A Conversation with Johns Hopkins Medical and Public Health Researchers in India

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>>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.

2020-12-31

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