groups. And you know, specifically we've seen from some, from some epidemiologic work that we've done into that we did in 2013, that access to HIV services was poor across the board. So this was a large sample, nearly 27,000 persons across those 27 cities you saw on the map. And you can see out of nearly 3000 HIV positive people who inject drugs only 41 percent had ever been tested for HIV and out of nearly 1200 HIV positive MSM, only 30 percent had ever been tested for HIV. And when you look downstream
at, at antiretroviral therapy access and viral suppression, the outcomes are even poorer. So in response to this, we implemented and evaluated an integrated care intervention to improve HIV testing and treatment outcomes among these groups. And essentially our approach was to take all the services that were available, so all of these things are delivered by the government free of charge, but in separate centers and integrate them where we could bring them all to the same center where we couldn't at least offer a link or referral as a facilitated referral mechanism. We evaluated the approach by a community randomized trial in 22 cities, where we implemented the intervention for two years and have baseline and evaluation assessments to assess impact. So our approach was really to collaborate with the government and what existed to a degree, but to build from what was already there. So you can see on this slide, the services that we scaled up. So we offered onsite HIV testing and counseling, antiretroviral therapy for HIV
through a link referral model, TB screening was on-site, but then linkage to government centers for treatment. We had onsite sexually transmitted infection management, some basic viral hepatitis screening, and then other preventive services. So for PWID, we offer needle and syringe exchange, medication for opioid use disorder, for all populations condoms. We really beefed up individual and group counseling, and there was some general medical care. And importantly, the approach that we took was really person centered. So really bringing everything together in centers that were tailored to the population. This was really critical to reducing stigma
which was a huge barrier for these populations beforehand. What we found was that HIV testing, which was a primary outcome for this trial was 31 percent higher in the intervention sites versus the control sites at the evaluation of the trial. So what you see in this figure, are the triangles, essentially the size of the triangle represents how much change we saw in HIV testing from before the intervention to after, green is good change and red is going in the opposite direction. So
essentially you see more positive change in the intervention site compare to the control sites, but we didn't actually see as much as we expected, right? So we saw improvement, but it wasn't, wasn't exactly what we hoped it to be. And so some additional analyses showed us that really some of the challenges were that one center wasn't enough. So the intervention worked, but everything in India is a lot, right? There's a huge population. And so one center in a given city wasn't enough to reach everyone. There were other services that we weren't able to offer, things
like hepatitis C treatment because that wasn't covered by the government at that time. And then this was really a supply side strategy, right? So we increase the supply of population friendly, comprehensive services, but to improve things, particularly like lifelong HIV treatment, we recognized that we needed a demand-based approach to compliment this. So next steps with this project, so, so even with the results that we shared, there has been some movement in terms of adoption from the Indian National AIDS Control Program. So this is
a brief that they put together largely based upon our findings. There are some still logistical and cost challenges to widespread adoption, but there is some movement. In terms of our research agenda, we are still testing additional interventions. Again, as I mentioned, the downstream HIV outcomes
saw even less improvement than HIV testing. So we're looking at different interventions to improve those outcomes. And we just launched last week, a new trial to integrate hepatitis C treatment into the PWID-focused HIV prevention and treatment centers. So to be continued. I just want to acknowledge the mini study staff and participants across India who contributed to this research and our many collaborators across the US in India, our funding sources, and of course the national AIDS Control Organization, India. Thank you. >>Thank you, Dr. Mehta. We're going to take questions at the end of each of the at the end of all the talks. So
we're going to move on now to Dr. Sunil Solomon. Dr. Solomon is Assistant Professor of Medicine in the Division of Infectious Diseases at the Johns Hopkins School of Medicine in the Department of Medicine. He studies the epidemiology and clinical management of HIV and co-infections in India. I'm also, also happy to say that Dr. Solomon is also an alumnus not only of Johns Hopkins, but of another really wonderful program. He is a Fogarty Research Fellowship recipient and so really happy to have Dr. Solomon join us today. Please go right ahead, Sunil. >>Thank you for that introduction. Good morning, good afternoon, or good evening,
depending on where you are. I think today, I'm just going to talk about one of our programs, which is Accelerate. Which is actually a USAID funded program, which is out of the PEPFAR fund, I'm sure many of you are familiar with PEPFAR, and it is a program that we're implementing in collaboration with the National AIDS Control Organization. So the objective of the program really is to implement, evaluate, and transition sustainable and novel methods of improving the HIV care cascade with the goal of achieving HIV AIDS epidemic control in India. As you can see by the map on the right, we currently work in about in six states across India, in Maharastra, we work in..., in Telangana. We work in five districts,
but we provide about site level expertise to the entire state. In Andhra Pradesh we work across all the 13 districts that we work primarily with children, living with HIV and AIDS and in the Northeast..., we work primarily with children living with HIV and AIDS. So this was a five-year award that we started in April, 2019. So just to give you a quick snapshot of what this award aims to do is we are providing technical assistance to the National AIDS Control Organization, as well as also implementing things on the ground, in these different states that I highlighted. So we work across the entire care continuum from prevention to testing, to linkage, to antiretroviral therapy, improving the quality of care at these antiretroviral therapy centers, strategies to improve retention and vital suppression with a special focus on orphans and vulnerable children and adolescent populations. I feel like that's a population that gets a lot of attention in Africa,
but even in India, there's a lot of young MSM, young people who inject drugs and young vulnerable populations who are completely online, who are completely being missed by these different programs. So just to highlight a few strategies and prevention, we're looking at prep, and we're looking at a differentiated prevention model, which is more like a predictive analytic tool, which could prescribe, which could predict someone's risk when they come into a program. So you sort of design their package of prevention services based on their risk profile. So if they're high risk, they get more prevention services. If they're lower risk, less prevention, basically to improve the efficiency of the program and testing. We're looking at HIV self-testing,
we drafted the white paper for the National AIDS Control Organization on how HIV self-testing needs to be rolled out in India. In terms of retention and viral suppression, we're looking at SVA, which is 99DOTS. I think many of you in the TB field are familiar with it, but we're trying to reroute it through the National AIDS Control Organizations helpline to try and make it more efficient. Besides for this, we also have a lot of cross cutting areas across the entire continuum. One of them is the workforce strategy. So we only are looking at this model of building a virtual one-stop shop. And then we also do a lot of capacity building and technical resource groups.
So over the past year, just to give you a quick snapshot, some of the achievements. So we developed India, we drafted, I guess, India's first prep guidelines. We're hoping it will be released anytime now. We have about 99 percent retention in the linkage to ART. We tested about 2,160 new clients with HIV last year, across Andrha Pradesh and Maharastra. We provided testing and all this is within the context of the COVID pandemic. So that's
something that I will show you in the next few slides, about how it impacted our growth. And in terms of quality of care, we've been assisting NACO with doing the level autopsy to try and identify reasons why people living with HIV are dead or people die in India and try to improve quality of care and interventions to address these main causes of retention. So, one thing and the other, the OBC program or the adolescent program, we reached about 48,000 children and caregivers last year across these districts in India and about 86 percent of these children were adolescents. So we really are working with the National AIDS Control Organization, the Ministry of Social Justice and Embalm, and to try and figure out what is a comprehensive adolescent focused model. We also support the technical resource groups at National AIDS Control Organization for people who inject drugs, men who have sex with men and transgender individuals. And we also supported the entire world AIDS day event this year. So just to give you a quick snapshot of some of the achievements last year, so this is what our testing looks like. So you could say like, so we started this
program on October 1st, so the January to March is where we should have been going, like identify what 860 new positives every quarter, but you can see the impact of COVID, which costs the nationwide lockdown on March 24th and it dropped in both the physical testing and in the virtual testing. So it really did have this dramatic impact and so that's one of the reasons we are trying to fast track and roll out HIV self-testing, because there are all these positive people who would have been otherwise diagnosed, who are currently in the society. And it, and the other thing that happened almost simultaneously was ensuring that there was no interruption antiretroviral therapy. So as soon as the COVID pandemic hit, we worked with telecom STP it's controlled society and pivoted the program to start home delivery of antiretroviral therapy. So between April and September, we delivered about 17,580 courses that antiretroviral therapy to people living with HIV and children living with HIV at their houses. So I just want to end with a slight shot of what the program looked like. So
the picture of the middle and the top, right, are from last year where everyone was in person, we had like the first virtual consultation. We also have draft the note taking paper or the concept position piece where you watch your populations in India. We had a lot of interactions with the health minister during World AIDS Day, but everything below and to the top left is what COVID did to us. We switched from a completely physical to a completely virtual. We started doing a lot of online messaging, online campaigning, and even a field level activities are all taking care, taking place with the appropriate PPE. So I'll stop here now, happy to take questions later. Thank you.
>>Thank you, Dr. Solomon, greatly appreciate it. We're gonna move on now to Dr. Smisha Agarwal, who is Assistant Professor in the Department of International Health at the Bloomberg School of Public Health. She's also the Research Director for the Johns Hopkins Global Mobile Health Initiative. The M health Initiative. She's interested in research that is designed to
evaluate interventions that can improve maternal child health. She's worked as a researcher for a lot of other organizations before she came to Hopkins, including FHI 360 and the Pop Council. She's been a Technical Advisor to the World Health Organization, USAID, and many others organizations. And we're really happy to have Dr. Agarwal today. Describe some of her recent research. >>Well, hello. Hello everyone. And it's a pleasure to talk to you about some of
our work today. So over 10 years ago, I returned to a remote village in India after a brief 18 months overseas. And in these villages of...in Maharashtra, there is intimate intellectual city, a handful of tube wells for drinking water, and like other rural parts in India, adults that you see is just about 60 percent and much lower for women. What I noticed though, that in the brief span of 18 months, that I was away, every household had a working mobile phone and ingenious ways in which they kept these phones charged mainly to listen to cricket updates. For us though, another purpose developed for these phones, working with community health workers, we created a system that allowed them to use these phones, to conduct prenatal care assessment as they went door to door to check on pregnant women. And they input critical data, which was immediately uploaded to the cloud and this allowed trained nurses and doctors to then remotely monitor these women, identify and respond to high-risk pregnancies. Personalized
information for each pregnant woman merged with timely reminders for healthcare workers, also ensured improvements in quality and comprehensiveness of care. So much has changed in the last 10 years and our relevance to our work is the phenomenal access to mobile devices with over 715 million unique subscribers, as well as the rapid migration to smartphones with a user base of over a billion smartphones in India with 4G networks that are at the lowest prices. And this has a tremendous impact on productivity in the economy, whether it's financial, agricultural, or healthcare. In the last decade, we've also seen significant shifts in how we access healthcare. Primary healthcare systems are changing, and individuals may spend no more than 15 minutes with doctors, but they spend 15 days online searching for answers to their healthcare problems. And we see here in this survey hat close to 30 percent of the users in India said that they use their mobile phones to access healthcare information. A number that is rapidly rising.
And primary health care systems are slowly but surely expanding to the online space. And these spaces, they fill a critical gap. They provide people centered care that focuses not just on delivering competent, competent care, but also valuing user experience. Many skilled providers, they don't provide or advise patients on information that is critical indispensably into to their wellbeing, whether it's pregnancy complications or the types of conditions that Dr. Mehta and Solomon discussed. In the context of India, many conditions are shrouded in stigma, shame and are taboo to talk about. And these online spaces, they fill an essential gap. They provide accessible health information. They provide
this information without judgment in a safe space, and they provide a space where users can receive social support perhaps from other uses. However, in the context of COVID-19, we've also seen that these spaces can provide misinformation. So several of us may have may have heard or used conversational agents or chat bots that are integrated with WhatsApp or with Facebook, where we receive information. These bots are one way to counter misinformation. They are evidence-based, and they can be integrated with a variety of channels. So take, for example, this WHO bot that was used by over 12 million users in just eight weeks. It
follows an algorithm, and it provides information on one of these seven topic areas. And if you look to the screen on the right, you'll see that if I ask it a question like in natural language, it is unable to serve its purpose. It does not provide me without an appropriate response. And so while these bots are helpful, they're also limited in what they can do. So our team
of scientists, computer scientists, and public health folks at Hopkins, okay, we've been working to develop approaches that really serve to push the put the user at the center of that health and can provide answers to queries in natural language and advances in natural language processing and big data have really enabled us to do so. At the start of the pandemic, our teams developed a repository of COVID-19 questions from across Google, such as over 40,000 social media questions and through scraping COVID-19 questions on various reliable and unvetted websites. And we trained models to essentially understand user intent in natural language match method to an information library, and then respond to the user question in an appropriate way. So if you look at the screen on the right, if the user types of question, and this is just a sample question, we are able to understand this question and respond to it. Our team was in the process of developing such an interface for reproductive health of a stigmatized areas in reproductive health. And we repurposed our efforts for COVID-19 and we're in the process of now adapting these mechanisms for the Indian context.
So through the types of data that are available, we're able to reach a pretty high level of sensitivity in these models. But of course, several challenges remain, which I look forward to discussing in the question-and-answer section. Thank you. >>Thank you. Dr. Agarwal, wonderful presentation, some timely topics. We'll have more to talk about that in a moment.
Our last, but certainly not our least speaker is Dr. Vidya Mave, who is a colleague of mine for many years. Dr. Mave is Associate Professor of Medicine in the Johns Hopkins Division of Infectious Diseases in the School of Medicine. She's joining us today from Pune, where she is the Director and Clinical Research Site Leader of the NIH funded clinical trials unit focused on HIV and related coinfection research and clinical trials.
So Dr. Mave, welcome. >>Okay. Thank you, Bob Bollinger. Hello everyone. Next slide, please. So I'm going to briefly discuss about Johns Hopkins, India collaboration in Pune, which was started in 1992 by Bob Ballinger himself, with basic science research in HIV in National...Institute. And since then, we have been continuously funded by National Institute of Health over the last 20, 25 years. And in 2001, we started with a large prevention of mother to child transplant of HIV trial, which later on became a standard of care by WHO, where all HIV exposed infants receive at least six weeks of Nevirapine for prevention of either HIV and or mortality. In 2007, after the success of this trial, we were awarded with the
HIV clinical trials unit where we conduct HIV and TB clinical trials to optimize the treatment of HIV and OTB. And since then we've been continuously funded by RK mechanism, R mechanism RU mechanism by NIH. Currently we have about eight current partners within India and a hundred plus active studies are either based in Pune or other parts of India, and also we're funded by different national and Indian funding organizations. We also have several recent trainees to the Fogarty
International Program, which was led by Bob Ballinger himself. Next slide, please. A major part of our program in Pune is based out of BJ government medical colleges, where college, which is Maharashtra state government run medical college and hospital where we have a shared lab. And we also have a patient enrollment area and a pharmacy as well as data management infrastructure. And we have enrolled over 14,000 participants over the last
four or five years. And in addition, we have expanded our program outside of the BJMC to other medical colleges like DY Patil medical college KEM hospital, as well as Bharati Vidyapeeth. Next slide please. And the, the number of recent studies we cover are a wide range, including tuberculosis, HIV, maternal child health, anti-microbial resistance studies and the studies we conduct are some of the...national cohorts. Where we for example, for tuberculosis, we are, look, we are establishing an active TB cohort along with household contact bookwork, where we are identifying biomarkers and validating them that can predict who develops TB adverse outcomes, or as who develops TB among their household context. We also have several studies which
addresses the optimal therapies for tuberculosis, HIV, and other diseases. Including recently a TB vaccine study where the common BCG vaccine are given or are on a trial to assess whether it can prevent the current TB event. So now our group also have been collaborating for basic science researchers, but in India, as well as abroad for studying Omix genome wide association studies that sort of immunological studies and our group has been leading several protocols, including that for AIDS clinical trial groups as the last impact studies. Next slide, please. And with this program, what we have established is that we have an outreach program within Pune which actually gets in referrals from about 11 tuberculosis units, as well as about four or five EIP centers for us clinical priors. We also do belong to big donation have procured a mobile event which does workshop for vulnerable populations, as well as does some clinical care, as well as enrollments of some participants through that mechanism. As you can see on the right-hand side, we have the state of art pharmacy facilities. Next slide, please.
And also we have now a state-of-the-art laboratory facilities during TB facility, which is a biosafety level, three level facility as well as a large bio depository which is connected to clinical data that helps to help, helps to identify and validate biomarkers and other immunilogical studies. As you can see on the, on the below, we have, since 2007, a number of studies have increased on a, on a nice curve, upwards. And we have currently about 90 plus active studies to our program. And this has been possible to great collaborators within India, as well as the leadership of...based out of Baltimore and my colleagues and your friends.
Next slide, please...who have been around with this program for a long while. As you can see on the left-hand side, we have about research personnel over 150 plus, all of them working the research program in Pune. And on the right-hand side are a Baltimore group and below...myself and...thank you all. >>Thank you, Dr. Mave. So I want to encourage all of those of you in the audience to please go ahead and post your questions in the chat. We'll come to some
of those, we're getting some great questions already. While we're waiting for, for those to come up, I, I do have a question for, for each of you perhaps to begin. You know, we all of us who and, and not only at Hopkins, but our partners in India have worked hard on a variety of different research projects, like the ones you've described over the years, but you know, our goal of course, is to prove improve health outcomes. We do research to,
to lead to health outcomes and improvements in health in the communities we serve. So my question may be a tough one, but I'll take that prerogative and ask you know, what, what do you think is the single most important thing that's required to ensure that your research leads to measurable, scalable and sustainable improvements in health outcomes, in the communities, in which you work in India? So let me, let me go to Dr. Mehta first and see, see what she has to say about that. >>Thanks, Bob. So, so I would say collaboration and partnership
with stakeholders early in the process. So that's one of the things I've certainly learned over time and we've trusted our Indian colleagues with, so it's too late to engage for example, for our work, which is HIV related, the National AIDS Control Organization and the relevant state level partners at the end. You know, when the results are there and when you're disseminating, engaging them early in the process, as soon as you're starting, as you're thinking through the grant, as you're starting to implement and taking their feedback, we've had to adjust several things, you know, early on in the research process to accommodate their input. And I think that's been really instrumental in moving things forward. I would say that's the most important piece >>Dr. Solomon, what would you like to, to add? >>Thanks. Well, I think that surely did sum it up,
but I think one thing that we should remind ourselves is the, the reason we do research, right? The research is not being done for publications, which is what most of us tend to forget these days is, well, we want to get this published in this journal, that journal, but right from the start we need to recognize our research is only going to impact our research population, but to truly have an impact, it has to be through the government in India. So like Shruti said, I think what one thing we have done is we've engaged the national AIDS control organization, right from the beginning, right from the time we're picking sites, picking cities, picking populations, we've kept them engaged, so they have a sense of ownership and we also know what's happening. And the other thing we also do is we try to use as many resources already available by the government to improve sustainability. So I think those are the, I think thinking of it as sustainability and building upon improving efficiency of existing resources is probably one of the most important things to do. >>Dr. Agarwal, how about you? What, what do you think is something that would you know, help improve the impact or one of the challenges to improving the impact of your work in India? >>I can second and third what should Shruti and Sunil already mentioned about collaborations and partnerships. I think one thing that I might add that the government of India is actually
already undertaken in the National Digital Health Missions and it's a bit more technical, is that for a lot of digital interventions to be successful and especially there is, there is a need for some basic, some basic structures and the recent national digital health mission and the policy statement has identified health ID to having a unique health identification, that's really building off the success of that...program. And it allows us to then digitally track individuals into their healthcare journey, into their communities and health facility. And from a research perspective allows us to track population level impact of these programs. And along with that the policy actually also lays out the importance and commitment of the government to open standards, which will really help accelerate research and innovation in the space. Instead of re-engineering interventions, we'll have some baseline resources to work with and having like these government supported standards to adhere to really provides a signal for not just us, but all public and private sector actors to how technologies for health should be developed, take some of the guesswork out of it. And for a country as diverse as India with multiple languages,
it ensures that the standards have compatibility to various official Indian languages. So we're not rebuilding for various population groups, but we've got some initial, you know, baseline to work off of. So I think that's been very exciting for the work that we do. >>Thank you. Dr. Mave. >>Yeah. So I totally agree with Shruti, Sunil, and Smisha. In addition I believe that
the research we do should be relevant to our population in India. And then then with the collaboration with the government and also the stakeholders it will be more possible to be sustainable and be simple and scalable in India. Thank you. >>So just to follow up on that, Dr. Mave. What are some of the really specific things that you and your team are going in India to address some of the barriers to impact that we've, that you've just outlined? What are some examples of things? >>For example so recently we are about to launch a one, one study, for example it is looking for a strategies of activity findings for TB, for example. And so generally active baselining happens among the household contacts of TB patients only if they are less than six years of age. And then then we we usually forget them at the end of the TB treatment
including the... So there are some policies in place which actually discusses about two different kinds of activities, finding strategies, either you do the telephoning or versus health contact tracing. So along with the colleague in School of Medicine Dr. Jonathan Golub, we have developed a program or an intervention which will either do the telephonic activities finding versus household contact finding. So the, these, this is an important topic for the Indian government, at least the national TB program. So they are partnering with us and but about the long test study and, and these are since it's very important for the national program and also it's relevant for the TB elimination goal of India. So I think
so this is where my discussion about being relevant and and then it is going to be scalable because we are employing on the national program personnel to implement. >>Thank you. Well, we're getting some great questions from the audience on and some of them about this issue, and one of them is coming from..., and I'll direct this back to Dr. Mehta who brought up this point,
initially. She's asking, how do you identify who the key stakeholders are and how do you contact them when you're just starting out in your research? >>Yeah. So that's a great question. And the one thing that, that you learn early on that's critical to success in India is having the right partner in country, right? You can't actually be the person as the outsider who goes and knocks on the door because they're just not going to listen. You know, you haven't been there, they don't know you. And so you know, I've been really blessed. Our team has been really blessed to be working with this organization on the ground in India, YRG care, and we really rely on them, right? They've made those contacts, they've established those relationships and we trust them. And so we work together on that aspect. So if you're a junior, if you're a new person
starting out, I'd say it's building the collaborations on this side with mentors to help you form those relationships. But I think that that Indian partner is truly critical. >>Great. let's see. This is a question, perhaps a follow up question for Dr. Solomon. Elaine asks what have been the most effective strategy, strategies for developing relationships with the Indian government and other key stakeholders in India? What is it about what YRG and other partners you have in India? What is it that they do that that's working best? >>So, I think one of the things that we have been able to successfully do or partner with the government is really work with them, collect primary data and disseminate it to the government itself. Just to, take the example of the whole virtual populations, right? So I think many of us who have left India, still have that picture of India from 1970s or eighties on your, left India, India actually has evolved. India has
like this rampant virtual population, which the National AIDS Control Organization, UNAIDS, WHO, all of them recognize exists, but no one knows how to tap into that. So I guess what we did was we started off by doing some initial work, working through like Grindr, Tinder, all these different online portals. And we actually had virtual sexual health workers who used to go to these places, get people, get them tested. And so that actually showed the government that we were not doing this, something that we wanted, but we were actually doing this to help the government achieve its goals. Right? So I think building that trust for the government, for them to recognize that you are not doing this for yourself, but rather really supplementing and complementing the government program. I think that's, what's really important. And once you show them that this is the impact, and this is how it's going to impact your program towards achieving its goals, they will definitely start engaging you as you go forward. >>So let me, if I could Dr. Sunil, a follow up question
that's coming from PD, and it's a question about partnering with corporate and private stakeholders in these programs. And what's the scope of collaborations with India with the private sector, for some of the research programs? >>I think there is a great scope for collaboration with the private sector, especially with the CSR funding coming in. I think there is an area that most of programs haven't capitalized upon. They could definitely support program support initiatives.
We've had some really successful collaboration with a lot of private donors who have given us funding for specific components, like our orphans and vulnerable children programs. They've given us a lot of support in terms of food, nutrition, books, education fees. So that's an area where they can support, but we've also been working very closely with the private sector, because even if you're looking at just the HIV program, it's estimated about like a hundred thousand to 150,000 patients get care in the private sector. So this is a population that's completely being missed and so trying to engage the private sector, both like individual practitioners, as well as larger companies into these different programs is useful. The companies also have like different strengths. So I think it's playing to the strengths of the
companies themselves. For example, I guess, there are these groups that are all about education. There are these groups that are all about research. So I think it's tapping up on those, those, the plus points of those different companies and really using, leveraging what the leveraging, what the private partnerships can bring into your program, but at the same time, making sure that the goal earliest to push the whole goal of achieving epidemic control in India forward, because the last thing you want to do is bring in a private partner and push the government away. I think it's about a delicate balance between the private sector, yourself, and the government. I think it's important for all three people to be engaged in all these conversations. >>So I'm going to follow up along this lines with Dr. Agarwal, I mean, obviously
in the digital health arena it's important to have corporate partnerships and private partnerships. Maybe you could say a bit about your, how you view those in, in, in the context of your work. >>Yeah. I think one of the partnerships that our research we've that I think is really critical, especially for interventions that are targeted directly to clients that don't go through the formal healthcare system, partnerships with the telecommunications groups is really important. It's also been one that I think is, is very challenging because our worlds speak different essentially. And in the early days of digital health we were exploring partnerships with...and other groups in, in Africa. And they were
they were very keen on providing data packages or SMS packages at subsidized or free of cost. And very soon those types of collaborations started to dwindle in large part because they were interested in economies of scale. So nothing under a few million and the healthcare sector could in ramp up its operations fast enough, or the marketing operations fast enough to, to actually get those kinds of numbers. And so I think figuring out how we can leverage these existing platforms. Like if, you know, in, in India, the major telecom operators have upwards of a hundred million subscribers, you know, how we can leverage these platforms effectively to then disseminate and share health information and have those platforms be an entry point into accessing populations that are in large part virtual at this point is I think really, really critical and also challenging. >>So there's some follow up questions for you, Dr. Agarwal, from Carrie about your work in health, she's asking, how do you prevent misinformation from creeping into digital response platforms? >>Yeah, I think Facebook and others have tried to address that with not much success, unfortunately.
I think honestly there are a lot of there are a lot of like players on these digital platforms and evil bots that are, you know, that as spreading misinformation on Twitter. And I mean, the, the WhatsApp groups and our aunts and uncles are spreading enough misinformation on WhatsApp. So I don't think we can necessarily control all of that. What we can ensure is that we're finding ways, there are large teams actually at the Whiting School of Engineering that are figuring out like models to identify misinformation tag it and Twitter has been doing a lot of that. And then
I think countering some of this misinformation by having reliable channels that are government supported or supported through national, international platforms like WHO and others, which I think was one way in which the WHO in the context of COVID-19 was trying to ensure that that information is shared through non-traditional channels, through channels that, you know, that younger folks and through folks that don't access formal health care services can can leverage. So I think just ensuring that we are right there where the evil bots are is important. >>Quite a challenge. So we have some more specific questions coming in. Let me direct this one to Dr. Mave. Ananya is asking, what have been your key strategies for effective capacity building for your research personnel in the field, as there is definitely a gap in local training standards and research protocol standards. >>Right. So I guess training on, on different protocols and different laboratory techniques,
and that has been done in collaboration with different institutes in the US, like Johns Hopkins have been a key player to develop into capacity, including research methodology, and how to ask the basic questions. For example, Bob Ballinger, himself, led a training program for many, many individuals in India. And secondly, is that sometimes with, with the new grants the new applicants come onsite. And then then what we do is we then send some of our colleagues to US universities and get trained in running those laboratory capacity, learning those techniques of assays and so on. And then they come back and run those assays. And finally the NIH programs have these kinds of standardized syllabus for, for good clinical practice and human subjects, practice training which is a must for all research personnel.
And similarly we have good clinical laboratory practices as well. And that training also happens to all laboratory personnel and that in some ways the, the capacity building happens not only for, for additional laboratory techniques, but also for the personnel on, on a variety of important research information. Thank you. >>So you know, we've all of us of course been affected by the COVID epidemic. It's affected all of our research and all of our collaborations, both
here in India, Dr. Solomon mentioned showed us some, some data on that impact. I wanted to follow up on that a little bit, maybe with and ask Dr. Mehta a question from Stuart who asks, do you anticipate that, and I'll paraphrase this, do you anticipate that any of the processes or procedures or learnings that have been successful related to HIV, will any of those inform strategies for the COVID response in India? >>Yeah, I think, I think it all goes both ways, right? What we've learned from HIV can applied to, to COVID and what we've learned from COVID actually, or what we're learning from COVID will eventually be applicable to HIV. I think one example that I can say just right off the board that we've talked about in our own group is just testing. Right? One of the big challenges with, with COVID is getting access to testing
you know, having people reliant on going to centers, the availability of testing. And one of the things that we're working with on our programs right now is self-testing, you know, kind of minimizing those barriers to make it as accessible to people, have as many centers, and even offer strategies where there's a lot of stigma like self-testing and home-based testing. And I think that, you know, some of that's already happening with COVID, but, but I think things like that's just one example of a lesson that we can learn. And I think, again, everything about HIV is about equity and, you know, ensuring access to all populations of all of these services and COVID has just, you know, highlighted disparities even more so, so again, strategies that we have in place for HIV I think are directly applicable. >>Sunil, do you want to add to that? >>I think surely I think
the other thing that I think is very relevant from HIV, which we are still grappling with COVID is a people centered response, right? Like our response is almost coming from the government down saying, this is what you should do. We're going to shut this down. We're going to shut that down, without actually considering what the people who are being subjected to this is. I think we learned it much later on HIV that people living with HIV also live normal lives. They need to get married, they need to go to school, they need to do the other things. And then we started building all these support services around. Whereas for COVID like we haven't built those support services. When you lock people up in houses or for long periods of time, there's going to be a
high rate of substance use, there's going to be a lot of depression. Like we haven't built all the support services around. So I think looking at it also from a people centered approach, because the only way we're going to beat it is if the entire world works as one community and right now that isn't happening. I think some of it is because we haven't really looked at it from a person's
perspective individual's perspective of like, what are these different restrictions and bans or non-pharmaceutical interventions impacting. So I think that's the only thing I would add. >>Thank you just to follow on or a bit maybe we'll, we'll pass this question onto Dr. Agarwal from Ralph who asks, how do you feel the pandemic might influence behavior changes that support the use of mobile health care information and practices? >>Yeah, that's a great question actually. We've had, we've seen, I think the US is one case in point where there has been a lot of resistance to, to the use of technologies in the healthcare space. And overnight we saw telehealth centers
being set up or, you know, different avenues for telehealth being set up in the US and certainly been the case for, for other countries as well. One of the conversations with, with Facebook has been in the use of WhatsApp for telemedicine since WhatsApp has such a large penetration in, in low-income settings and can be operated on low bandwidth requirements. So it also pointed out actually the vacuum of functional tele-health systems, right? That an existing system such as WhatsApp, that's really not it's not optimized for use in a clinical setting. It doesn't have features that are important for a telehealth for a telemedicine consult, but that's often the primary way in which communities are linking and connecting to their doctors. So I think I think COVID actually has been in, in some ways really positive for expediting the speed with which these technologies have been developed. And also, I think emphasizing to groups that are resistant to its use that this is one direction for the future. I think the younger populations
or certain populations are already sort of you know, the, the leaders are using these types of media quite freely, but there has been a lot of resistance, which hopefully I think has, has been scaled back due to COVID. >>Thank you. So the next question related to COVID I'm gonna ask Dr. Mave and Dr. Solomon to both comment on because COVID affected our ability to do research, particularly in other areas like HIV. And the question from...is
you know, are you providing how are you, how does this affect your ability to provide antiretroviral treatment and medications for HIV to patients during COVID? How, how has your, your team tackled the stigma associated with HIV in this, in COVID and how do you optimize the clinical care for your patients in your research studies who might have HIV or hepatitis during COVID? So let's ask Dr. Mave about how, how COVID has affected your ability to deliver HIV care or to care for tuberculosis patients and what strategies you have in place to overcome? So then, and then we'll, we'll ask Dr. Solomon to comment on that as well. >>Yeah...thank you. That's a good question. And in, in context of for research, for example, we did pay some, some issues to deliver...medications, or and, but then we developed some strategies that outreach
workers and counselors who are already in touch with our potential research participants were able to connect with them and come halfway between where clinics are and their home. And then, you know, work with the local authorities to ensure that they can come to and then deliver the medications. But yes. So for the part of the HIV care, as Sunil earlier mentioned, perhaps he can take that question on, at least for the research participants we, we had to meet halfway, but then the lockdown kind of got relaxed during July, August. And then we participant started coming to the clinic as much as possible if they cannot come, then we met them halfway somewhere in the middle or somewhere in the tuberculosis unit or centers, so on.
>>So Sunil, your, your program takes care of thousands of patients with HIV and viral hepatitis and other conditions, tuberculosis. What are, what is your program doing to both ensure they could get their care, but also protect your staff during the COVID epidemic? >>I think a couple of things from what I've shown you on the slides was like, what I showed you was just the testing that really dropped. But in terms of treatment, we were able to actually pivot almost immediately. And we offered either home-based ART delivery. We also mailed medications to people's houses, and that was another way that people were very open to receiving. And we also did field based delivery sites. Like what would that
also suggested where you meet them somewhere? So I think someone had asked about stigma to the interesting thing about COVID and HIV in India was like for the first time, I think patients, HIV infected patients in our clinic they're happy because they were not the ones being stigmatized because there was the people with COVID who had like these barriers across their door saying, COVID patient don't go in and something we're like, Oh, now all of India knows what we feel like. That's the sort of response we got from a lot of the people living with HIV in India. And in terms of clinical care, we've sort of switched more to telehealth. And I think WhatsApp, like Smisha was saying, is like predominantly used by most patients in India. So we been able to do a lot of consultations over WhatsApp, and whenever there was an emergency, we had them come in. In terms of protecting our staff, we made sure all our staff had PPE. We had them give them free access to testing anytime they felt they were exposed. We also had them coming in in shifts. So one of the each team would do like two weeks, so
they wouldn't expose each other. So if someone was infected and the next team would come into place. But, but the research side really has been impacted. So we have built in a lot of these COVID reset screening. We've had to put plexiglass between the different windows.
And we also do work a lot with homeless and vulnerable populations. So it really has been challenging going forward. In terms of harm reduction, we did assess the National AIDS Control Organization and revamping to do home-based five days dosing, seven days dosing of medication assisted therapy. So that actually helped a lot with harm reduction. So overall, I think we did a
decent job in India. I think the testing is where we really did see a big impact, but in terms of treatment and clinical care, we take the patients already in care we sort of continued and care, I think wider suppression testing and everywhere where laboratories were involved was affected, but in terms of just getting in and showing continuity of care, I think we did a pretty decent job. >>Thank you. We just have a few minutes left. And in, in in those last couple minutes, I wanted to return to one of the things we talked about earlier in the conversation about the, how to optimize the impact. And you talked to, all of you talked about how important the partnerships both public and private partnerships are necessary in India, identifying the right partners, relying on them to ensure that what you're, what you're doing in the research side is having impact. You know, this is the we're launching the Johns Hopkins India initiative, as you know.
I wonder whether you have some specific guidance or advice for what Johns Hopkins can do, and we've talked about what our partners in India can do to help improve the impact of what we're doing, but what can we do on the Hopkins side specifically to ensure that your Indo JHU research partnerships lead to measurable and sustainable improvements in health outcomes, in the communities, in which we work? Let me, let me start with Dr. Mehta. >>Yeah, I think, I think two things, I think one, you know, one of, one of the things is that we've been established working for so many years, so we've learned how to do this, but we always get questions from people who are just trying to start out. So I think establishing some of this and facilitating this, this development of collaborations for people who are starting out and want to do work in India. I think that would be a huge piece that the Institute could contribute. I think training also came up and this is one of the things we always think about we, you know, with, with not having as wide of a Fogarty program anymore, training in research, in practice and, and things like advocacy, right? So providing training for, for not just folks from here, but for our partners in India to do some of this work on the ground, those are just two things that quickly come to mind. >>Thank you. Dr. Mave do you want
to add to that? What else could we do at home? >>Yeah, I totally agree with Shruti. I think the platform you're providing just now is also a great way to disseminate what we do in India. And so that all the stakeholders can also then visualize and see and then maybe participate in helping us connect with the right partners and also the program. >>Well, thank you. We're now reaching the end of the hour and I want to
make sure we thank Dr. Mehta, Solomon, Agarwal, Mave for wonderful presentation to discussion and thank all of you for joining us and look forward to having you join us in future sessions like this. And we look forward to also to receiving your continued guidance and advice, all of you both on the panel, as well as those of you in the audience. And, and thank you again for joining us this morning and this afternoon, or this evening, depending on where you are. And I hope everyone has a safe and happy holidays. >>Thank you. >>Thank you.