I arrived in Chennai, the capital city of Tamil Nadu, a state in southern India at 2 am on Thursday, January 30, 2008.  As I searched for my name among the signboards held by unfamiliar faces standing outside the airport, my heart was beating fast with trepidation at the thought of getting into a taxi at 2 am.  The root of my fear was not about being alone in the car with a taxi driver arranged by the medical university I was working with, but about his driving in the crazy roads of Chennai.  My previous trip to Chennai was 10 years back, and I actually cried in the backseat as our driver overtook car after car, closely missing the speeding semis in the next lane. I arrived to my deserted hotel (the YMCA where visiting students normally stay at was booked), after a surprisingly peaceful car ride. 

My adviser at the medical university, Dr. S. Parameshwari, was busy at a conference that weekend and would meet me the following Monday.  I would be working on a research study in a rural part of Tamil Nadu, Namakkal, located seven hours outside of Chennai. Dr. Parameshwari and I would be traveling on an overnight train Tuesday.  I needed to get a local cell-phone and salwar-khamis tailored to wear to work before I left Chennai and was hoping someone from the department would be available to help. Luckily, I met a couple on the plane that visited Chennai every year.  They graciously helped me get everything I needed without paying 2, 3, or 4 times the actual cost, as I would have if I went by myself. 

I finally met my adviser, Dr. Parameshwari and a medical student from the University of Washington, Rachel, who was doing a clinical rotation in Namakkal.  She had been staying at the YMCA for the past week and neither of us knew that we would be going to Namakkal together. After reaching Namakkal on Wednesday morning, Rachel and I were taken to the staff house provided by the medical university. All the ladies who stayed at the house greeted us with incredible hospitality.   We were fed delicious, home-cooked food -- this continued for the rest of our stay in Namakkal!  We occasionally ate a scoop of Nutella when we missed junk food from home.

Rachel was an incredible friend and support for the rest of my stay since we were able to share our experiences and compare health systems in the U.S. and India. To my surprise, I actually started working the very same day I arrived in Namakkal. The purpose of my research study was to find predictors of knowledge and adherence to PMTCT (Prevention of Mother to Child Transmission of HIV) methods in three centers located in government hospitals. HIV prevalence among pregnant women in Namakkal District is 1.80%, compared to 0.25% in the state of Tamil Nadu. Truck driving is the main industry in this district and truck drivers are identified as a high-risk group in India's HIV epidemic. They are described as a 'bridge population' that transfers HIV infection from high-risk commercial sex workers to the general population. Truck drivers are away from their families for an average of two months at a time and many have sex with commercial sex workers while away from their wives and partners.

I was introduced to the counselors and lab technicians who do HIV counseling and testing for all couples that are expecting a child.  Pregnant mothers who are found to be HIV positive are enrolled in the PMTCT program and are provided comprehensive care to reduce the risk of transmitting HIV to their infant.  My questionnaire was administered with the help of a counselor who introduced me, described the purpose of the study, and asked the study questions to each participant.  I wrote down all the responses and interrupted only to clarify answers.  My Tamil was quite good, but was not proficient enough to smoothly administer the questionnaire alone.  I was initially overwhelmed by the stories of these women, many who were my age or younger, who became infected by HIV after getting married to men who were on average 8 years older.  Many women also had family problems as a result of their HIV status and worked as day laborers, a profession that does not provide financial security. The job description of a day laborer is agricultural or construction work under the hot sun, while earning a meager daily wage.  Many women can no longer withstand the demands of this job as their HIV progresses, especially when they start antiretroviral therapy.  The counselors warned me not to leave work everyday still thinking about the lives and problems faced by all the women.  It is definitely a learned skill to maintain compassion and empathy for each woman you meet without leaving work feeling burned out.  I tried to focus on the potential benefits that can arise from publishing the findings of my research and also to implement a program in the next two years that can help improve the socioeconomic status of HIV positive women in this community. 

The results of my study indicated that higher self-efficacy was significantly related to accurate knowledge about PMTCT methods, while lower self-efficacy was significantly related to having one or more HIV positive children.  Support groups and self-help groups, proven to increase self-efficacy, may improve knowledge of PMTCT methods among these women.  Higher social support was also significantly related to increased adherence to PMTCT methods.  Lower social support is associated with lower socioeconomic status and implementing a program that helped women become financially independent may indirectly improve adherence.  Sewing clothes, weaving baskets, and also owning a cow that provides milk are some ways women can earn a steady income without jeopardizing their health.  An empowerment program that includes vocational training and microfinance lending can help improve the lives of HIV positive women in this community.  I truly learned a lot from all the women who participated in the study and from the counselors who work daily in this field.

Hospitality in rural communities is unparalleled, and I was invited by many participants to come visit their homes and eat with their families.  The staff in Namakkal took incredible care of me, and we visited many temples on our Sundays off.  These visits usually involved a four-hour bus ride on reckless, Indian roads where we stood for at least half the journey.  I actually felt safe on buses -- they were the biggest vehicle on the road and pedestrians, cows, rickshaws, motorcycles, cars, and even semis gave them right of way!

BRAVO! turned my proposal into an incredible reality.  A very special thank you to Carol Bender for working very hard with me on my application and also to Christine Duddleston, for handling my travel arrangements.

Anandani Nellan, MD/PhD and BRAVO! student.   Dr. Iman Hakim, is Anandani's adviser at the UA and her BRAVO! sponsor in India was Dr. S. Parameshwari.