Early this year 25-year-old Abhi* went to a private clinic to get treatment for a lump near her neck that was hurting. The doctor told to go to the municipal clinic. Abhi works as a sex worker in the Delhi’s GB Road red light area.

Abhi, who moved to Delhi from Nepal, did not to go to the municipal clinic as advised. She can barely speak Hindi and she feared being treated badly by government doctors, something she had heard about from other sex workers.

Luckily, help soon came to her doorstep. In March, the National Coalition of People Living with HIV collaborated with Delhi’s tuberculosis department to conduct an active tuberculosis case finding project among sex workers on GB Road. Abhi was diagnosed with extrapulmonary tuberculosis in the lymph node. She had suffered from TB about three or four years ago but had not completed her treatment for the disease at that time.

So far, the HIV programme is the only disease control programme in the country has been successful in reaching out and providing treatment to sex workers. Now the country’s tuberculosis programme wants follow suit and reach out to communities that are at higher risk of infection – including sex workers, slum dwellers, tribal communities – instead of waiting for them to approach the health system.

“Sex workers are involved in high-risk behavior and are at greater risk of HIV,” said Dr Lopamudra Datta from Delhi State Aids Control Society. “If you are at high risk of HIV, then the risk for TB is also high.”

So far, there has been no TB outreach and the programme has mostly relied on patients coming to health facilities to seek treatment. After declaring earlier this year that TB will be eliminated by 2025, the government has decided to start an active case finding programme where health workers will screen people for TB.

One large-scale active case finding exercise was conducted in 2013-’14 implemented by Project Axshya and supported by Global Fund. The exercise covered 281 districts across the country with 1.9 crore people and detected more than 13,000 TB cases.

Press conference held by the government and health NGOs about the active case finding exercise at GB road.

This year, the central TB department decided to conduct three campaigns of active case finding in 55 high burden districts across 18 states including Delhi, Maharashtra and Karnataka. During the first campaign, which lasted for 15 days in January, as many as 46 lakh people were screened, 69,000 sputum samples were tested and more than 2,500 new cases were detected.

The door-to-door active case finding campaign among sex workers was an extension of this programme.

Single window service

Bannu would never visit a public hospital if she could help it. The 48-year old who works in a brothel on GB Road said, “Sarkari hospital main dhakke khane padte hai. Koi qadar hi nahi.” We only get pushed around in government hospitals. I do not believe in going there.

During the active case finding between March to April, Bannu was screened for tuberculosis after she complained of a persistent cough.

Bannu was taken along with others to the New Delhi Tuberculosis Centre where, to their surprise, all their tests were done within an hour. They had never seen such quick results at any other public hospital.

“All the tests were done quickly,” said 35-year old Kirti. “I did not even have to stand in a line.”

In routine practice, the government hospitals first test sputum for TB bacteria. Only if the results are negative and the symptoms persist is an X-ray taken to check for any sign of TB in the lungs.

Patient giving his sputum sample in Delhi's Chandani Chowk's Chest Clinic.

Dr Kamal Chopra, director of New Delhi Tuberculosis Centre, said that they made an exception for this groups of sex workers. Worried that they may not return if asked to come in for follow-up tests, the doctors at the centre performed both sputum tests and X-rays simultaneously.

“We gave a single window service,” said Chopra.

Of the more than 2,500 sex workers on GB Road, 1,875 were screened for symptoms, 57 were referred to the TB centre for testing and two were found positive.

Chopra said that he had expected to find more cases in the area. He is now optimistic that the exercise will motivate sex workers to seek treatment under the government’s TB control programme.

“The idea is to do a sensitisation programme where people are told about what symptoms to look out for TB,” he said. “There would be cases found after the active case finding for which we have linked the sex workers with outreach workers who can help them seek treatment.”

Difficult to reach

The active case finding at GB Road started in March and continued for a month. Four teams consisting of outreach workers with non profit organisations working in the area and one from the National Coalition went from door to door, to 95 rooms in 22 buildings, to find cases.

“In my team itself some people were reluctant to go to GB Road,” said Chinmay Modi from the National Coalition. “If you do not know the area it is intimidating. Pimps stopped me four times from talking to women.”

Health workers working in the area say that the brothels at GB road are notoriously difficult to reach out to, unlike red light areas in other parts of the country.

“One has to take permission of the managers and pimps before speaking to the sex workers,” said Kusum, president of the All India Network of Sex Workers. “Women are a lot more independent in other parts of the country such as Kolkata, Mumbai and South India.”

Shakti Vahini and Indian Medicine Development Trust are two non profits organisations working in the area that run the targeted intervention projects. Workers with these NGOs talk about trouble gaining the trust of the community that has at least 156 HIV positive sex workers. “Of these only 45 take treatment for HIV regularly,” said Dr Naghma who works with Indian Medicine Development Trust. “Some refuse to take treatment or just disappear.” Naghma provides TB medicines at the local NGO centre.

Dr Naghma (on the right) with Mohammed Salman, a social worker and counsellor Rita Rani who led the teams in brothels looking for TB cases

Ruchika Sahu, senior TB and HIV supervisor with the Delhi TB department who helped in this active case finding programme by counselling patients, said that the women were very reluctant to talk to her. “They would not enter the room [where she was counselling] if the attendant is not with them,” said Sahu, noting that many of them were reserved and timid.

Kusum said that sex workers are reluctant to seek treatment at government hospitals because of the stigma. “They worry that someone will ask their address, which will reveal their status” as sex workers.

This limits their access to government health services, like when their children fall sick or need vaccinations.

Kusum said that the state TB department’s move to reach out to the sex workers is quite commendable.

“This will open doors for other kinds of health services,” said Kusum.

*Names of sex workers has been changed to maintain privacy.

This reporting project has been made possible partly by funding from New Venture Fund for Communications.