 Good afternoon. I hope you had a good lunch and break So we are happy to continue for session number three and For that would like to invite the presenters and the chair to come to the stage So now I would like to present Angela Gopalan She's the founder and executive director of the NOS foundation in India trust a deli based NGO Dedicated to fighting HIV H Established in 1994 NOS foundation provides support to stigmatized and vulnerable communities HIV in 2000 Anjali also founded the NOS care home to provide a safe and supportive environment for children living with HIV The home employs a holistic approach to look after the nutritional educational medical and psychological Needs of each child and has been designated as the only care center for children in the entire northern region bestowed with several prestigious awards Anjali also spearheaded an eight-year legal battle and 377 of the Indian penal code with the court ruling in favor of NOS India Welcome and I hope also welcome to the other presenters, and I hope we have again a very engaging session Thank you and welcome to this session We have two speakers, and I've been told to actually keep time So I'm not usually rude by nature, but I may sound so right now So we have two speakers with us One and and the first speaker is Paul Lung dim who has been working as a Coordinator at the Delhi network of positive people Since 2013 and is responsible for coordinating projects concerning expanding access to essential services increased treatment adherence reduced stigma and discrimination and improve the quality of life of people living with HIV his HIV status was confirmed in 1995 and he has vitro viral treatment since April 2013 So may Paul is going to Share his thoughts on monitoring stockouts in that in the national AIDS program facilities in India This is a case study that was done by DNP plus and the way this works is after the second So we'll take questions after both presenters have finished as we have some time for doing precisely that Oscar My name, my name is Paul. I'll be presenting on monitoring stock out in national AIDS program facilities in India DNP plus mission is to improve treatment services for people living with HIV Monitoring stock out or shortage of ARV OI medicines or diagnostic kit in ART program We started monitoring stock out shortage of government anti-retroviral therapy ART center our methodology in this man for monitoring stock out is We monitor Monitoring of stock of ARV and diagnostic at the ART center in Delhi from the last eight years and I'm going to present retrospective study of daily monitoring of all nine ART center in Delhi from June 2012 to February 2015 this study has meant the MSF ethic review report approved criteria for analysis of Routinely collected program data because It is DNP Daily activities to carry it out daily Stock of ARV orchids PLT is maintained and no harm is Done to the PLH IV as confidentiality is maintained PLH IV has complete trust on DNP plus and this ART center in Delhi what we did is We screen article to identify treatment interruption We ask patient about their experiences to with ARV or testing whether they have received The required amount quota of ARV or whether they have got tested for their routine this and we questions stop working in the ART center ART center on availability of essential supply and here I'll like to Explain a bit more on stock out what exactly is stock out men Stock out men no physical stock of medicine and kids and Shortage mean medicines were given for less than the Designated one month supply to patients routine taste not available on designated date for monitoring and diagnosing resistance our results shows that 32 episodes were recorded on shortages and just in 2014 15 episodes were out of the 32 recorded episode and this resulted in repetitive ART visit ART center visit by patients. So because since they are not getting one month quota, they have to visit they are told well after 15 days or after three days and Even some have to see their regime from real to SLN stubborn and it Humper their economy economically travel cause all they have to purchase with your own money and Last but not the least they are Psychologically affected and this is to picture of how we recorded evidences of stock out or shortages in the first picture. We saw the circle Sows that starved in is given in place of ten of a bill the patient has to be given ten of a bill but Since there is stock out starved in was given and in the second picture We can see three days in the circle mark So the patient has was supposed to get one month, but due to stock out or shortage Due to shortage of ARV three days was given three-day dose was given to the patient and This is the later sent to security secretary health minister Regarding stock out of viral load kids. We have the two later to NACO official Regarding viral load testing kid stock out, but we met no response. So We went ahead and send this letter to health minister Trying to make him aware that Viral load testing kid had been on stock out for the past one year. How we tried resolving it Some with technical support from MSF SS campaign We met NACO officials We met procurement agencies live rights We met a procurement agency rights because they were there is a delay in time issuing of Procurement or tender and break ARV manufacturer so that can they can bid for timely when they are not bidding timely, there is shortage or ARV or kids and When such thing happens stock out or shortages happen will roll letters to the W. H. O HIV Department UNA it's global fund and pediatric supplier to make them aware of stock position the stock out position and when nothing When the stock out is happening for a long time who we even sent legal notice to help ministry and when repetitive Stock out so test continues. We even intimate and engrave and gates media or Journalists and we dare our issues and concerns are published in article in national and international media These are a few picture the first and second picture shows over sitting protest at NACO office the first picture picture is in 2011 when there was ARV's a national wide so and the second picture is In 2013 We had another sitting protest at night. That is the way when we How we walk out and the third picture is showing us having a silent protest at 10-year celebration of ART program in India organized by NACO to highlight consistent recurring a stock out of ARV that is hampering PLH IV life when stock out or shortages Continues There are times when even the NP had to go ahead and purchase drug ARV for patients and then monitoring of the supply chain led to identification of stock out shortage in public facility Resulted in behavior chain in the clinic staff They started to inform about stock position. We put Sibla firma company to be for pediatric formulation WHMSF Clinton Foundation emergency donation Pressure to finalize bid for first line and second line ART in September 2014 Motivated other positive network to come out and actively report on stock out light Mumbai 8th forum and positive women network limitation in DN DNP plus the limitation We have no Particular staff or resources or fun to do this Monitoring we are just doing extra. That is the limitation and the situation is still grim budget of national AIDS program further reduced and the command met met by Indian Health Minister This is what the command met. It's was a concern tune. That is the mindset Never ending delay in in swing and finalizing bids. So monitoring is a challenge supply chain reform is still pending and viral or kid stock out is Happening for the past 12 months. What we need is National monitoring system on stocks for timely stock out report So that timely replenies man can be had Okay Thank you Thank You Paul Now I'd like to introduce Padma Dostali who is the coordinator at the Center for enquiry into health and allied themes She was instrumental in founding the the Lhasa Public Hospital Crisis Center and sat on the National Committee Which under the Ministry of Health and Family Welfare? Developed the national guidelines and protocol for medical legal care to survivors and victims of sexual violence As a member of the WHO guideline development group steering committee She contributed to establishing clinical guidelines for responding to intimate partner violence and sexual assault She has undertaken research on standards of care and private sector health care It's unregulated growth women's work and the health implications of violence against Padma is going to speak on making the health health sector responsive to sexual violence The lessons learned from this. Thank you. Thank you, Anjali. Thanks for that introduction. I will So this is this presentation is really as the title suggests It's lessons learned from an intervention project that we are running in Mumbai and when we talk about the health sector response to sexual violence One good thing that we all recognize is that the health sector has a dual role to play when it comes to responding to sexual violence In terms of the clinical and therapeutic care and also the forensic Before we get into the actual context. What has changed in India is the After the 2012 Delhi incident of brutal sexual assault of the physiotherapist The legal there was there were some legal amendments made just a certain legal mandate which further Emphasize on the critical role both in terms of therapeutic and forensic on Part of the health system. So right to treatment for survivors of sexual violence was not a legal mandate It was an expected role that the doctors needed to play and not just focus on forensics But that has come through with the law both in the CLA 2013 as well as the child sexual abuse law that came in in 2012 There's also a provision for mandatory reporting to and the entire definition of consent as far as rape is concerned has been clarified and there is a Clarification saying that absence of injuries in rape victims does not mean consent and rape has been the definition of rape is expanded from penal vaginal penetration to include all orifices anal vaginal and oral and Insertion of penis. So I think that makes the health system in a very different Situation to and the challenge for them to more sensitively now going back to what is the current response of the health system to sexual violence? This is a typical medical legal form That you will find in most health facilities of India across the country One is that there's informed cons the informed consent is merely a blanket consent Which is assumed because it's a case of it's a medical legal case So it's a police case. So there is no Specific consent for different procedures. So there's a blanket consent taken history is often written as alleged history of rape Without getting into details of the nature of assault. It's all history of rape There's a whole focus on hymen examination Rupture of the hymen is mentioned prominently without mentioning whether it's an old rupture or you know when the hymen had ruptured The size of vaginal opening is definitely mentioned in almost all cases whether it's a child Adolescent or an adult two fingers pass one finger passes with difficulty. These are the kinds of comments There's no mention of the delay in reporting. What is the what did the victim do after the assault? Did she wash herself clean herself? What are the use of restraints? So, you know, was she threatened? Any intoxication the delay in reporting? There's just no mention of that in the medical legal form The evidence is collected just as procedure. So it's irrespective of the kind of assault So if she's reporting anal Sexual assault still her vaginal swab would be taken. So if she's reporting oral still anal and vaginal will be taken So there's just no sense. It's just done very mechanically Irrespective of whether she was menstruating all the swabs will be taken because that is a procedure to be followed by the doctor There's no medical opinion. No correlation to her history and what the doctor has found The most glaring gap is in the absent therapeutic care. Most often treatment may just not be given there. There are cases documented clearly where women have had to come back for abortion because an emergency Contraception was not provided or children have been brought back for burning Micturation complaints because they were not given any treatment when they but the medical legal evidence was collected But the treatment was not provided. This is just to emphasize that, you know pain killers have been prescribed in the form For the patient for genital injuries But the doctor has written on the medical legal form that the patient is uncooperative Instead of saying that a perversion nation was not possible because of a genital injury This is the kind of comments that are made All of this is rooted in the most insensitive gender You know Absolutely stereotypical notions about rape which are still there in the latest Questions of forensic textbooks. There's no time to get into the details, but this presentation is here So it talks about the kind of you know types of women who can resist who cannot resist It keep rape is the easiest allegation to make but difficult to prove There's a whole focus on Commenting on sexual habituation of women So they're instructed the doctor the medical textbooks actually instruct doctors to do all this and this exists in the 2013 editions now coming to medical evidence in sexual violence as you all know it could be in the form of trace evidence It could be injuries on the body or it could be infections But one needs to understand that medical evidence has its limitations Because they could be gap between when the incident took place and when she reported to the health facilities The nature of sexual assault will determine what kind of evidence is going to be found Whether your condom was used whether there was intoxication whether drugs were given all of this Affects the kind of evidence that could be found on a rape victim a post assault activities So the fact if there is no medical evidence It does not mean that sexual assault did not take place coming to the model that we've set up in three hospitals in Mumbai in collaboration with the mission of Mumbai there so it's a collaboration between Seherth and three hospitals We've set up a comprehensive health sector response Where? Informed consent has been operationalized to seek consent for treatment for evidence collection for reporting to the police and for collection of evidence So at all stages for all these four procedures consent is taken and it is for it has been followed for all survivors who report to these hospitals Detailed documentation of history of assault. There's a gender sensitive examination collection of relevant forensic evidence and provision of a medical opinion There's also medical treatment, which is provided free of cost and first contact psychological first aid is provided and Documented chain of custody has been set up because often we found in most hospitals evidence is collected But it's just lying because there's no documentation as to who in whose care This is supposed to be kept referral to appropriate agency So this is the kind of model and what I'm going to talk about is the lessons learned from execution of implementation of this module since 2008 this is based on medical medical the medical legal protocols that have been maintained total cases were 448 and what what's been picked up for analysis is 411 and 17 code in analyzed We found that after 2012 so 2008 to 12 we had about 94 cases across these three hospitals and after 2012 Which is when the there was a huge campaign in India the three-fold increase in the number of survivors coming to these three hospitals If you look at the age of survivors, we have about 42 percent who are less than 12 their children another 35 percent Who are adults and about 23 percent who are adolescents? Nature of sexual violence it's non-penetrative assaults which have been 25 percent and I think that's the Huge difference that the definition of rape has been changed makes for in terms of access to justice for these survivors Profile of perpetrators almost 77 percent of the in cases the perpetrator was known to the victim 25 percent of these cases followed up for Counseling and other this is the analysis of legal outcomes and if you look at you know the 17 court judgments two minutes Yeah factors leading to Convictions we found that the documentation of detailed history by the doctor the trace evidence when it was explained in terms of presence or absence of trace Evidence so if the ejaculation was her body So you know it was explained that therefore there's no trace of semen the detection of lubricants So the absence of injury was explained the fact that she was menstruating so the doctor was able to explain that there was no Therefore there is no forensic evidence Even injuries were interpreted in terms of you know the delay in reporting the fact that the assault took place 35 days back So the injuries have healed or the redness the distinction between redness or soreness caused because of sexual violence and that by STD factors leading to equity fin there was no interpret the interpretation put up by the doctor for injuries was not picked up by the prosecution Evidence was not explained In an offense of fingering Where the doctor has said that you know there was fingering and therefore there is no forensic evidence The judgment actually and the final judgment says absence of semen So in a case of fingering you're not going to find semen occupation of the judicial system with Medical evidence and especially forensic evidence comes through and their biases towards rape comes in For offenses of non-penetrative sexual assault also the court asked for You know semen why was there? There's no semen that was found Of course, there were social factors where cases were withdrawn These are details, which there's no time to go through but this presentation will be available So these are just to dip you know really say what is that how the doctor explained the medical evidence? What's emerging from this analysis is that for the courts and the prosecution is that they need to recognize Infections also as evidence so even cases so if the whole preoccupation is with semen and You know injuries So if that but infection itself provided that itself forms should there needs to be recognized as medical evidence to conclude It's possible to you know conduct these medical legal in a gender sensitive way Evidence-based scientific forensic practice is absolutely essential and that can really stand the test of time Doctors need to explain the absence and presence of injuries guidance on medical evidence and its limitations Has to be added to doctors and prosecution Police and the judges because there's obviously seems to be a lack of Recognition of it. These are few issues that I would like to flag one is that mandatory reporting to the police has come in and That really comes in a way You know it kind of contradicts the whole right to treatment provision that the law has brought in because those who don't want to report to the Police often they can be denied treatment and informed refusal for informing the police which has been What we are practicing in these hospitals that it really requires ethical practice Most doctors would like to just go by with the law So when the law and the ethics there is a kind of you know dilemma often doctors choose to go the legal way They don't want to take an option and this is a problem Especially with women who are reporting you come for abortion. So often they are reporting rape After two months. So it really makes no sense for the doctor to mandatorily report to the police The other is married women reporting marital rape and you know what our country and our parliament thinks about marital rape We've had about 12 cases within these four hundred and forty one who reported rape by their husbands or boyfriends So my right to rape is very common And I think it requires a legal because the rape law excludes rape by the intimate partner A criminal case cannot be made by the police Transgenders and boys are also reporting here We've had about two transgenders in the last two years and about three percent of these four hundred and eleven are boys Who reported with sexual violence? This is to acknowledge the interventionist because we are we are on call twin for for these hospitals and we provide 24-7 on-call services to the doctors and survivors and their families and Lastly, I would like to thank the MSF for having including us for this conference. So thank you Thank you very much. I would like to end