Spreading Tentacles

HIV/AIDs today is prevalent in almost all parts of the country. In the recent years, it has spread from urban to rural areas and from individuals practising risk behaviour to the general population. Double Helical does a reality check…

In India, the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) epidemic is now 15 years old. Within this period, the dreaded disease has grown into one of the most serious public health problems in the country.
HIV is a retrovirus that attacks and destroys a vital component of the human immune system. The initial cases of HIV/AIDS were reported among commercial sex workers in Mumbai and Chennai and injecting drug users in the north-eastern state of Manipur.
The infection has since then spread rapidly in the areas adjoining these epicenters. It was by the year 1996, Maharashtra, Tamil Nadu and Manipur together accounted for 77 per cent of the total AIDS cases with Maharashtra reporting almost half the number of cases in the country.
Even though the officially reported cases of HIV infections and full-blown AIDS cases are in thousands only, there is a wide gap between the reported and estimated figures because of the absence of epidemiological data in major parts of the country.
The latest estimate for the HIV/AIDS infected adult population in the country is 3.8 million in 2000. The overall prevalence in the country is still, however, very low, a rate much lower than many other countries in the Asia region.
The available surveillance data clearly indicates that HIV is prevalent in almost all parts of the country. In the recent years, it has spread from urban to rural areas and from individuals practising risk behaviour to the general population.

More women patients
Studies indicate that more and more women attending ante-natal clinics are testing HIV-positive thereby increasing the risk of perinatal transmission.
About 85 per cent of the infections occur from the sexual route (both heterosexual and homosexual), about 4 per cent through blood transfusion and another 8% through injecting drug use. About 89% of the reported cases are occurring in sexually active and economically productive age group of 18-49 years and one in every 4 cases reported is a woman.
The attributable factors for such rapid spread of the epidemic across the country today are labour migration and mobility in search of employment from economically backward to more advanced regions, low literacy levels leading to low awareness among the potential high risk groups, gender disparity, sexually transmitted infections and reproductive tract infections both among men and women.

Misery of the patients
The social stigma attached to sexually transmitted infections is devastating. Discrimination against people living with HIV/AIDS denies them access to treatment, services and support and hinders effective responses. It creates a climate in which decisive action from the government may be side stepped. There have been cases of refusal of treatment and other services to AIDS patients in hospitals and nursing homes both in government and private sectors.
This has compounded the misery of the AIDS patients. More often it is mistaken to be a contagious disease and patients are isolated in the wards creating a scare among the general patients. In the workplace there are cases of discrimination leading, on some occasions, to loss of employment.
The active part played by some non-governmental organisations in bringing out public interest litigations against such cases of discrimination and the judicial pronouncements by courts in support of the rights of such people has partly helped in alleviating the misery of the affected persons.
People living with HIV/AIDS have provided the best response to the stigma and the denial that shroud the epidemic. They bring faces and voices to the realities.
However, only clear and candid information about how HIV is and is not transmitted will alleviate unnecessary fear and discrimination. Efforts need to be made to train all medical and para medical health care workers to create a congenial environment where HIV/AIDS patients are admitted and treated without any fear and scare.

No adequate treatment
The treatment options are still in the initial trial stage and are prohibitively expensive. While there is no vaccine in sight, multi-drug anti-retroviral therapy, popularly known as ‘cocktail therapy’, is not a cure to the disease and may help only in prolonging the life of the patient.
Standardisation of treatment regimens for these drugs is still evolving and there are fears of patients developing drug resistance and side effects if the therapy is not administered under proper medical supervision.
Also, there are instances of quacks taking advantage of the situation and promising cures and defrauding unsuspecting people who are infected with the virus of large sums of money. Transmission of the disease through blood, though limited to 4% of the cases down from 8% in 1992, is also a serious issue as unsuspecting population can get infected through this route if safe blood is not ensured.

Complex situation
Existence of a large number of small and medium blood banks, many of them in the private sector has also compounded the problem.
Up to some extent, the Supreme Court directive of May, 1996 has helped in phasing out unlicensed blood banks by May, 1997 and professional blood donors by December, 1997. Mandatory testing of blood for HIV along with syphilis, malaria Hepatitis B and C has helped in checking transmission of HIV virus through blood transfusion.
Transmission among injecting drug users is also one of the major causes for the spread of HIV/AIDS in the country. Even though the cases are more prevalent in the north-eastern states, incidence of HIV through injecting drug use is evident from many parts of the country, especially in the urban areas.
Harm reduction programmes which involve exchange of syringes and needles, coupled with peer education, community outreach, access to health services and a range of treatment modalities from abstinence to oral drug substitution have been adopted by other countries to effectively reduce transmission of HIV through injecting drug use. In India the harm-reduction approach is yet to find wider acceptability because of ethical and moral considerations.
Although transmission of HIV through use of needles, razors and other cutting instruments in beauty parlors, hair-cutting saloons and dental clinics is insignificant, lack of hygienic practices in majority of these establishments also poses a health risk to the unsuspecting general population who visit these places every day.

Tuberculosis new challenge
Standardisation of AIDS treatment regimens is still evolving with continuing fears of patients developing drug resistance and its various side effects. Moreover, the treatment of TB among the HIV-infected persons has emerged as a new challenge. Some of the drugs which are recommended for TB treatment pose complications in cases of HIV-infected persons.
Treatment of TB among the HIV-infected persons is a new challenge to the National TB Control Programme which has now adopted Directly Observed Treatment Short-course (DOTS) strategy for control of TB infection. Looking for HIV among TB infected persons will also cause the problem of scaring away a large number of TB infected cases in the country from seeking treatment under the DOTS strategy.
There is an urgent need to bring all the establishments connected with AIDS to maintain acceptable standards of hygiene to take measures to minimise and almost eliminate the chances of HIV transmission through the use of needles and sharp cutting instruments. With a high prevalence of TB infection in India the problem of HIV/TB co-infection also poses a major challenge. Nearly 60% of the AIDS cases are reported to be opportunistic TB infection cases.
There is no risk of any TB patient getting infected with HIV unless he or she practises high risk behaviour or gets infected from transfusion of HIV-infected blood. HIV/AIDS is not a disease which spreads randomly and is transmitted as a consequence of a specific behavioural pattern and has strong socio-economic implications.
It doesn’t only costs huge sums of money in terms of controlling the opportunistic infections such as TB, pneumonia and cryptococcal meningitis, but seriously affects individuals in their prime productive years causing serious economic loss to them and their families.

Way forward
As a part of community medicine strategies, the national AIDS control policy principally aims at the following strategy for prevention and control of the disease like prevention of further spread of the disease by making the people aware of its implications and provide them with the necessary tools for protecting themselves.
Controlling STDs among vulnerable sections together with promotion of condom use as a preventive measure, ensuring availability of safe blood and blood products and reinforcing the traditional Indian moral values among youth and other impressionable groups of population are among the required measures through which we can tame the growing menace of AIDS.