AIDS CONTROL PROGRAMME-THE STRATEGY AND THE ACTION
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In this issue
Nov.-Dec. 1993
Vol. XXXVII, No. 11-12
Kartika-Pausa
Saka 1915
AIDS Control Programme—The strategy and the
action
P.J?. Dasgupta
265
Combating AIDS: Time to act
268
Dr D. Sengupta
Preventing AIDS: Educating youth to protect
themselves from infection
270
Dr Shiv Lal
OBJECTIVES
Swasth Hind (Healthy India) is a monthly journal
published by the Central Health Education Bureau,
Directorate General of Health Services, Ministry of
Health and Family Welfare, Government of India,
New Delhi. Some of its important objectives and
aims are to:
REPORT and interpret the policies, plans, program
mes and achievements of the Union Ministry of
Health and Family Welfare.
ACT as a medium of exchange of information on
health activities of the Central and State Health
Organisations.
Programmes against AIDS at workplaces
Dr Khorshed M. Pavri
273
Situation of AIDS in India and measures for prevenlion and control
Dr A.K. Mukherjee and Dr S. Venkatesh
277
HIV infection and tuberculosis
284
Dr S.K. Kate
AIDS and women
Dr S. Kant & Dr C. Singh
287
Contact tracing: Method and its importance in
S.T.D. and AIDS Control Programmes
289
Dr V.K. Tewari
AIDS: A select bibliography (1991-1993)
M. Sharada & K.C. Singh
291
Talking about AIDS: Communicating with youth
295
FOCUS attention on the major public health pro
blems in India and to report on the latest trends in
public health.
Developing and implementing school policies to
address HP/ infection and other health
297
KEEP in touch with health and welfare workers and
agencies in India and abroad.
Roads that HIV will not take
REPORT on important seminars, conferences, dis
cussions, etc. on health topics.
Book Review
policies
A. Isaksson et al
Preventing the
responsibility?
spread
of
299
HIV:
Whose
303
III
cover
Articles on health topics are invited for publication in this Journal.
Editorial and Business Offices
Central Health Education Bureau
(Directorate General of Health Services)
State Health Directorates are requested to send in reports of
their activities for publication.
The contents of this Journal are freely reproducible.
Due acknowledgement is requested.
The opinions expressed by the contributors are not necessarily
those of the Government of India.
SWASTH HIND reserves the right to edit the articles sent
for publications.
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AIDS CONTROL PROGRAMME
—The Strategy and the Action
P. R. Dasgupta
Why is AIDS so scary? There are two principal reasons. Firstly, there is no vaccine or
cure for AIDS. Secondly, it attacks most of the age-group of 15-45 years. The strategy
today is to prevent the transmission of infection. This can be attempted only with
increased awareness and knowledge about the transmission of infection and the risk
behaviour which facilitates such transmission.
IDS, this apparently innocuous
four-letter word, is an enigma
which has defied all the efforts
of health professionals and scien
tists to find any effective cure or
vaccine against it Consequently,
the prevalence figures during the
last few years have been mounting
ominously the world over without
any manifest sign of remission.
A
Opinion
leaders,
decision
makers and a very large number of
people generally assume that AIDS
should be the concern of health
professionals, health adminis
trators and those who are afflicted
with it This is not cor
rect AIDS has ceased to be a
mere health problem and has now
acquired dimensions which per
haps have very few parallels in the
history of mankind. It affects
all of us, either directly or in
directly.
In the year 1978, the Health
Ministers from most of the coun
tries in the developing and deve
loped world met at Alma-Ata and
Nov.-Dec. 1993
1—13 DGHS/93
gave a clarion call to all the coun
tries to achieve Health For All by
the year 2000 A.D. The task
appeared difficult, but certainly not
impossible at that point of time.
Little did they realise that a
dangerous viral infection, which
later on was termed as the Human
Immuno-deficiency Virus or what
is now popularly described as HIV,
had already taken roots amongst a
group of homosexuals in the U.S A.
and that it would soon spread its
tentacles in the most menacing
manner possible. The first case of
HIV infective was detected in
1981. Within a span of a little more
than a decade, we have now about an
estimated number of 10—12 million
adults (about 6 to 7 million men and
4 to 5 million women) and one
million children infected by HIV.
Of these, nearly 1.7 million have pro
gressed to AIDS and a vast majority
have most likely died. According to
a current estimate, about 5000 peo
ple may be getting infected with HIV
everyday all over the world. Thus
the dream of Health For All.by the
year 2000 A.D. has been replaced
by a macabre nightmare in which it
is projected that by the year 2000
AD. a total of 30 to 40 million men,
women and children may be infec
ted with HIV and nearly one-fourth
of them in Asia.
In India, sero-surveillance about
the trend of HIV infection was
launched from late 1985 and the
first case was detected in 1986.
Since then approximately 18,98,670
blood samples from people practis
ing high-risk behaviour have been
screened all over the country. Out
of these, 13,254 have been found to
be HIV positive. This gives a sero
positivity rate of 6.98 per thousand
which, even though the sampling is
biased, is fairly high. The current
projections are that at present
nearly a million Indian people will
be infected with HIV. By 1996 this
figure might go up to 2-3 million.
This is the grim reality that faces us.
Scary
Why is AIDS so scary? There
are two principal reasons. Firstly,
265
there is no vaccine or cure for
AIDS. There are a few drugs
available in the market, but so far
theirs only known effect is to
lengthen to a limited extent the
incubation period or to slow down
the progression from HIV infection
to serious illness. However, it
must be noted that the infection is
irreversible, that the drugs have
fairly toxic side-effects and that
these are frightfully expensive
also. Thus, those infected with
HIV would, within a period of 8—
10 years, develop AIDS or AIDS
related illness and would die soon
thereafter. The second scary
aspect of AIDS is that it attacks
most of the age-group of 15—45
years. This age-group represents
the sexually active segment of the
population. It also happens to
provide the major work-forces in
the country in the unorganised as
well as the organised sector. If
this age-group gets decimated, as it
has already happened in several
parts of Africa, the social and
economic consequences would be
catastrophic.
How to deal with the situation?
If there is no vaccine or cure, how
does one deal with the situation?
As of today, the strategy is basically
that of preventing the transmission
of infection. This can be attemp
ted only with increased awareness
and knowledge about how the
infection gets transmitted and
about the risk behaviour which
facilitates such
transmission.
Thus knowledge and education is
the
key. Unfortunately,
the
current levels of knowledge, per
ception and awareness are rather
low. Many have heard of HIV
and AIDS in some form or other
and quite a few perceive this as a
266
fall-out effect of sexually errant or
deviant behaviour. And of course,
there are myths galore about get
ting AIDS through kissing or hug
ging or petting. There arc people
who think mosquitoes can transmit
AIDS. If this perception leads to
an energetic drive to eliminate the
mosquitoes, there would certainly
be a beneficial impact on the
health scenario. But, alas, AIDS
would remain.
Fight against ignorance
We have to fight against such
ignorance and disinformation if we
have to fight AIDS. Let us
therefore understand in a common
man’s language as to how the
Human Immuno-deficiency Virus
or HIV, Le., the Virus which leads to
Acquired Immuno Deficiency Syn
drome or AIDS get transmitted. It
is this knowledge which can tell us
how one can prevent such trans
mission and how one can avoid
getting infected, it has now been
established that there are only three
well-defined routes through which
HIV can get transmitted. The
most common of these is the sexual
route. HIV can be transmitted
through unprotected homosexual
and hetero-sexual intercourse
when one of the partners is already
infected. It is easier for the virus
to be transmitted if the uninfected
partner is already suffering some
sexually
transmitted
dis
eases. The second route of HIV
transmission is through infected
blood, blood-products, organs and
tissues and contaminated needles
and syringes either as a part of
drug-abuse or bad hospital/clinical
practices. The probability of
transmission of HIV through infec
ted blood and blood-products is the
highest—more than 90 per cent
The third route of HIV transmis
sion is from an infected mother to
her child during pregnancy, at
birth or shortly after birth. The
probability of transmission of HIV
transmission by this route is about
30 per cent.
The challenge and the response
By and large it has been found
that the largest number of infec
tions have been transmitted
through sexual route in almost all
the areas excepting the NorthEastern States. In the NorthEastern States, the incidence of
HIV infection is overwhelmingly
through the sharing of con
taminated needles by the drug
abusers who are mostly the school
and college drop-outs. We are
now getting disquieting indications
that the young drug-abusers in
most of the towns and cities are in
creasingly turning to injectable
drugs for getting their kicks. If
this is not checked, HIV infection
through -sharing of contaminated
needles would increase by leaps
and bounds. HIV therefore poses
a grave challenge to the Society and
calls for a societal response. The
Government of India have respon
ded to the challenge by taking up in
hand a programme costing about
Rs. 222.6 crores to be implemented
during the current Plan period.
About one-third of this amount
would be spent in promoting
public awareness and community
support. This involves : (a) prom
otion of safe practices including
safe sex, use of sterilised/disposable needles, use of uninfected
blood and blood-products and
upgrading the standards of health
care; (b) influencing sexual be
haviour patterns in the society; and
(c) improving the knowledge of risk
SWASTH HIND
behaviour groups, potentially
vulnerable groups and health ser
vice providers about HIV/AIDS.
Since the access to risk behaviour
groups as well as the rural com
munities through the existing
government machineries would at
best be limited, we expect to draw
heavily on all forms of NonGovernmental Organisations for
the successful implementation of
this programme.
Another one-third of the total
budget on this programme would
be on ensuring blood safety and
rational use of blood. It is, indeed,
tragic that in a country of over 860
million people, we generate only
about 19 lakh units of whole
blood. This is less than 50% of our
estimated total annual requirement
of blood. More than 20% of our
annual generation comes from pro
fessional donors who are mostly
hosts of several infections in
cluding HIV. Unless we therefore
augment substantially the volun
tary donation of blood, the existing
mismatch between demand and
supply would continue to be met by
professional donors. A big part of
our programme would therefore
consist of motivational efforts to
augment voluntary donation of
blood. Simultaneously, compo
nent separation facilities would be
provided in 30 major blood banks
in the country to ensure that
whatever blood is collected is put to
optimal and rational use through
separation of the various com
ponents of blood. This would also
facilitate greater storage as frozen
components can be stored over a
longer period. Meanwhile, 180
Centres have been established
throughout the country where
blood samples can be tested free
and all the blood banks have been
provided with linkages to these
centres.
Preventing spread of HIV infection
The third component of the
National Programme to prevent
the spread of HIV infection is
building capacity for surveillance
and clinical management. The
trends in the incidence are being
carefully monitored through 62
Surveillance
Centres
located
throughout the country and train
ing programmes have been taken
up in hand to tone up the diagnos
tic and management skills of
physicians in all the States. We
expect that this would facilitate
humane and non-discriminatory
treatment of AIDS patients who are
often stigmatized both by the
society as well as the health
professionals.
Another important component
of our programme is control of sex
ually transmitted diseases, as AIDS
is basically a sexually transmitted
disease. The main objectives are
to initiate early and timely dia
gnosis and treatment; promote
knowledge about prevention of
STD/HIV and use of condoms; and
to emphasise the importance of
treating partners/contacts in the
community.
All these are however efforts to
catalyse a societal response in
which the overwhelming emphasis
would be on prevention through
promotion of a health life
style. We are convinced that edu
cationists have a major role to play
in evoking and nurturing this kind
of a response. Already the
National Services Scheme have
picked up the awareness genera?
tion programme among the 4-2 and
college students through the
programme called Universities
Talk AIDS. This needs to be
strengthened and intensified and
taken to the target group in Urban
slums and rural communities and
to those who are outside the
educational stream.
You cannot afford to take chan
ces with AIDS; for if you do, life
would not be the same again.
Do You Know?
Age is no safeguard. People of any age can have high blood pressure, but if you are
over 25 you are doubly at risk. For most, 3 simple ways to reduce high b.p. are
a balanced diet, salt reduction and weight reduction.
Nov.-Dec. 1993
267
COMBATING AIDS:
TIME TO ACT
DR.D. SENGUPTA
If proper steps—safe sex and correct consistent use of condoms by adult sec
tor of population—are taken even in the absence of any vaccine or cure for
AIDS, the epidemic can be averted. It is time to act, now.
A TTA O (Acquired Immuno
2>JL JL/
Deficiency
Syn
drome) currently has swept the
Western world and has caused a
devastation in the Sub-Saharan
Africa. The Plaque’s epicentre is
likely to be South-East Asia, par
ticularly, Thailand and India.
Currently, it is estimated that
15—16 million people are infected
by HIV, i.e., the virus causing
AIDS. According to the WHO
estimate, about 1.5 to 1.6 million
people are infected with Human
Immuno deficiency virus (HIV).
AIDS has a long incubation
period. Therefore in the years to
come, this country is going to be
flooded with late AIDS cases with
various opportunistic infections.
The disease affects mostly between
20—45 years, which is the most pro
ductive group of population both
economically and otherwise.
The disease, as is known, ap
peared first in the medical scenario
in 1981. At that time a group of
young homosexuals were detected
to be suffering from pneumonia
caused by some benign organism
which by itself does not produce
disease in healthy human beings.
268
This was pneumocystis Carinii.
Soon it was discovered that these
people were having mucosal candidasis and peculiar vascular
tumour known as Kaposi’s Sar
coma. These people were homo
sexuals, having multiple sexual
partners, also suffering from other
sexually transmitted diseases like
gonorrhoea, syphilis, etc. These
people were also using Arryl Nit
rate (stimulants) inhalation which
also depressed the cell mediated, as
it was only detected in the homo
sexuals to start with. It was given
the name of Gay related Immune
deficiency (GRID). Soon the
physicians discovered that it not
only occurs in homosexuals, but
also occurs through transfusion of
infected blood, in intravenous drug
users who were sharing needles.
The disease is also transmitted ver
tically from infected mother to the
newborn baby. The scientists
realised that the disease is being
caused by some transmissible
agent similar to hepatitis-B.
This new virus is damaging the cell
mediated immunity. It is well
known that the virus causing the
disease was discovered subsequen
tly by Luc Montagnier of the Pas
teur Institute, Paris, which was
cofirmed by Robert Gallo of the
National Institute of Health,
Bethesde, USA. Since then, the
researchers were active and in a
short period of time, the method for
detection of antibody in the blood
was discovered and kits were
developed which could tell who are
infected by the virus. But as it is,
scientists have not been able to dis
cover any drug or vaccine for con
taining the virus. The virus
causing the AIDS is a member of
the Retrovirus group. The charac
teristic of the virus is to get
integrated into the gename of the
host cell, so once infected by HIV, it
becomes
a
life-long
infec
tion. The other virus remains
separate from the gename and
could be eliminated easily, this ret
rovirus cannot be eliminated.
Position in India
In India, the disease first
appeared in 1986 when the top
research body “The Indian Coun
cil of Medical Research” detected
HIV in as many as 14 female com
mercial sex workers of South
India. Since then, the disease is
spreading and according to the pre
sent surveillance report the infec
tion has appeared in the general
Swasth Hind
population as well. Manipur
reports, one per cent of the ante
natal mothers infected with HIV
infection. To start with, it was
thought that the disease is urban in
distribution, but now it is proved
beyond doubt that this disease also
occurs in the rural section as well.
It is seen from the surveillance
records that the disease has in
reality entered the Indian Subcon
tinent We are in an advantageous
position when compared with the
sub-Saharan Africa, where it has
caused a fearful epidemic. In
some parts of the Central Africa,
villages after villages have been
devastated with the death of the
younger age group of population
between the age group of 20—45,
who have been completely wiped
off. Only young orphaned children
and old people are surviving.
There are hospitals in this part of
Africa, where 40—50% of the beds
are occupied by people suffering
from AIDS. In India, the epi
demic is still in the window period;
if proper action is taken the ram
page of the epidemic can still be
averted.
As has already been mentioned,
the disease has no cure nor vac
cination, but can only be preven
ted. One has to act now becuase if
proper measures are taken, one can
prevent that disease taking an
epidemic form. It is necessary to
inform the population for a proper
awareness that the disease is not a
myth but a reality. We may be fac
ing a situation worse than Africa if
proper action is not taken at this
point of time.
Blood is an important source of
transmission of AIDS. Hence,
proper control of all the Blood
Banks is needed. It has to be
impressed on every individual that
voluntary blood donation is a must
and taking blood from professional
donors has to be stopped at any
cost The doctors should be
educated about the proper use of
blood. The use of blood products
are in no way less hazardous. All
the blood products are to be
screened for HIV infection before
use.
People have to be informed
about the gravity of the disease and
its potentiality of spreading as an
epidemic through the proper use of
the media. In- common Indian
language, facts about AIDS have to
be disseminated among the dif
ferent segments of the people.
The mode of spread has to be
emphasized not only amongst the
general public but also among the
various groups of health pro
fessionals also—medical and para
medical staff. But at the same
time, AIDS Frankestein is not to be
created amongst the Doctors.
Infection control measures in all
hospitals have to be strengthened.
Proper sterilization (including
injection syringes), proper barrier
precaution and careful disposal of
the wastes have to be ensured.
Safe sex and correct consistent
use of condoms have to be empha
sized to adult section of the popula
tion through media, newspapers,
hoardings and posters.
If proper steps are taken, even
in the absence of any vaccine
or cure for AIDS, the epidemic can
be averted. It is time to act
now.
Prevention—the best way
Workshop on Orientation Training Programme on AIDS
A workshop for Orientation
Training Programme on “AIDS”
was organised by the National
AIDS
Control
Organisation
(NACO) and the Indian Associa
tion of Dermatologists, Venereo
logists and Laprologists (IADVL)
of Delhi branch on 18th July, 1993
in New Delhi.
The subject relating to Diagnosis
of HIV infection and AIDS Related
Diseases were discussed. The
experts also deliberated on over
view of an integrated approach for
Nov.-Dec. 1993
2—13 DGHS/93
specific areas relating to prevention
and control of AIDS.
Shri P.R. Dasgupta, Project
Director for NACO has stressed
that Dermatologists and venereo
logists should take active participa
tion in AIDS control programme in
a scientific manner. He asked the
medical professionals to come for
ward for the management of AIDS
cases and prevention of HIV
infection.
Speaking on the occasion,
Dr Vandom, WHO consultant gave
a global picture of HIV infection
including India. Dr D. Sengupta,
National Consultant, NACO urged
the technical groups to examine, in
detail, specific areas relating to pre
vention of AIDS Diseases. He
also said that 377 AIDS cases had
been detected and Tuberculosis
was the main infection occurring in
AIDS cases.
Earlier, Dr H.K. Kar, President
IADVL of Delhi branch welcomed
the delegates and outlined the
objective of this training pro
gramme.
—FIB
269
PREVENTING AIDS :
Educating Youth to
Protect Themselves from
Infection
Dr Shiv Lal
In view of the fact that as many as 20% of HIV infections are projected to be
occurring in the age-group of 10-24, it is imperative to initiate appropriately
designed interventions for this age-group.
HERE being neither a cure nor a
vaccine, the only way to com
bat the spread of AIDS is through
prevention. This
necessitates
mobilizing all networks in the
society to impart information
about AIDS and the necessary
skills to enable people to protect
themselves. Before this process
can begin, people need to be con
vinced that AIDS is indeed, a threat
to them personally and to the
society at large. They therefore,
need help to be convinced to take
personal action.
T
with regard to sexuality can be easy
and accessible target groups for
education on sexuality and healthy
and safe sexual behavioural prac
tices. If on the one hand their
vulnerability to be led into promis
cuous and unsafe practice is pro
found owing to lack of sex
education, the very same groups are
highly receptive and easily adapt
able into developing right kind of
safe sexual behavioural practices if
imparted appropriate kind, of sex
education.
Generating awareness among
people practising high risk be
haviour constitutes important
measure as a part of primary pre
vention strategy. At the same time
educating school children and
youth is important to prevent the
emergence of such kind of risk
practices as such, among these
generations as a part of primordial
prevention. The school children
and the youth who are yet to
develop or are in the process of
inculcating behavioural patterns
Strategies for Intervention
270
Educating school children and
youth is important because it will
halt the process of passing of the
virus to the next generation.
There is an urgent need to talk to
school children and youth on all
aspects of HIV/AIDS including
aspects of STD and sex
uality. Moreover sex education in
any form is not yet part of the
functional curriculum of the
schools. The school children do
not have any access to any formal
sex education, thereby the reliance
on peers and substandard literature
is great This leads to the ger
mination of misconceptions and
beliefs which in overall, harms the
general growth of the individual.
The process of moulding behaviour
also takes place during this time
and thus any education at this
point of time would be instrumen
tal in shaping the future course of
the individuals.
Communicating about AIDS/
HIV and STDs is extremely dif
ficult as it is necessary to discuss
sexual practices, a topic many peo
ple in many cultures would rather
leave alone, and bring the com
munication to a very personal level
for it to be effective. Only if each
individual examines his/her be
haviour in the light of the AIDS
epidemic and makes a positive
behaviour change, can any impact
be made. Consistent messages
from all channels—mass media,
SWASTH HIND
traditional media, health care
workers, and interpersonal chan
nels need to work in tandem for
achieving this objective. Apart
from mass media, targeted pro
gramming and development of
support services have been success
ful in achieving this objective.
The strategic plan for AIDS
Control in India gives prime
importance to information, educa
tion, and communication strategies
(IEC) to combat the spread of
HIV. Since AIDS is a threat to the
society, the health sector alone is
not sufficient to combat the spread
of HIV infection. All sectors must
get involved. The National AIDS
Control Organisation (NACO) is
thus now initiating several pro
grammes which will serve as effec
tive intervention for the young
population of our country.
Student Youth
In the year 1991 a programme
called “Universities Talk AIDS”
was started by the National Service
Scheme, Department of Youth
Affairs and Sports in collaboration
with the WHO and Ministry of
Health in 59 universities of the
country. Thereafter it generated a
lot of enthusiasm and awareness in
the country. Various materials for
college youth were developed
besides numerous seminars, public
discussions debates, etc. to sensitize
the youth and their Peers.
In 1992 as part of the World
AIDS Day observance, 230 colleges
all over the country participated in
a week-long activity within the
campuses dnd declared themselves
as ‘AIDS aware’.
Nov.-Dec. 1993
Given the success of this pro
gramme, the National Service
Scheme has now in collaboration
with the NACO expanded this pro
gramme to the entire colleges going
community in the country. A
training module for the student
youth has also been developed by
them with assistance from NACO
and WHO. Based on this Train
ing module four master trainer
workshops have already been held
for over 150 key NSS Officials from
the 150 universities of the coun
try. The second phase of training
educators would begin soon. A
state level training for the colleges
and schools of Sikkim has already
been completed and follow up
activities are in progress.
Non-Student Youth
Similarly, to reach out to non
student youth, the Nehru Yuva
Kendra Sangathan has come for
ward to initiate HIV/AIDS/STD
related activities in almost all dis
tricts and blocks of India through
their Kendras and affiliated Youth
Clubs. An approach paper for
this has already been finalized and
action plans have been made. A
special initiative by the NYKS has
been taken in' the North East,
especially in Manipur where a
massive awareness programme
would be initiated in the month
of November.
Youth NGOs
Several other Youth NGOs have
also come forward to join in the
effort of HIV/AIDS Preven
tion. A workshop on Youth
Action on AIDS was held at Chan
digarh to train these NGOs on
planning such activities. Five
similar workshops would be held
throughout the country. Several
NGOs like ICYO, AISEC, SPYM,
DESH etc. are already working in
this area.
Schools
There has been progress in the
process of including adolescence
education as part of the school
curriculum. It is envisaged that
this will include all aspects of sex
uality, STD/HIV/AIDS besides
family life education which is not
present as a subject now. The
introduction of these in the school
curriculum will however take a
minimum period of three years
before they can find place in the
schools. Besides introduction it
will also envisage training of a large
number of teachers at all levels
which will take some time.
A workhop on Curriculum
Development was also organised
by the WHO in collaboration with
NACO and NCERT. A basic
framework for introduction into
the school curricula has been
prepared.
There is however an urgent need
to reach out to the students,
especially those in the period of
adolescence. This is the time
when they are experiencing the
process of growing up and are
ready to experiment The sociolo
gical changes of the recent past
have exposed the school popula
tion to various sexual practices and
271
nuances which make them vulner
able to infections related to STD
and AIDS.
To reach out to the school popu
lation before the incorporation in
the curriculum takes place it is sug
gested that we use an extra
curricular approach. This will
utilize the various school networks
and clubs that exist in the coun
try. The approach would be
event-oriented and the participa
tive in nature. A package of
activities that can be utilized for the
schools is under preparation.
Conclusion
In view of the fact that as much
as 20% of the HIV infections are
projected to be occurring in the age
group of 10-24, it is infperative to
initiate appropriately designed
interventions for this age group.
Sex education which has been a
debatable subject so far needs to be
viewed with a renewed angle in the
context of HIV epidemic. Es
pecially the children in the higher
classes in the schools and college
youths need to be focussed for such
kind of sex education as would lead
to removal of prevailing myths and
misapprehensions pertaining to
sex. This would further avert their
turning to sensational and tantaliz
ing substandard literature of ques
tionable
scientific
propriety.
Above all this would pave the way
for development of healthy sexual
behaviour among these prospective
adults who need to be safeguarded
from the tentacles of HIV/AIDS
epidemics.
WORLD BANK TEAM LAUDS AIDS CONTROL PROJECT
A high level World Bank team led by Mr. Salim Habayeb called on Shri B.
Shankaranand, Union Minister for Health and Family Welfare on 5 August,
1993. The team was on a two-week visit to India on a supervisory mission to over
see the activities of the National AIDS Control Organisation. Mr. Habayeb
expressed deep satisfaction of the progress made in the implementation of the
National AIDS Control Programme and said that everything was proceeding
satisfactorily and according to schedule. The process of establishing inter
sectoral collaboration, in fact, he noted, had already started ahead of
schedule.
Shri Shankaranand noted that World Bank investment in the health sector
had been steadily increasing and expressed his appreciation of World Bank assis
tance to the government in the health sector. The AIDS disease did not recognise
any boundaries and was a threat to the whole international community. He
urged the World Bank to tackle the problem keeping in mind the global perspec
tive and called for international cooperation in the fight.against AIDS. He also
hoped that the World Bank would continue to assist the government in the fight
against the disease.
—pib
272
Swasth Hind
Programmes Against AIDS
At Workplaces
Dr Khorshed M. Pavri
There is a need for brief (Vi—1 day) but continuing educational programmes for
employers/supervisors of workplaces just as these are required for hospital
administrators and deans.
11 In the sweat of thy face
shalt thou eat bread”
—Bible
VERY adult must work for his
bread (roti); while some are
able to get it buttered, a few may
even manage to get jam. But the
majority have no choice of where
they work for their own and
family’s livelihood. They are
pushed to take up whatever work,
wherever it may be available.
Some unfortunate ones are even
forced through circumstances into
workplaces which may be hazar
dous. In contrast, there are some
lucky people—mostly from high
socio-economic strata—who are
able to select their careers and thus,
their workplaces.
Categorisation of Workplaces:
Before observing about program
mes against AIDS at workplaces
and, whether they are needed at all,
let us review various categories of
workplaces (Table 1). There are
places which pose various levels of
potential risk through sexual (A)
Nov.-Dec. 1993
3—13 DGHS/93
and blood-borne (B) modes of
transmission. Category C includes
workplaces that have no known
risk involved.
Programmes at Workplaces: The
important question is why should
we have programmes against AIDS
as a special entity? Should we not
have programmes against other
STDs as well? What about viral
hepatitis which is more likely to
spread through blood as compared
to HIV? There is a consensus that
educational and even intervention
programmes for workplaces in
categories A and B (Table 1) should
take these other entities into con
sideration. In India, very little has
been done for the category A-3
(Mobile services) and category A-4
(women workers). In the category
B, Personal
service
workers
(PSW)—at risk of transmitting
blood-borne infections—have not
received much attention except for
some concern about barber shops1.
Since all these workers have
occupations involving close per
sonal contact with clients it is
necessary that some educational
programme concerning blood
borne infections, like
viral
hepatitis and HIV be targeted to
them. These, however are not
within the scope of the present
communication; I was asked to
write about programmes concern
ing workplaces which have no
known risk for AIDS, i.e. category
C. (Table 1)
Do we need Specific Programmes
against AIDS at workplaces with
No known risk?
All anti-AIDS programmes—
whether educational or for inter
vention—emphasize the esta
blished feature of the three restric
ted modes of transmission; sexual,
blood-borne and perinatal. In
these circumstances, there is no
apparent risk of HIV transmission
in the workplaces shown in cate
gory C (Table 1). If some hotels
are used mainly for sexual encoun
ters, these could be singled out for
certain
specific
instructions.
Similarly if accidental bleedings
273
occur, these are expected to be han
dled at these workplaces just as it
would be on roads, railways or in
homes. In other words, relevant
information meant for general pop
ulation spread through mass media
(particularly the electronic ones)
could adequately serve this
pupose.
The problem of AIDS thus
becomes a societal problem, a pro
blem of economics which needs to
be tackled on a long-term basis
along with other programmes
attempting to empower the poor
and the powerless.
where strict confidentiality was
kept about HIV seropositive
eqiployee(s). Counselling
pro
gramme for them was started at
once in addition to various ongoing
health education programmes for
AIDS prevention.
AIDS: A Human Rights Problem :
An important issue is whether we
deal with AIDS as a (i) virological/
immunological problem, (ii) a
public health problem, or, a (iii)
societal problem mainly of
human rights. AIDS is all these
and more; what is needed is to have
these issues in their proper
places. For example, the first has
its place in laboratories while the
second and third are for public, in
streets, homes and workplaces.
These also need a proper perspec
tive. Only then can appropriate,
cost-effective programmes could be
made targeted at proper place and
in perspective.
“Absence of Occupation is not rest,
A mind quite vacant is a mind
distressed”
From the above it appears that
programmes to impart appropriate
information/knowledge to em
ployers of no (low?) risk workplaces
should be given a top priority.
Subsequently, these enlightened,
well informed employers them
selves will organise educational
even intervention programmes (if
needed) for their employees.
AIDS: A public health problem :
The C category workplaces are
more likely to spread respiratory
and water/food borne infections
than sexual or blood-borne ones.
The former cause not only ‘acute’
illnesses of varying, short duration,
but can also lead to chronic health
problems. Therefore, if health
educational programmes are to be
made, they should include various
public health aspects including
hygiene and nutrition.
AIDS : A Societal/Socioeconomic
Problem: Any such programme
should be exclusive for those who
need it most, viz., the poor, and the
powerless. They constantly en
counter various physical and social
risk factors as depicted by Wallersteina (See Box). For such people,
stigma and social exclusion are
neither new nor linked with AIDS
alone. Their fight is not for
human rights, it is for their very
survival.
274
—Cowper.
Some of the issues peculiar to
HIV/AIDS are connected with HIV
testing and its aftermath. Informed
consent, confidentiality of results and
the individual’s right to work are
indeed important Occupational
safety and health of employees are
responsibility of employers. In
governmental as well as large non
governmental private establish
ments, employers undertake finan
cial responsibilities for providing
medical/health care to their
employees. The fact that HIV car
riers are likely to suffer from a
variety of illnesses and ultimately
die of AIDS has become an eco
nomic concern for many large
industries/business
establish
ments. Anecdotally it was learnt
that a few very responsible
organisations have started HIV test
ing for fresh recruits in order to
reduce this burden by not employ
ing HIV-infected individuals. In
the process, not only the indivi
dual’s right to work but the need for
‘informed consent’ of the indi
vidual is neglected. In fact, this
latter concept is little known and
less practised even by health care
workers including doctors in
India.
The concept of confidentiality is
likely to be observed; however, it
can be maintained if only select few
persons are aware of the result 'I
know at least of two establishments
Conclusions: In a very interest
ing and enlightening communica
tion, Nancy Scheper-Hughes3
quotes a former Commissioner of
Public Health for the city of New
York : “We came to think of AIDS
as fundamentally a crisis in human
rights that had some public health
dimensions, rather than as a crisis
in public health that had some
important human rights dimen
sions.” Truly, a profound per
ception about the reaction of the
Western World to AIDS. On the
other hand, Cuba reacted to AIDS
as a public health problem without
much concern for individual
human
rights. Consequently
however, they achieved a remark
able public health accomplishment
by controlling AIDS in their coun
try3. As far as AIDS in India was
concerned, we took a position along
with the Western World, no matter
how we had perceived and treated
public health problems of leprosy,
tuberculosis and STDs.
A desirable spin off from this
policy on AIDS has been considera
tion of certain concepts related to
individual human rights by our
AIDS policy makers. Whether
SWASTH HIND
TABLE 1
Categories of Workplaces and Potential Risks of Exposure to HIV/A1DS
CATEGORY OF RISKS
A Through Sexual mode
of transmission
B Through Blood-borne
transmission
C No Known Risk
(Potential ? veiy low)
1. High Risk
—Commercial sex workers
(CSWs)
(Male, female, eunuchs)
I. High Risk
•Paid (professional) blood
donors at commercial Private
Those working in :
• Hotels, restaurants,
other food services.
2. Intermediate Risk
Single migrants (urban areas)
working in:—
•factories, •Construction sites
•offices, Market places
2. Low Risk
•Health Care Workers:
Hospital staff of different
Categories, Blood Banks,
Pathology laboratories, nurses,
surgeons, dentists, physicians
etc.
• Factories
(living with families)
• Business establishments
• Industries
• Colleges/schools
• Other places
3. Intermediate/Low Risk
3. • Personal Service Workers (PSW.)
engaged in:
tattooing, ear-piercing,
acupuncture;
barbers, hair-dressers,
massage therapists.
•Truck drivers,
•Sea-fare rs
•Other Mobile services
4. Low risk
Women in;
•Bars and other such services
•Domestic service.
FIGURE 1
PHYSICAL AND SOCIAL RISK FACTORS Ref. 2
Living in Poverty
Low in Hierarchy
High Demand
Psychological
Physical
Low Control
Perceived: External Locus
Learned Helplessness
Actual: No Decision Making
Lack Economic/Political Power
Chronic Stress
Lack of Social Support
Lack of Resources
Nov.-Dec. 1993
Lack of Control
Over Destiny
275
these same concepts have reached
all those responsible for actual
implementation at the respective
workplaces—including hospitals
and nursing homes—remains a
moot point Indeed, there is a need
for brief 04—1 day) but continuing
educational programmes for employers/supervisors of workplaces
listed at category C (Table 1) just as
these are required for hospital
administrators/dcans.
Finally, I would like to stress
once again what has been stated
often, that the cause of most of our
public health problems are poverty
and ignorance. An opinion in
Nature4 on ‘India’s latest earth
quake’ sums it all up succintly.: “In
short, if the proximate cause of last
week’s tragedy was the earthquake,
its underlying cause was the con
tinuing poverty of rural India.
The question to ask is not whether
the microseims of the past few
years could have been used to
avoid the tragedy, but when India’s
new-found industrial prosperity
will trickle down to relieve some of
the most cruel poverty in the
world.”
Indeed, poverty, not only of rural
India but also of urbanised India
coupled with ignorance may con
stitute formidable cofactors for
AIDS also. One can only hope
that fear, fascination and finances
for AIDS will give the needed
momentum to the ongoing pro
grammes against these two ene
mies.
REFERENCES
(1)
AIDS and barber shop : CARC CALL
ING 5(4): 32-34, 1992.
(2)
Wallerstein N. Powerlessness, empower
ment, and Health: Implications for
health promotion programs. Am. J.
Health Promotion 6(3): 197-205, 1992.
(3)
Scheper—Hughes, N. AIDS, public
health, and human rights in Cuba.
Lancet 342: 965-967, 1993.
(4)
Anonymous: India’s latest earthquake
Nature 365: 476, 1993.
Involvement of Voluntary Agencies in
AIDS Control Sought
for the involve
ment of Non-Governmental
Agencies (NGOs) in the AIDS con
trol programme have been, fina
lised for use by the State AIDS Cell
in nearly 30 States/Union Terri
tories. These guidelines have
been formulated after active
interaction with State governments
and representatives of NGOs by
World
Health
Organisation
(WHO) and National AIDS Con
trol Organisation (NACO). The
guidelines provide for a system of
collaboration with NGOs to ensure
appropriate support structures for
AIDS prevention. There is an
enabling provision for each State
AIDS Cell to have an NGO adviser
who will provide contractual con
sultancy services to the cell. In
addition, a reputed NGO involved
in community development would
be chosen as a nodal agency in
each State/UT.
uidelines
G
The State AIDS Programme
Officer, through the NGO adviser
and nodal agency, would dis
seminate these guidelines to ail
registered NGOs. Those interes
276
ted in taking up the task of AIDS
prevention and control would be
asked to submit a self-assessment
report to the AIDS Control Cell
which would then be screened,
according to a pre-set criteria for
shortlisting NGOs by the NGO
Adviser.
Once a proposal has been
approved, the State AIDS cell
would release funds and/or assist
NGOs to collaborate with donor
agencies for financial support At
the end of the project period the
NGO would submit its report to the
AIDS control cell with a proposal
for a further project period. As in
other programme areas, the nodal
agency will assist the NGO in its
planning endeavours. As the role
of the nodal agency will be crucial
to NGOs in programme planning
and management, the guidelines
contain detailed criteria for short
listing nodal agencies before a final
selection is made.
The terms of reference for a
nodal agency include identifying
and mapping various NGO net
works, NGO intermediary organi
sations and groups within the
states, examining the potential of
involving NGOs in AIDS control
activities through an assessment of
their performance in addressing
issues of health and development
and stimulating the response of
new NGOs to the HIV/AIDS
crisis. The NGOs would also be
expected to identify intermediary
NGOs to network with the support
clusters of NGOs working in
specific geographic locations or
programmes, organise back up
support either directly and/or
through intermediary organisa
tions to assist individual NGOs in
programme planning, including
proposal writing, and other inputs
for programme development, mon
itoring and evaluation based on the
need of individual NGOs and also
organise training and networking
through a systematic programme of
workshops, publications, docu
mentation and dissemination'to
stimulate NGO activity and
enhance ‘communication between
NGOs and the government —PIB
Swasth Hind
SITUATION OF AIDS IN INDIA
AND
MEASURES FOR PREVENTION
AND CONTROL
Dr A.K. Mukherjee
and
DR S. VENKATESH
The first AIDS case in India
was reported in 1986. Since
then 494 AIDS cases have
been reported from 19 States
and U.Ts by 31st October,
1993. A total of 19,33,884
blood samples were screened
by the end of October
1993. Out of these, 13,448
were found to be HIV
positives. According
to
current projections, nearly one
million people may be infected
with HIV at present. By
1996, this figure might go up to
2-3 million. The ominous
AIDS clock has started tick
ing, say the authors. The
theme for the World AIDS
Day has appropriately been
chosen as Time to Act. We
have to do our best, both
individually as well as collec
tively, to arrest the epidemic
before it becomes too late.
NOV.-DEC. 1993
4—13 DGHS/93
HE World witnessed in the past
Million men, women and children
homosexual men and drug injec
tors in the developed countries
turning into a pandemic affecting
millions of men, women and
children in all continents. 1981
saw the detection of the first case of
HIV infection. Twelve years later
the world now has an estimated 1012 Million adults (about 6 to 7
Million men and 4 to 5 Million
Women) and One Million children
with HIV infection. Of these,
nearly 1.7 million have progressed
to AIDS and a vast majority have
most likely died. Current esti
mates, place the number of people
getting infected with HIV everyday
all over the world at about 5,000.
Globally there may be one million
adult cases and deaths every
year. A majority of these deaths
will be in developing countries—
about half a million in Africa and a
quarter of a million in Asia.
decade what appeared at first
may get infected with HIV and
T
to be an illness largely confined to
nearly l/4th of them in Asia.
Hetero-sexual transmission of
the Human Immunodeficiency
Virus is on the rise in both
developed and developing world,
predominantly in sub-Saharan
Africa, Asia and much of Latin
America. Women are increas
ingly affected; by the year 2000, the
infection rate amongst women is
expected to be equal to that among
men. Projections for the year 2000
A.D. indicate that a total of 30 to 40
AIDS Situation in India
We had launched Sero-Surveillance for HIV infection in late
1985. The first case was detected
in Madras in 1986. Since then,
there has been an increase in sero
positivity rates. From a mere 2.5
who were HIV positive per 1000 tes
ted in 1985-87 the rate had become
11.2/1000 by the end of 1992—over
a period of just eighth years.
Though this is not at all reflective
of general population rates as 90
percent of the population groups
screened come from high risk
groups, yet it clearly shows that
infection among the high risk
group has been increasing and this
constitutes a major threat to the
general population as through
these groups the infection gets
passed down to the low risk
groups.
277
While the sero-positivity rates
among the groups indulging in
multipartner sex have almost tre
bled from 5.6/1000 to 16.2/1000 dur
ing the last two years, a parallel
kind of trend, though at a much
lower level, has also been observed
among the low risk groups. The
sero-positivity rates among blood
donors increased from 0.37/1000 to
0.85/1000 and among antenatal
groups from 0.6/1000 to 1.16/1000
over the last two years.
Tamil Nadu, the state where HIV
infection was detected first of all,
has, over the last four years shown
a consistent and steady escalation
of HIV infection among the STD
attenders. Similarly, in Bombay,
where there are well identified Red
Light Areas, the surveillance re
ports among the commercial sex
workers have been really alarming
with a marked rise in HIV
prevalence from 10% in 1986 to 32%
in 1991. This rise, is quite com
parable to the trends earlier obser
ved in some of the African cities
like Nairobi, Addis Ababa from
mid 80s onwards where the spread
of HIV in the general population
seems to have been preceded by
shaper increase in the HIV pre
valance among the high risk
groups. This fore-warns us about
the impending epidemic of HIV
involving the general population as
has happened in these countries.
Till the end of October 1993,
19,33,884 blood samples have been
screened all over the country. Out
of these, 13,448 have been found to
be HIV positives. This gives a
sero-positivity rate of 6.95 per thou
sand, which is fairly high. The
largest number of infected cases
have been found in Maharashtra
and Tamil Nadu, followed closely
278
by Manipur, Delhi, Pondicherry,
Uttar Pradesh, Karnataka and
Goa. No state or Union Territory
is totally free from infection, even
though the screening and detection
is not even in all the places. What
is more alarming, however, is the
fact that more and more women
attending ante-natal clinics are
testing HIV positive. It was repor
ted as 0.5% in Bombay and 1% in
Imphal in 1992. This clearly
indicates that the virus is no longer
confined to the high-risk groups
but has entered the low-risk groups
as well.
In the North-Eastern States, the
incidence of HIV infection is
overwhelmingly through the shar
ing of contaminated needles by the
drug abusers who are mostly the
school and college drop-outs. If
this is not checked on a war
footing, HIV infection through
sharing of contaminated needles
would increase by leaps and
bounds. The rapid rise of HIV
sero prevalance to as much as
56.1% within a short period of three
years i.e., 1989-92 in Manipur, and
other North-Eastern States is re
flective of the trends observed in
similar groups in other parts of
the world.
According to current projections,
nearly a million people may be
infected with HIV at present By
1996, this figure might go up to
2-3 Million.
The first AIDS case was reported
in Bombay in 1986. Since then
494 AIDS cases have been reported
from 19 States, and U.Ts by 31st
October, 1993. Maharashtra and
Tamil Nadu are leading in the
number of cases having reported
117 and 152 cases respec
tively. Among
the probable
means of acquiring these infec
tions, multi-partner sex dominates
(75.3%), followed by blood transfu
sion (12%), sharing unsterilized
equipments by injecting drug users
(6.5%), 83% of all infections were
below age of 50 years and more, 2/
3rd were between the ages of 2040 years.
Strategies for Prevention and Con
trol of AIDS/HIV Infection
Realizing the gravity of the
epidemiological scenario prevalent
in the country the government of
India has accorded utmost priority
to this problem and launched a
comprehensive multisectoral pro
gramme for the prevention and
control of AIDS in India.
The establishment of sur
veillance centres was done by
ICMR upto 1990. Thereafter, sur
veillance and all other aspects of
AIDS Control were assumed by the
AIDS Cell located in the Direc
torate General of Health Ser
vices. From October 1992, a sepa
rate dedicated wing, called the
National AIDS Control Organisa
tion (NACO), has been established
within the Ministry of Health &
Family Welfare to co-ordinate the
programme.
A strategic plan is being imple
mented for prevention and control
of AIDS in India for a period of 5
years (1992-97) at an estimated cost
of Rs. 222.6 crores through assis
tance from World Bank in the form
of a soft loan of USS 84 million, a
grant of USS 1.5 million from the
World Health Organization and
the balance in Indian Rupees made
available by the Government
through budgetary grants. A third
of this amount would be spent in
promoting public awareness and
SWASTH HIND
community
support Another
one-third would be for ensuring
blood safety and rational use of
blood. The third component of
the National Programme to pre
vent the spread of HIV infection is
building capacity for surveillance
and clinical management Other
important components of our pro
gramme are control of sexually
transmitted diseases and hospital
infection, and strengthening pro
gramme management
Multi-sectoral approach
As control of the disease cannot
be achieved solely by the health
sector, a multisectoral approach
has been adopted. A National
Committee functions, under the
chairmanship of the HonTjle
Union Minister of Health and
Family Welfare, to bring together
various ministries and NGOs. It
is the highest level deliberative
body which oversees the perfor
mance of the Programme and pro
vides policy directions. A multi
sectoral committee under the chair
manship of the Secretary (Health),
assists in the development of a co
ordinated policy to prevent and
control the spread of HIV/AIDS in
the country.
All Union Ministries and Dep
artments which could have any
conceivable link with NACO and
its programme have identified focal
points in their Ministry/Department who will serve as the res
ponsible officers for the develop
ment of Ministerial/Departmerital
plans of action in the battle against
this new challenge. Similar steps
are envisaged at State and Union
Territory Government level.
A sensitization meeting was held
for all the Secretaries of the
Nov.-Dec. 1993
Government of India under the
chairmanship of the Union Cabi
net Secretary. Key officials of the
State governments have been
sensitized and oriented about the
problem of HIV/AIDS and the
need for IEC. At the meeting of
the Central Council for Health &
Family Welfare the State ministers
of health as well as the health sec
retaries were sensitized to the need
for concentrating efforts on to HIV/
AIDS/STD prevention. Several
State governments have also initi
ated steps to foster inter-sectoral
collaboration within the various
State government departments.
We have also initiated a dialogue
with the various chambers of com
merce like CII, the Bengal Cham
ber of Commerce, PHD chamber
of Commerce, TISCO, Educational
organizations like NCERT, Nehru
Yuvak Kendras, Schools and the
uniformed sector like the police,
Army, Navy and the Air For
ce. Organizations like Rotary,
Lions and Interact have also come
forward with proposals for integra
tion in their ongoing programmes.
STD/HIV/AIDS awareness pro
grammes have also been' intro
duced in the Jails.
Efficient Programme Management
The National AIDS Control Pro
gramme is currently being imple
mented in the country through the
States/UTs, as a Centrally Spon
sored
Scheme. Under
this
scheme; each State Government/
UT Administration has established
State AIDS Cells for planning,
coordinating, implementing and
monitoring the project Their
staffing pattern has already been
agreed upon and the entire cost is
being met by the Government of
India.
For ensuring efficient pro
gramme management, a National
AIDS Control Board has been con
stituted at the National level, under
the chairmanship of Secretary
(Health), to approve NACO poli
cies, to expedite the sanctions to
approve procurement etc.
In order to strengthen the techni
cal and research capabilities of the
programme, a Technical Advisory
Committee meets, under the
chairmanship of Director General
of Health Services (DGHS), with
eminent experts from the different
fields in the area of health. A
number of Technical Sub-committees have been created on the dif
ferent issues, i.e., control of Sex
ually Transmitted Diseases, Blood
Safety, Surveillance, Research,
etc.
Safety of Blood and Blood Pro
ducts
The very first AIDS patient
reported from India was a person
who had been infected with HIV
through multiple blood transfu
sions received during a coronary
by-pass surgery in USA. Subse
quently the first blood donor
seropositive for HIV was detected
in July 1987. Infusion of blood
and blood products has emerged as
one of the most efficient modes of
transmission of HIV infection, the
estimated infection rate through
this route being 90%.
To study the status of blood
banks and transfusion services in
the country, we had engaged a pro
fessional agency in 1989. The
Ferguson Report revealed that
there are an estimated 1018 Blood
Banks in the country handling
about 19 lakh units of blood
279
(350 ml. per unit) per annum. Of
these 1018 Blood Banks, 567 are
under the State Government
Municipal Sector, 41 under Central
Government managed hospitals,
56 are in the voluntary sector and
203 Blood Banks are in the private
sector. As per WHO norms of 7
units of blood per bed per annum,
the present collection is short by
50% of our total requirement
We have launched a central
scheme of assistance to States to
upgrade and provide minimum
facilities to all blood banks in the
public sector. In the 7th five year
plan, 138 Blood Banks had been
modernised and 90 more Blood
Banks were taken up during 199293. All the 380 remaining Blood
Banks in the public sector will be
modernised during 1993-96.
by the simple fact that the relative
risk of transmission for HIV zooms
up as much as ten fold in the pre
sence of ulcerative STDs such as
Syphilis, Chancroid, etc. There is
a considerable body of evidence to
suggest that HIV on its part, not
only aggravates the severity of
manifestations but also renders the
response to the conventional thera
peutic regimens less effective.
Our Strategic Plan for blood
safety has eight objectives:
We have set a target of establish
ing 31 components separation cen
tres. During 1992-93 work began
on the establishment of an initial
six centres. The remaining cen
tres shall be established during the
next two years. One Plasma Frac
tionating Centre has already been
set up in Bombay. We propose to
start a post-graduate degree and
diploma course in blood transfu
sion services towards promoting
Rational Use of Blood.
The National STD control pro
gramme in operation in India since
1946, was based on the provision of
clinical care through a limited
number of specialised STD clinics,
could reach not more than an
estimated 5-10% of all STD
patients. There was practically no
attention to primary prevention.
♦ strengthening the National
Blood Transfusion Services
♦ ensuring an adequate supply of
blood to all blood centres
♦ ensuring the safety of blood and
blood products
* developing and strengthening
facilities for plasma fractiona
tion and the production of
components
• strengthening external quality
control of blood and blood
products
• developing and strengthening
effective management, monitor
ing and evaluation of blood
transfusion services
♦ undertaking research on blood
transfusion services operations
to improve safety, efficacy and
supply
During the past three years, 180
HIV Zonal Blood Testing Centres
have been established in 112
cities. These Centres have lin
kages with Blood Banks both in
public and private sector and pro
vide free testing facilities. All
samples are tested either by ELISA
or rapid/simple test The unit
found positive for HIV is discarded
by heat treatment at 60 degree
Celsius upto 90 minutes followed
by incineration.
280
The Drugs & Cosmetics Act and
the rules framed there-under regu
late the working of Blood Banks,
and provide for two Drug Inspec
tors in the major States and one
Drug Inspector for the smaller
States to ensure a better control on
their working. The Act has been
suitably amended in the wake of
HIV epidemic with appropriate
provisions like mandatory testing
for HIV, and conforming of Blood
and Blood components to stan
dards laid down.
Controlling STDs
The HIV/AIDS epidemic has
brought into resurgence concern
about sexually transmitted dis
eases. Not only do STDs share
common epidemiological deter
minants, i.e. common risk be
haviour features with HIV/AIDS,
but they also catalyze the acquisi
tion and transmission of HIV.
The strength of the association bet
ween STDs and HIV can be gauged
To increase the effectiveness of
STD control activities, we have
chosen a two-pronged approach.
On the one hand, we are streng
thening the existing infrastructure
of STD clinics so that these
facilities become referral centres
for primary level health care pro
viders. At the same time, we are
supporting the development and
implementation of targetted inter
ventions, with priorities for the
groups with risk behaviour. Such
interventions integrate Informa
tion, Education and Communica
tion
(IEC)
for
safersexual
behaviour with the provision of
clinicial services for STD case
management and the provision
of condoms.
Services for STD case manage
ment will be integrated in general
health care facilities, so as to avoid
stigmatisation. To provide non
stigmatising and easily accessible
services for women, STD services
will be integrated into existing
MCH/FP and antenatal clinics.
Linkages with MCH Activities
Women and children constitute
the target group not only for
SWASTH HIND
National Family Welfare Pro
gramme but also for AIDS Control
and also because of the fact that
both the programmes directly or
indirectly pertain to common area
of sexuality/reproductive
be
haviour. So, the development of
suitable linkages is especially
appropriate. Some of the areas
for the linkages are programme
Management and IEC. This is by
promoting dual role of condoms as
a contraceptive and as a prophylac
tic against HIV/STD, and expand
ing family welfare campaigns to
include an AIDS prevention com
ponent Health workers are also
being involved to create an en
vironment which is conducive to
healthy interaction on areas such
as sexuality, and reproductive
health. They play a key role in
generating support for the AIDS
control programme, in the health
sector, as well as in influencing
attitudes to this new disease.
Health workers also play an
important role in the reduction
impact The main thrust for
reducing the negative impact in
volves creating a supportive, caring
and accepting environment, with
no moral judgments on the patient
and his family, as well as coming to
terms with the prognosis. Health
and Family Welfare personnel have
a very important role to play in this
regard, as they are the first point for
care in the community, and can
also educate the family on how to
care for patients at home.
Condom Programming
The condom serves the dual role
of a contraceptive as well as a pro
phylactic
against HlV/AIDS.
Hence we are reshaping Condom
Programming for the country to
dovetail with the latest needs. To
ensure the quality, necessary
amendment is being made in the
existing schedule to bring the con
dom specifications within the
Nov.-Dec. 1993
5—13 DGHS/93
quality parameters as prescribed by
WHO.
Hospital Infection Control
Hospital infection control mea
sures' have been targeted for
improvement since the beginning
of the epidemic. The fear of
accidental infection from HIV
invariably influences the be
haviour of health care workers
towards their patients. It is also
essential that the patient feels con
fident that he will not acquire HIV
infection from the health care
facility. Towards this end, we
have made substantial efforts in
training, strict enforcement of
antisepsis and asepsis and adop
tion of universal precautions in
infection control.
Generation of Awareness
With no vaccine or cure for
AIDS in sight, prevention is our
only hope. This entails changing
behaviour through Information,
Education and Communication
and social mobilization. Consis
tent messages from all channels—
mass media, traditional media,
health care workers, and interper
sonal channels need to work in tan
dem to achieve this objective.
We have adopted a multi-prong
ed strategy comprising of a nat
ional awareness campaign, tar
geted interventions for people prac
tising high risk behaviours,
collaboration and support to
NGOs, intersectoral collaboration,
training and operational res
earch.
A national advertising agency
has been awarded a contract to
produce a national umbrella
awareness campaign. We are
working with communications pro
fessionals and NGOs to develop
target materials for identified risk
behaviour groups, such as commer
cial sex industry, injecting drug
users, truck driver and other mobile
men, industrial workers, and many
more. We plan to identify and
strengthen, in conjunction with the
States, IEC institutions to support
State level IEC activities. Model
interventions with identified risk
groups for replications will be sup
ported. Guidelines have been
developed on how to integrate
NGOs into programme activities.
We are setting up a structure to
ensure good quality counselling
services,, through a comprehensive
training programme. A nation
wide high risk behaviour survey is
planned in conjunction with exist
ing social science institutions in 65
major cities.
IEC programming cannot exist
in isolation. Educational mes
sages and information need to be
backed up with condom program
ming, STD services and informed,
well-trained health care workers.
The National Service Scheme
(NSS) of the Department of Youth
and Sports has, with its innovative
“Universities Talk AIDS” pro
gramme, initiated with the assis
tance of WHO, undertaken a
process of providing information to
one of the most important target
audiences—young
adults. The
project aims at raising awareness of
AIDS/HIV among student popu
lations, sensitizing and mobilizing
students to initiate peer group and
community discussions on AIDS
and AIDS prevention, and
developing a series of targeted
messages for students in India.
In the first phase, 69 universities
were involved and over 100,000 stu
dent Youth covered. In 1992 over
200 colleges were declared AIDS
aware. NSS has also developed a
series of posters and leaflets and
other media messages which are
281
also being used in our awareness
programme. A standard training
module and a manual, have been
developed, and are being used to
train Trainers of youth. In the
next phase, it is proposed to cover
all colleges and universities - in
the country.
A National Action Plan for
involving the Nehru Yuvak Ken
dras, as a way of reaching non
student youth, is being finalized.
Key officials of this organization
including the five Zonal co-ordinators, 40 regional co-ordinators
and 100 district level co-ordinators,
besides several Block level workers
have been sensitized. The South
Zone kendra has already conduc
ted three workshop for their grass
root level workers. A meeting of
the NYKs in the north-east was
convened recently.
The national workshop on Youth
Action on AIDS was held at Chan
digarh; about 30 participants from
various
youth
NGOs
par
ticipated. Action Plans were
developed for organizing grassroot
level activities for youth. Similar
workshop are also being planned
in the five regions of the country.
The Scouts and guides have
initiated steps to integrate HIV/
AIDS as one of their priorities
activities for the next five years.
The World Scouts headquarters
manual is also being adapted for
use in India.
We have established close liaison
with NCERT (the National Coun
cil for Education, Research and
Training) to integrate STD/HIV/
AIDS in the School Curriculum.
Counselling
As the epidemic progresses, it is
essential to Jbe prepared to reduce
its overwhelming sociological and
psychological impact on indi
282
viduals, families and com
munities. This can be accom
plished by planning and training
counsellors, setting up community
based care structures and improv
ing access to health care facilities
for those afflicted. In this, we
require the co-ordinated efforts of
government, the private sector
and NGOs.
A
comprehensive
training
Module for development of coun
selling services and a plan for train
ing have been finalized and would
be operational soon.; For various
organizations, both in the govern
mental and noh-govemmental,
who can respond to the need of
counselling urgently and efficien
tly, a counselling handbook has
been prepared, which can be used
for training.
For the training and monitoring
of the counselling programmes,
five regional centres would be
established at leading social/medical institutions in different parts of
the country. 40 intermediate cen
tres at the State level would identify
and train community level coun
sellors at the peripheral level.
Trained counsellors would be
available at major hospital, social
institutions, community health
centres and places where the
incidence of STD/HIV/AIDS is
high.
Community Based Care
AIDS patients and those with
related illnesses can be taken care
of in the home setting with proper
support and backup from the com
munity and local health facilities.
The fears of health care and com
munity workers need to be allayed
with clear information and edu
cation. A plan of action is being
developed, which includes com
munity based health care ser
vices. This necessitates training
which will help dispel misconcep
tions and prejudices among health
care personnel. A start in this
direction has been made by initiat
ing training of doctors, and prepar
ing a module for pre-service and
in-service training of nurses.
Surveillance
For planning, mobilizing the
required inputs, and designing the
interventions, monitoring the trend
of the HIV/AIDS epidemic is
extremely essential. We have
established a nationwide network
of 62 surveillance centres in dif
ferent cities of India. These cen
tres are carrying out screening
activities among-the different cate
gories of people which include high
as well as low risk groups. To
monitor the trends and pattern of
infection, a sentinel surveillance
approach has been adopted.
Combating Discrimination
Protection against any kind of
discrimination and stigmatization
and maintaining of dignity of those
afflicted with HIV/AIDS is an
integral part of every component of
the programme. For surveillance
and clinical diagnostic purposes,
the element of (confidentiality is
strictly adhered to. Guidelines
have been issued to protect the HIV
infected from any kind of dis
crimination in the hospitals. In
addition, a social, legal and ethical
sub-committee has been specially
constituted to take views on HIV/
AIDS related issues which have
legal, social and ethical impli
cations.
Operational Research
Operational research leads to
outputs which can be used for
designing of appropriate interven
tions. This activity is being car
ried out with the partnership of
colleges in different cities, to
SWASTH HIND
simultaneously gain their involve
ment and strengthen their capacity
to deal with the problem of HIV/
AIDS.
Targeted Interventions
A number of high risk behaviour
practices which are associated with
higher rates of HIV infection will
ncec targeted, integrated app
roaches. This includes the de
velopment of special IEC app
roaches and materials, and the pro
vision of support services such as
condoms
and
STD
ser
vices. Some targeted populations
we have identified arc injecting
drug users, migrant workers, indus
trial workers, women, military per
sonnel, the commercial sex in
dustry, street children, truck drivers
and slum dwellers.
A targeted intervention with sex
workers in Bombay is under way by
the Bombay Municipal Corpora
tion in conjunction with local
NGOs and the Xavier Institute of
Communications. The
project
targets 10,000 sex workers and their
clients along with pimps, madams,
police and transportation wor
kers. IEC is being effectively com
bined with condom promotion and
the provision of STD services
through a newly opened general
clinic in the heart of the red
light area.
In Calcutta, the All India Insti
tute of Hygiene and Public Health
is carrying out an intervention with
6,000 sex workers, their clients,
pimps and local community of
Sonagachi. Local NGOs alongwith
a
development
com
munications organization, are act
ive collaborators. A community
based programme it has involved
local youth clubs who have donat
ed space for general clinic. Peer
educators among the sex workers
spread important messages about
AIDS. Again the integrated
approach of IEC, condom pro
gramming and the provision of ser
vices is a major aspect of the
activity. The Community Action
Network, a new NGO, is tailoring
this integrated approach with the
more hidden sex industry in
Madras.
Targeted interventions are also
planned with groups like those
practising Multi-partner sex. Unin
formed sector (CISF, BSF, Army,
Police), Industries, Women Slum
populations, Youth and Jails.
Role of NGOs
NGOs are in a unique position to
intervene in facilitating the adop
tion of safer behaviour. By their
unique relationship with the com
munity and targeted group, and
their acceptability, NGOs can
make a strong impact It is
imperative that NGOs integrate
HIV/AIDS components into their
existing programmes, building on
the base they already have. The
areas in which they can assist
are: Advocacy, targeted Com
munication, Condom Promotion,
Counselling Services, Support Ser
vices, Research, and in safeguard
ing human rights. Each area and
each NGO will have a unique res
ponse to the challenge presented by
AIDS.
In order to optimize the par
ticipation of NGOs and maximize
the returns of intervention, it is
necessary to have close coordina
tion and collaboration between
NGOs and the Government
Much can be gained by sharing
experiences and approaches, by
basing innovations on past expe-.
rience, and learning from each
other.
The ominous AIDS clock has
started ticking. The theme for the
World AIDS Day has appropriately
been chosen as TIME TO ACT.
We have to do our best both
individually as well as collectively,
to arrest the epidemic before it
becomes too late.
Lj
Think about all the good reasons for giving up smoking:
—your children’s health,
—your own health,
—the cost of smoking,
—the smell.
Nov.-Dec. 1993
283
HIV Infection and
Tuberculosis
Dr S. K. Kate
The World Health Organization has declared tuberculosis as a global public
health emergency. And infection with Human Immuno Deficiency Virus
(HIV) is the greatest risk-factor for tuberculosis.
HE World Health Organization
(WHO) has recently declared
tuberculosis (TB) as a global Public
Health emergency1. The number of
cases of tuberculosis reported
annually in the United States
declined steadily from 1953 to 1984.
In a dramatic reversal of this trend,
the number rose by 3 per cent in
1986, 5 per cent in 1989 and 6 per
cent in 19902. In 1991, K. Stable
and D. A. Enarson3 observed that
infection with immunodeficiency
virus (HIV) is the greatest risk
factor for tuberculosis.
T
of CD4 cells, coupled with defects
in macrophage and monocyte
function4. Because CD4 cells and
macrophage have central role in
antimycobacterial defences, dys
function of these cells places
patients with HIV infection at high
risk for tuberculosis. Tuberculosis
in an infected HIV individual can
occur due to (i) multiplication of
tubercle bacilli in quiescent foci (ii)
Progression of recent infection to
disease and (iii) Superinfection *,*.
Epidemiologic Relation of Tuber
culosis & HIV infection
Pathogenesis
During the initial (Primary)
infection of immunocompetent
persons with Mycobacterium tuber
culosis, macrophages ingest the
organisms. After processing, it’ is
presented to T cells. CD4 cells
secrete lymphokines that enhance
the capacity of macrophages to
ingest and kill mycobacteria. The
hallmark of HIV infection is pro
gressive depletion and dysfunction
284
According to the Indian
National Tuberculosis Control
Programme, the prevalance of
infection for all age group is 38.0%
as indicated by a positive Mantoux
test7. It is estimated that one
undiagnosed smear positive case of
tuberculosis will infect ten persons
during one year of contact*.
TWo types of virus (HIV-1 & HIV2) have been identified as causing
AIDS. The median period follow
ing infection, free of AIDS is about
11 years. An estimated 13 million
men, women and children have
already been infected with HIV*.
Tuberculosis develops at an earlier
stage in HIV disease than other
opportunist infections3. The two
have become such close partners
that TB has become the most
important opportunistic disease
associated with AIDS in India1.
The incidence of tuberculosis in
patients with AIDS is almost 500
times the incidence in the general
population3. Out of 65 sputum
positive for AFB patients, studied
at our centre from March 1993,
three cases were
HIV Sero
positive.
Poverty is an important cofactor
of double trouble tuberculosis
and HIV10.
General Clinical Features
Tuberculosis is often first clinical
manifestation of immunodefi
ciency. The most striking clinical
Swasth Hind
feature of tuberculosis in patients
with HIV infection is the extremely
high frequency of extrapulmonary
involvement, usually with con
comitant
Pulmonary
tuber
culosis11.
Disseminated infection with
mycobacterium avium intra cellu
late (MAI) is common in the ter
minal phase of AIDS12. Other
non-tuberculous mycobacterial in
fection include M. Xenopi,
M. Kanasasii, M. gordonae.
Retrospective studies have sug
gested that at least one-half of
patients have no other indication of
HIV infection at the time of
diagnosis of tuberculosis; such
patients usually demonstrate a
significant reaction on tuberculin
testing only those who develop
tuberculosis after onset of AIDS
are likely to have no reaction to
tuberculin5. In HIV infected tuber
culosis patient without AIDS, the
clinical appearance does not differ
from that of other tuberculos
patient3. Lymphadenitis, Bac
teremia, Tuberculous abscesses and
tuberculomas in the brain
paranchyma, presence of AFB in
stools are frequent abnormalities in
patients with HIV infection. A
chest roentgenogram and acid fast
smears of sputum are essential for
suggesting the diagnosis of tuber
culosis.
Chest Roentgenogram
Apart from Hilar adenopathy,
upper lobe infiltrates, miliary pat
tern, cavitation, atypical radio
graphy appearance /. e., disease
extending beyond apex is more fre
quent Pleural effusion is also
reported13.
NOV.-DEC. 1993
6—13 DGHS/93
Histology Study
The presence of AFB bacilli in
different organs Giver, spleen, kid
ney, Supra renal) without tissue res
ponse was observed in one of the
centres in India14.
Treatment
The tuberculosis unit of WHO15
has issued guidelines for drug
management. The guideline states
that optimal six month regimen
(HRZE, i. e„ isoniazid rifampicin,
pyrazinamide, ethambutol for 2
months followed by (HR) Iso
niazid rifampicin for 4 months) or
8 months regimen (HRZE iso
niazid, rifampicin pyrazinamide,
ethambutol for 2 months followed
by isoniazid, ethambutol (HE) for 6
months) should be adopted.
Guideline also recommended that
streptomycin in the initial phase be
replaced by ethambutol to avoid
the potential for transmission of
blood borne pathogens through
contaminated needles.
Severe
Stevens Johnson syndrome (Severe
skin reaction) limits the use of
Thiacetazone.
The fatality rate of tuberculosis is
rising. Death is more likely to be
due to causes other than tuber
culosis.
Such patients often
develop severe diarrhoea or over
whelming bacterial infection to
which they succumb.
Of the
patients who survive, response to
therapy does not appear to differ
whether the patient is infected with
HIV or not15.
Primary Prophylaxis for tuber
culosis is the most promising pre
ventive intervention17. Preventive
therapy with isoniazid has been
shown to reduce the incidence of
tuberculosis reactivation and is the
recommended prophylaxis in the
USA for tubercular positive and
HIV positive individuals18. Further
studies of efficacy and feasibility
are under way to evaluate this
intervention17.
The Centre for Disease Control
and Prevention (CDC) in the USA
has published a new case defini
tion, where pulmonary tuberculosis
is included as an additional AIDS
indicator disease. In HIV Seroposi
tive individuals, tuberculosis can
develop before the CD4 T cell
count drops to less than 200/jil.
Extra pulmonary tuberculosis has
been included in the definition
since 1987.
The addition of
pulmonary tuberculosis will bring
completeness to AIDS case defini
tion, especially for a country like
India, where it is endemic19.
In the ’fight against these, the
following factors are important
Faster diagnosis. affordable
treatment, education and incen
tives to patient development of
new drugs including vaccine and
fight against poverty are commit
ments mentioned by Prof. Keith
(10-20). Poverty, tuberculosis and
HIV are partners in crime. (10).
The Government of India has
shown its commitment to fight
against it by establishing a
National TB task force. (10).
It is time to act for our health
care managers, policy makers,
politicians and doctors to control
both HIV and tuberculosis.
285
REFERENCES
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4.
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6.
EDITORIAL: Partners in crime.
CARC CALLING Bulletin of centre
for AIDS research and control ICMR,
New Delhi.
Vol. 6, No. 2, April-June 1993. page
1.
BARNES
P.F..
BLOCH AB.
DAVIDSON
P. T.
&
SNIDER
DIXIE E.
Tuberculosis in Patients with Human
Immunodeficiency virus Infection.
The New England Journal of
Medicine.
Vol. 324. No. 23. June 6.1991 page 16441650.
7.
K. Styblo, D. A. Enarson:
The impact of infection with human
immunodeficiency virus on tuber*
culosis (p. 147-162)
Recent advances in Respiratory Medi
cine Number five edited by David
Michell Churchill Livingstone 1991.
9.
Bender B. S.. Davidson B. L, Kline R.,
Browne Quinn Te.
Role of the monuclear phagocyte sys
tem in the immunopathogenesis of
human immunodeficiency virus infec
tion and the acquired immuno
deficiency syndrome Rev infect Dis
1988 10:1142-54.
KateS. K.
Pulmonary Tuberculosis, an AIDS
Indicator Disease? CARC CALLING
Bulletin of centre for AIDS Research
and control ICMR vol. 6: 2. April
1993, page 5-6.
8.
Selwyn P. A, Hartcl D. Lewis V. A
et al
A prospective study of the risk of
tuberculosis among intravenous drug
users with human immunodeficiency
virus infection.
New England Journal of Medicine.
1989, 320 545-50.
Kabra S. Madhulika
Tuberculosis in children:
Indian Journal of Paediatrics,
Vol. 6, No. 1, March 1993, page 1-6.
Styblo K:
Recent Advances in epidemiological
Research in Tuberculosis, Advances in
tuberculosis Research 20 1. 63 1980.
Press Release (WHO) (16 April 1993)
World AIDS Day 1993: Time to act
CARC CALLING:
Vol. 6 : 2. April-June 1993. 33.
10.
Pavari Khorshed:
Partners in crime tuberculosis and
HTV/AIDS CARC CALLING
Vol. 6, No. 2, April-June 1993, 7-8.
11.
Tuberculosis and acquired immuno
deficiency syndrome
New York City MMWR 1987 36,
785-90 795.
12.
Wong B, Edwards F. F., Kiehn T E
et al 1985
Continuous High grade Mycobac
terium avium intraellulare bacteremia
in patients with the aquired immuno
deficiency syndrome.
American Journal of Medicine, 78:3540.
13.
Pahwa R. S. Pahwa V. K, Panda B. N„
Neema S. K, Rajan K. E,
Clinical Spectrum of HIV infection in
patients of Tuberculosis.
JAPI Vol. 40, No. 12, 807, 1992.
14.
Proceedings of AIDS Workshop:
Grant Medical College, Bombay, 30
March. 1993.
15.
unpublished document WHO/TUB/91.
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CARC CALLING Vol. 6, No. 2, AprilJune, 1993 4.
16.
Chaisson R. E., Schecter G. F., Theur
C.P., et al
Tuberculosis in patient with Acquired
Immunodeficiency
Syndrome.
American review of Respiratory Dis
ease 136 : 570 574, 1987.
17.
Peter Piot, Bfla M., Kapita, Elizabeth
N„ Ngugi, Jonathan M., Mann Robert
Colebunders, Rudolph Wahitsch (p-89)
AIDS in Africa—A Manual for
physicians W. H .O. Geneva 1992.
18.
American Thorasic Society & Centre
for Disease Control, treatment of tuber
culosis & Tuberculosis infection in
adults and children.
American Review of Respiratory Dis
ease 134 : 355-363 (1986).
19.
Pavri Khorshed: New case definition
for AIDS CARC CALLING
VoL 6, No. 4, Oct-Dec. p. 22. 1992.
20.
Prof. Keith Me Adam ;
Lanect 341 : 1145 1993.
POTENTIAL VACCINE FOR AIDS
An important discovery in the search for an AIDS (acquired immuno deficiency syndrome) vac
cine has been revealed by a research team from the University of Reading and the Institute of Cancer
Research. They have found a potential vaccine against a dozen different strains of the human
immuno-deficiency virus (HIV).
Specialists had thought an AIDS vaccine may be as elusive as one against influenza because, like
flu, HIV changes its outer coat to avoid being detected by antibodies in the vaccine. However, the
researchers reported that they have merged a polio vaccine, one of the safest known, with a portion of
the outer coat of HIV.
The result is a potential vaccine that in laboratory studies has prevented 12 HIV strains from
infecting human blood cells. Dr. Jane McKeating of the Cancer Institute said the hybrid vaccine
was “as good, if not better” than any other candidate vaccine presently being tested.
(Source : IPPF Openfile, 9 June 1989)
286
Swasth Hind
AIDS AND WOMEN
Dr S. Kant & Dr C. Singh
Improving the social status of the women will determine not only their
vulnerability to AIDS but also their access to health care system in case of con
tracting the disease.
T the start of the AIDS
.epidemic it was noticed
that the victims were mostly
homosexual males. Sexually active
young men were the focus of atten
tion. The realisation that predomi
nant mode of sexual transmission
of HIV in Africa and South East
Asia is heterosexual rather than
homosexual altered the perception
regarding potential AIDS victims.
The World Health Organisation
has estimated that by the year 2000
AD, the number of HIV infected
women will reach 13 million.
Infact, one million women will be
infected in 1993 alone. By 2000 AD,
four million women will be dead
because of AIDS. Thus, within a
short span of time, women and
children have moved from the
periphery to the centre of concern.
A
Vulnerability to the infection
There are various reasons why
women are more prone to get HIV
infection as compared to men.
Briefly, they are:
(a) Biological causes: Though all
body fluids of a seropositive person
contains virus, the concentration of
virus is different in different fluids.
Chances of contracting the infec
tion is partly dependent upon the
virus concentration in the infecting
fluid. Concentration of virus in
vaginal secretion is considerably
less than that of seminal fluid.
Thus, an uninfected woman is at
Nov.-Dec. 1993
significantly higher risk of con
tracting the infection from a
seropositive male partner as com
pared to the uninfected male from
a seropositive woman.
(b) Epidemiological reasons:
Women marry men who are
generally older than themselves.
Being older, men would have had
more pre-marital sexual ex
perience. Therefore the marital
alliance puts the women at a higher
risk of getting the infection from
their spouses. Additionally, child
bearing may necessitate medical
intervention, including blood
transfusion. The risk of getting
infection from unsafe blood makes
the women more vulnerable' to
infection.
(c) Social reasons: Most of the
women are economically depen-*
dent on men. There is a general
belief that supporting a woman
economically, automatically en
titles the man to have sexual pri
vilege : Absence of good social
welfare measure makes the women
vulnerable to sexual exploitation
and hence at a higher risk of con
tracting the infection. The woman
may be willing to use condoms in
order to protect herself but it is the
male partner who has the final say.
This reflects the poor social status
of the woman in the society.
HIVinfection and pregnancy: Pre
gnancy in a seropositive woman
does not alter the natural history of
the disease. There is no increase in
the risk of developing clinical
AIDS among seropositive women.
Even when the woman develops
clinically manifest AIDS, pre
gnancy does not adversely acce
lerate the eventual death. However,
the chance that the foetus will
escape the infection is dependent
upon the seropositivity status of the
mother. The chance of in-vitro
infection to foetus is high if the
mother has AIDS. It is also high if
the mother contracts the infection
while she is pregnant. The risk is
again high if the mother had
delivered a HIV positive baby in
her earlier pregnancy. The chance
of in-vitro infection to foetus is low
if mother is already seropositive
but does not have AIDS when she
conceived the child.
HTV infection and obstetric care: It
is neither economically feasible
nor scientifically advisable to
screen every pregnancy for HIV
status. Quality of the screening test
cannot be maintained at grassroot
level. It could lead to false positive
reporting with disastrous conse
quences to the couple. There is no
recognisable high risk group
among pregnant women (except for
female commercial sex workers);
therefore high risk group screening
cannot be applied. In such a situa
tion it is advisable that all
deliveries be conducted with
287
necessary precautions if it is known
that the woman is a HIV positive.
Breastfeeding by
seropositive
mother: Breast milk is the best baby
food in the world. It not only
nourishes the child but also pro
tects against many communicable
diseases. However, it is also a
known fact that HIV is secreted in
the breast milk and can cause
infection to an uninfected child.
One has to weigh the benefits of
breastfeeding in protecting the
child against malnutrition and
infection vis-a-vis the potential
small possibility of transmitting the
infection. WHO-UNICEF concen
sus statement on breastfeeding by
HIV positive mother recommends
that in areas where primary causes
of infant death are infectious dis
ease and malnutrition, breastfeed
ing should remain the standard
advice to pregnant women, includ
ing those who are known to be HIV
positive. Baby's risk of becoming
infected through breast milk is
likely to be lower than risk of dying
of other causes if deprived of
breastfeeding. In median context,
breastfeeding should remain the
standard advice irrespective of the
HIV status of the mother.
Immunization of HIV positive
children: Infant mortality due to
vaccine preventive diseases is still
high in India. HIV positive infants
develop the same immunological
response to six vaccines used in the
immunization programme in
India, as any other normal child.
Therefore, all children, except
those suffering from AIDS, should
receive the primary immunization
and booster doses of the vaccine.
Children suffering from AIDS
should not be given vaccine against
tuberculosis (B. C. G. vaccine).
Health care of female AIDS
patients: The stigma attached to the
patients of AIDS along with
general discrimination towards
288
women effectively precludes a
reasonable expenditure on health
care of female AIDS victim. In the
absence of early and vigorous treat
ment of opportunistic infections,
these female AIDS patients are
likely to die earlier than their male
counterparts. Access to even free
governmental health care system is
dependent upon the societal
outlook towards female AIDS
patients. The general disapproval
of the society towards these patients
will inhibit the women to avail of
health care which is even unrelated
to their AIDS status.
Social impact of AIDS amongst
women
In India, sexual transmission of
AIDS is mostly through heterosex
ual contact. Therefore, in coming
years, more and more women in the
reproductive age group are expec
ted to get infected with HIV. It is
known that two-thirds of the
children bom to seropositive
mothers escape the infection. These
children run the risk of death of
one or both parents in the next ten
years. Illness and eventual death of
the mother has profound impact on
the health of the child. Lack of care
due to maternal illness or absence
of maternal care due to her death
could hasten the death of even the
uninfected child.
The biggest challenge in coming
times would be to provide care to
these unfortunate AIDS orphaned
children. The amount of social
welfare that would be needed to
cope with the situation would be
truly enormous.
Prepare for the worst: The stan
dard measures (e.g. immunization,
isolation, chemotherapy etc.) to
prevent the spread of a communic
able disease are not applicable to
AIDS epidemic. Availability of a
potent and effective vaccine against
AIDS is not in sight Whatever
chemotherapeutic agents are being
used, are still surrounded in con
troversy. There is no unanimity
regarding their beneficial effect on
HIV positive persons.
Health
education is the only available tool
to fight this dreaded disease. There
is an urgent need to provide
information/education regarding
the disease. NGO’s and voluntary
bodies can provide significant con
tribution in this effort.
In the long run, improving the
social status of the women will
determine not only their vul
nerability to the disease but also
their access to the health care sys
tem in case of contracting the dis
ease. Women probably require
greater access to health care as
compared to men because it is not
only their health which is at stake
but also the health of the depen
dent children. It is the death of the
mother which would cause the dis
integration of family, community
and society.
The trend of the AIDS epidemic
cannot be wished away. All of us
must prepare ourselves to face the
future challenge. There is a need to
train all categories of health per
sonnel, more so obstetricians, in
providing health' care to seroposi
tive and AIDS cases. Social welfare
measures need to be strengthened
and widened in scope so that
orphaned children are not
materially abandoned.
Many
young men, may be the sole bread
winner of the family, would die.
Their families who survive this
death may be in the worst possible
situation. How to provide them
with a source of income that would
keep their body and soul together
must worry us. Society must also
learn to change its values so as to
deal with the possible change.
Health indicators including IMR,
CDR, life expectancy at birth
would also be expected to take a
beating. The future scenario is
indeed daunting and we must pre
pare ourselves now to meet it
effectively.
Swasth Hind
CONTACT TRACING:
Method and its importance in
S. T. D. and AIDS Control Programmes
DR V. K. TEWARI
In view of the AIDS problem, “contact tracing”—actual contacts from whom the
patient has contracted infection—has become all the more important.
EXUALLY transmitted diseases
are major health problems the
world oven India is no exception. It
is; indeed, an impossible task to
assess the magnitude of the pro
blem in India due to lack of reliable
data and gross under reporting. It
is the most prevalent communic
able disease in India.
Health
education is one of the most impor
tant links in the S.T.D. control pro
gramme.
Amongst different
strategies/activities, like, clinical
services, screening and contact
tracing. Contact tracing is by and
large an economical measure in the
sense that it may help in checking
further spread of S.T.D. which
require more medical inputs for the
cure of the patients.
S
In view of the recent emergence
of dreaded disease of A.I.D.S., it is
Nov.-Dec. 1993
necessary to check the sexual
acquaintances of the patients visit
ing S.T.D. clinics. Besides finding
out the preventive aspects of
S.T.D.s including the AI.D.S., it is
equally important to find out actual
contacts from whom the patient
has contracted the infection.
Therefore, “Contact Tracing” has
become all the more important in
the present scenario.
What is Contact Tracing ?
Contact tracing refers to find out
the sexual contacts of the patient
during the critical period of his/her
sexual transmitted infections.
Contact tracing is therefore, an
essential part of the S.T.D. control
programme. Because there must
be at least one sexual contact
behind every S.T.D. patient
There is every apprehension that
the infected person will spread the
infection to others if he/she is not
brought under proper medical
treatment
Methods of Contact Tracing
The method of contact tracing
used depends on staff available,
literacy status of the patient as well
as of the infected source,
clinic hours, distance of medical
institution, socio-economic condi
tion of the patient as well as the
infected source.
Interviewing the patient about
their contacts requires tactful
behaviour and special communica
tion skills. The commonly used
289
methods used for contact tracing
are :—
2.
Helps in protecting the
health of individual as well
as community at large.
1. Discussion/persuasion.
2. Follow up over telephone.
3. Helps in spreading out health
education related preventive
aspects in the community.
3. Letter.
4. Home visit
Merits
5. Contact card/slip.
1.
In some countries like the U.K.,
contact tracing is undertaken on a
voluntary basis with the help of
trained social worker or health
visitor. In some part of the
U.S.A., contacts are sought as
quickly
as
possible
using
telephone, telegram and other
rapid means of communication.
Helps in checking further
transmission of infection
from the infected source.
2. Provides an opportunity to
medical and paramedical
staff to impart the health
education related message
with special reference to
S.T.D. control. Hence, this
is a useful health edu
cation exercise.
Importance of Contact Tkacing
De-merit
Effective contact tracing can
reduce the S.T.D. including the
incidence of diseases and their
complications and psycho-social
consequences; and can improve
the efficiency of the services.
In brief, the foremost impor
tance of a contact tracing are as
follows:—
1.
Helps in controlling the
S.T.D. Diseases by bringing
out the infected source under
. medical treatment and follow
up.
290
1. Sex being a taboo in the
Indian situation a detailed
probing irritates the contact
sometimes as he/she con
siders it an intervention into
his/her privacy.
Precautions
1. Case-probing should be as
targetted at only few in order
to avoid the embarrassment
of patients/infected source.
2. Flexible attitude towards the
convenience of the patient/
infected source in respect of
their reporting to the
hospital.
3. Message given to the patient/
infected source should be, by
and large similar to avoid
any confusion.
4. Privacy should be strictly
maintained.
5. Information to be recorded
in contact card/slip should
preferably be entered in pre
decided code.
Undoubtedly, the contact trac
ing is a highly appreciable techni
que in the field of case-finding;
however, it requires expertise
before applying it in real situa
tions. Sex being a taboo in the
Indian context further acts as a
barrier in the success of this
technique.
However, proper experience,
adequate patience and establish
ment of rapport with the patient
may bring about unexpected posi
tive results and facilitate the
S.T.D. control by making the sex
ual promiscuous persons aware of
risk involved. in the• undesirable
sexual practices.
’.
Swasth Hind
AIDS : A SELECT BIBLIOGRAPHY
(1991—1993)
M. Sharada and K. C. Singh
We publish below a Select Bibliography on “Acquired Immunodeficiency Syndrome” with reference
to Indian context, compiled by the National Medical Library (DGHS) as part of its activities aimed
at providing Documentation Services to the Health Science community in the country. It covers
selected contributions on Acquired Immunodeficiency Syndrome during 1991-1993. Entries
follow a classified arrangement using Main Subject headings and Sub-headings. Photocopies of
these articles can be ordered from National Medical Library (DGHS), Ansari Nagar, Ring Road,
New Delhi-110 029.
GENERAL ASPECTS
1. A family with HIV and
haemophilia. Goldman E,
et al. AIDS Care 1993;
5(1): 79-85.
2; HIV infection and child
health. ; Ramachandran P.
Care calling 1991 Oct-Dec;
4(4): 26-32.
3. AIDS and the mental health
services. John J K, et al.
Health Administrator 1992
Jul; XD: 79-89.
4. Human immunodeficiency
virus (Review). Singh R, et
al.
Indian J Dermatol
Venereol Leprol 1992 JulAug; 58(4)! 233-42.
7. Psycho-social aspects of HTV
Infection and AIDS in multi
ple transfused thalassemic
children. Khan M A Indian
J Pediatr 1992 Jul-Aug; 59(4):
429-34.
8. Neuropsychiatric and Psy
chological aspects related to
human immunodeficiency
virus
(HIV)
infection.
Thakur L C, et al. Indian J
Psychiatr 1992 Apr, 34(2):
114-23.
9. Presidential address public
health. Anjaneyulu
G.
Indian J Public Health 1992
Oct-Dec; 36(4): 105-8.
5. HIV/AIDS and environment
Jerajani R N, et al. Indian J
Homoeo med. 27(4) : 12-6.
10. Awareness . of
AIDS
(Acquired Immunodeficiency
Syndrome) among final year
medical students. Sharma R
C. Indian J Sex Transm Dis
1992; 12(1) : 21-2.
6. Psychiatric Morbidity in HIV
infected individuals. Jacob K
S, et al. Indian J Med. Res
1991 Mar; 93 : 62-6.
11. AIDS : Perspective
and
Strategy. Bhattacharya S, et
aL J Indian Med Assoc 1993
Feb; 91(2) : 44-5.
Nov.-Dec. 1993
12. Problems of Aids in develop
ing countries. Dutta G. P. J
Indian Med Assoc 1992 Oct;
90(10): 254-6.
13. Health research a key to
equity in health develop
ment Ramalingaswami V,
Soc Sci Med. 1993 Jan;
36(2): 103-8.
14. Combating Aids as a public
health problem in India.
Banerji D. Voluntary Health
Association of India 1992 : 5-:
23.
EPIDEMIOLOGY
15. The epidemiology of AIDS in
the Vellore region. Southern
India. . John T J, et al
Aids. 1993 Mar, 7(3) : 421-4
16. Behavioural risk factors for
acquisition of HTV Infection
and knowledge about AIDS
among male professional
blood donors in Delhi.
Chattopadhya D, et al. Bull
World Health Organ 1991;
69(3): 319-23.
291
' HIV—AIDS situation in
17.
India. Shiv lai. Care calling
1991 Oct-Dec; 4(4) : 36-41.
18. HIV infection in obstetrics
and gynaecology. Ramachandan P. Delhi Med J
1992 Jul-Aug; 21-7.
19. AIDS: A survey of know
ledge, attitudes and beliefs of
under graduate students of
Delhi university. Benara S K,
et al. Indian J Commun
Med. 1992 Oct-Dec; 17(4) :
155-9.
20. Recovery of human im
munodeficiency virus from
asymptomatic
prostitutes
from Tamilnadu. Seth P, et al
Indian J Med Res (A) 1991
Sep; 93:277-9.
21. Sero-Surveillance of trans
missible hepatitis B and C
viruses in asymptomatic HIV
infection in haemophilics.
Sengupta B, et al. Indian J
Med Res (A) 1992 Nov;
95 : 256-8.
22. The detection of HIV-2 infec
tion in Southern India. Babu
P G, et al. Indian J Med Res.
1993 Mar; 97 :49-52.
23. AIDS with special reference
to pediatric aspect Kamat J
R, et al. Indian J Med Scl
1992 Mar, 46(3) : 75-82.
24. MHA-TP testing on HIV
positive and negative women
in vigilance
home
at
Madurai.
Ganapthysundaram S, et al. Indian J
Pathol Microbiol 1992 Jan;
35(1): 44-7.
292
25. Incidence of HIV and VDRL
antibody positivity in STD
patients. De A, et al. Indian
Practit 1993 Apr, 46(4): 24750.
26. AIDS : its impact Sehgal P.
N. Indian Red Cross J 1992
Sep; 66(3) : 10-4.
27. Sexual behaviour and HIV
infection risks in Indian
homosexual men : a cross
cultural
comparison.
Kumar B, et al. Int J STD
AIDS
1991
Nov-Dec;
2(6): 442-4.
28. HIV Infection among long
distance truck drivers in
Delhi, India. Singh Y N, et
al. J Acquir Immune Defic
Syndr 1993 Mar; 6(3) : 323.
29. HIV-1 and HIV-2 infections
in a high-risk population in
Bombay, India : evidence for
the spread of HTV-2 and pre
sence of divergent HIV-1
subtype. Pfutzner A, et al. J
Acquir Immune Defic Syndr.
1992 Oct; 5(10) : 972-7.
30. Descriptive epidemiology of
intravenous heroin users a
new risk group for transmis
sion of HIV in India.
Sarkar S, et al. J Infect 1991
Sep; 23(2): 201-7.
31. HIV infection : beginning of
an, epidemic. Kher S K, et al.
Med J Armed
forces
India. 1991 Oct 47(4) :
266-9.
32. HIV serosurveillance in an
STD centre in Armed for
ces. Arora P N, et al. Med J
Armed forces India 1992 Jul;
48(3): 189-90.
33. Human immunodeficiency
virus-1
infection among
patients
with
sexually
transmitted diseases in Bom
bay. Kamat H. A. et al. Natl
Med J India 1993 Jan-Feb;
6(1): 11-3.
ETIOLOGY
34. Blood safety. Talib V H, et al.
Indian J Pathol Microbiol
1993 Apr, 36(2): 170-5.
35. The Salient feature of HIV
infection and AIDS. Sehgal
P N. Indian Red Cross J 1992
Sep; 66(3) : 4-9, 26.
36. Clinical and Laboratory pro
file of AIDS in India. Kaur
A, et al. J Acquir Immune
Defic Syndr 1992; 5(9) : 8839.
37. Sexually transmitted diseases
in pregnancy. Roberts R. et
al. J Appl Med 1992 Dec;
18(12) : 875-84.
38. Thrombocytopenia a mani
festation of HIV-1 infection
in a heterosexual male.
Hamide A. J Assoc Phy
sicians India 1992 Oct; 40(10):
697-8.
39. Serological profiles for HBV,
HDV, HIV-1 and HTLV-1 in
Saudi patients with a
malignancy. Arya S C, et al. J
Commun Dis 1991 Dec;
23(4) : 270-5.
40. Infection with hepatitis A, B,
delta and human immuno
deficiency viruses in children
receiving
cycled
cancer
chemotherapy. Kumar A, et
al. J Med Virol. 1992 Jun;
37(2) : 83-6.
SWASTH HIND
IMMUNOLOGY
41. Immunoglobulinopathy
in
HIV sero-positive. Ganapathysundaram S, et al.
Antiseptic 1991 Jul; 88(7):
353.
42. HIV Antibody screening of
commercially
available
blood products in India.
Tripathy S P, et al. Indian J
Med. Res (A) 1991 Jan;
93:15-8.
43. HIV infection in patients of
liver cirrhosis. Amarapurkar
D N, et al. Indian Med Res
(A) 1992 Jul; 95:171-2.
44. HIV-2 antibodies in serum
samples from Maharashtra
state. Kulkami S, et al.
Indian J Med Res (A) 1992
Sep; 95:213-5.
45. Acquired immunodeficiency
syndrome (AIDS) in multi
transfused children with
Thalassemia. Sen S, et al.
Indian Pediatr. 1993 Apr;
30(4): 455-9.
46. Laboratory investigations in
AIDS. Greval R S, et al.
Indian Practit 1993 Aug;
46(8): 569-71.
47. Serosurveillance
of HIV
antibodies in blood donors
around
Visakhapatnam
of Andhra Pradesh. Jogalakshmi D, et al. Indian
Practit 1991 Mar; 44(3) :
193-6.
48. Rising trend of HIV infection
with special reference to
blood donors. Wadia M R,
et al. J Assoc Physicians
India 1992 Aug; 40(8) : 513-5.
49. Incidence of HIV (Human
immunodeficiency
virus)
infection and VDRL reac
tivity
among
pregnant
women. Singh N B, et al. J
Obstet Gynaecol India 1992
Oct; 42(5) : 576-80.
MANAGEMENT & THERAPY
50. Care for AIDS patients in
developing
countries: a
review. Schopper D, et al.
Aids Care 1992; 4(1) : 89102.
51. Microtiter praticle agglutina
tion test for Anti-HIV-1.
Ganapathysundaram S, et al.
Curt Med Pract. 1992 Mar;
36(3) : 83-4.
52. Science challenging HIV
infection. Rao R R, et al.
Indian J Pathol Microbiol
1993 Apr; 36(2) : 176-89.
53. Manifestations of HIV infec
tion
in
the
nasal
passages. Greval R S, et al.
Indian Practit. 1993 Apr;
46(4) 283-6.
54. Limited evidence of human
immunodeficiency virus type
2 (HIV-2) infection in sera
from blood donors showing
positive ELISA but negative
or indeterminate Westernblot
reactivity for HIV-1 infection.
Chattopadhya D, et al. J
Commun Dis. 1991 Sep;
23(3): 206-7.
55. Diagnosis
of
Acquired
immunodeficiency syndrome
(AIDS) on radiological sus
picion of (P. Pneumocystis
pneumonia) Jindal S K, et al,
Lung India 1992 Aug;
10(3) : 94-6.
56. Neurocryptococcosis
in
Acquired Immunodeficiency
Syndrome. Sawhney IM S, et
al. Neurol India 1993 Jan;
41(1): 35-8.
PREVENTION & CONTROL
57. AIDS in Asia. Gilada I S.
Aids Care 1991; 3(4) : 391-4’.
58. Differences in HIV-related
knowledge and attitudes bet
ween Caucasian and ‘Asian’
men in Glasgow. Elliott L,
et al. Aids Care 1992;
4(4) : 389-93.
59. Protective value of gloves and
condoms in prevention of
HIV infection. Gangakhedkar R R. Care Calling 1991
Oct-Dec; 4(4) : 18-23.
60. AIDS and transfusion prac
tice. Jolly J G, et al. Indian J
Pathol Microbiol 1991 Oct;
34(4) : 305-8.
61. Distribution and trends of
HIV infection in blood
donors of four metropolitan
cities. Makro R N, et al.
Indian J Public Health 1992
Jul-Sep; 36(3) : 101-4.
62. A
study
on
existing
knowledge
about
AIDS
among
Naval
person
nel. Thergaonkar W P, et
al. J Commun Dis 1991 Sep;
23(3) : 191-4.
63. HIV infection in the Armed
Forces—our approach to
counselling. Punia H, et al.
Med J Armed Forces India
1993 Apr; 49(2) : 123-7.
64. Role of women in prevention
and control of AIDS. Ram E
P, et al. Nurs J India 1991
Apr; 82(4) 119-20.
Nov.-Dec. 1993
293
LIBRARY
Jj
x<
anq
A\ BOCUMcNTATIOH
7
65. Biosafety
guidelines
for
Diagnostic and Research
Laboratories working with
HIV. WHO AIDS series 9,
1991.
66. School health education to
prevent AIDS and sexually
transmitted diseases. WHO
AIDS series 10, 1992.
67. Role of doctors and health
workers in AIDS prevention
in India. Johri A C, et al.
Your Health 1992 Jun-Jul; 41
(6-7): 136-9.
TRANSMISSION
68. Blood donors and Aids.
Kumar K, et al. Indian J Clin
Pract 1991 Feb; 1(9): 21-4.
69. HIV seroconversion in a
young child following a
single blood transfusion.
Kumar L, et al. Indian Pediatr 1993 Apr; 30(4) : 511-3.
70. Perinatally acquired AIDS.
Khanna S A, et al. Indian
Pediatr 1993 Apr, 30(4) : 50810.
RECENT BOOKS
71. ABC of AIDS. Adler M W.
London; BMJ 1991.
72. AIDS and other manifes
tations of HIV infec
tion. 2nd ed. Wormser G P.
New York; Raven press
1992.
73. AIDS etiology diagnosis
treatment
and
preven
tion. 3rd ed. Devita V. T.
Philadelphia;
Lippincott
1992.
74. AIDS in the world: Global
Report. Mann J. Cambridge;
Harvard university press
1992.
75. Gastrointestinal and Nut
ritional manifestations of the
Acquired Immunodeficiency
Syndrome. Kotler D P. New
York; Raven press 1991.
76. HIV infection in women.
Johnson M A. London;
Churchill Livingstone 1993.
77. Immunodeficiency in HIV
infection
and
AIDS.
Janossy G. Basel; Karger
1992.
78. Practical AIDS pathology.
Klatt E c. Chicago; ASCP
1992.
79. Vaccines 91: Modern ap
proaches to new Vaccines
including the prevention of
AIDS. Lerner R A New
York; Coldspring Harbour
Laboratory press, 1991.
80. Women and HIV/AIDS.
Berer M. London; Pandora
1993.
THE INHERITED LOTTERY OF HEART ATTACK RISK
Some people may be more susceptible to a heart attack because they have not inherited a natural
ability to contain the level of a blood protein implicated in clot formation, according to researchers at
London's Charin Cross Sunley Research Centre.
In recent years, high levels of Factor VII have been found to be associated with increased risk of
heart attack. While it is known that the protein is affected by environmental factors such as smoking
and diet, the new studies have identified important inherited factors which also help to decide
individual risk levels.
Dr. Fiona Green from the London centre’s arterial disease research unit says she has pinpointed
a genetic variant responsible for a change in Factor VII that reduces its presence in the blood by up to
23 per cent. This variant, which is found in around 20 per cent of the population in the UK, is
therefore likely to give a degree of protection against clotting and so reduce the risk of a
heart attack.
The unit’s studies of another blood protein involved in clot forming, fibrinogen, have conformed
previous suggestions that it is also affected by inherited factors. But this time the genetic component
has been found to have the effect of slightly raising its levels by one to two per cent in both nonsmokers and smokers. However, this is not thought to be enough to influence the risk of a heart
attack
A
—British Information Services
294
Swasth Hind
Talking About AIDS :
Communicating with Youth
a special concern for
youth. Globally, about 20 to
25 percent of all HIV infections is
roughly estimated to occur in
young people aged 19 to 24 years.
This age group also accounts for a
disproportionate share of the
increase in reported cases of
syphilis and gonorrhoea world
wide.
ids is
A
In the South-East Asia Region
where young people constitute at
least 50% of the total population, a
growing proportion of young peo
ple are involved in behaviour
which places them at higher risks
of acquiring HIV infection.
Many of the young from their
early teens are engaging in high
risk sexual activities; they are also
experimenting with drugs and
sharing contaminated injecting
drug equipment In some poverty
stricken societies, both girls and
boys are known to sell sexual ser
vices to make a living for them
selves and for their families. And
yet on the other hand there is no
doubt whatever that the young
constitute one of our greatest
resources for health. With the
aspirations they harbour and with
their abounding energy and zest
for living, youth possess tremen
dous capacities and capabilities to
make this world a better and
healthier place to live in. They
also possess a vast potential for
mobilizing people for social action
and for creating effective networks
between themselves for achieving
their goals.
The time has come to mobilize
this excellent resource, to harness
Nov.-Dec. 1993
its untapped energies and to
actively involve youth in health
activities.
Youth have a very significant
role in the prevention and control
of AIDS, through various ways
which include educating others,
adopting exemplary healthy life
styles thereby being a role model
to other youth and by taking up
advocacy roles by using youth
power to influence peer groups
and arouse public opinion.
However, it is suspected that
currently a very small proportion
of youth in the Region can effec
tively play this role, an important
reason being that they do not
know enough about AIDS and
how it can be prevented.
Talking about AIDS to youth is
therfore an activity that must
receive high priority. The need to
disseminate to youth correct and
complete information about the
disease using all channels avail
able is urgent Often this in itself
is not enough. The vulnerability
of youth to HIV infection must be
understood in both its biological
and social contexts. The biologi
cal sexual drive during adoles
cence, and the susceptibilites to
group pressure are not easy to
overcome even when knowledge is
complete. Besides there are a
number
of
misconceptions
associated with AIDS which must
be dispelled. These cause un
necessary worry and paralysing
fears especially when young peo
ple are not informed of how HIV
is not transmitted. Youth are also
very often faced with conflicting
messages. While their religion
and parents place high value on
abstainence from sex before
marriage, their peers expect them
to defy such values. For this
main reason, it is important to
link counselling with information
and education programmes for
youth. Counselling will help not
merely to provide correct informa
tion but also to guide the young
person in the decision he or she
may have to make, if it is
necessary to change behaviour.
Additionally youth must be also
equipped with prevention skills
which they can apply to practice
safer sex, to negotiate safer sex
practice and to stay away from
alcohol and drugs. Alcohol and
drugs through altering the normal
functions can be held responsible
for making even knowledgeable
people behave irresponsibly at
critical moments. Youth may
also have to be imparted skills in
safe injecting practices. In some
societies, prevention skills are par
ticularly important to develop in
those who have not yet begun to
experiment with sex and drugs.
As it is easier to change behaviour
before it becomes firmly esta
blished, all efforts must be aimed
at those who are not yet sexually
active to help them maintain the
safer status for as long as it is
possible.
A serious shortcoming in the
Region is the taboo against talking
to the young about sex and sex
uality. The school curricula does
not provide such knowledge even
when it covers such topics as
295
A mass sensitization campaign to reach university students to educate them about AIDS was launched in India in 1991
through the National Social Service Scheme (NSS) in collaboration with WHO. The programme entitled “Universities Talk
AIDS** planned a nationwide message and materials development contest, the aim being to generate among students open dis
cussions about AIDS and produce effective messages for university students. Students from 65 universities in India were
involved in designing messages and materials for students through regional training workshops on the process of message
design and material development. The materials prepared were judged on the basis of the methodology used for their
development, creativity of design and effectiveness in conveying the message, and Awards were presented at a national
ceremony held close to World AIDS Day. The experience gained from this campaign will be found most useful in developing
a comprehensive programme on AIDS education for university students.
human reproduction and family
planning; out-of-school youth
have even less orientation to such
topics. Talking about sexual
issues comfortably is however cru
cial for AIDS education, more so
when talking to adolescents who
have been conditioned into think
ing that sex is dirty and something
that can only be enjoyed clandes
tinely. Issues related to sex and
sexuality must be discussed in the
context of the socio-cultural
influences which mould and
influence group and individual
beliefs and values regarding such
issues. The range of sexual orien
tations must be explained includ
ing homosexual, bisexual and
heterosexual practices,.
Messages
and
Communication
Channels
of
In communicating to youth, the
major risk factors for HIV infec
tion in the local youth population
must be known. It is also impor
tant to know what specific
behaviours expose young people
to risk. Is it multiple sex
partners, injection drug use, sexual
exploitation or any other com
monly praciticed behaviour ?
Only then can relevent and realis
tic messages be designed. It is
useful to conduct behavioural and
focus group discussions among
representative samples of young
people to determine this. Their
level of knowledge about AIDS
and especially their misconcep
tions must be known. It is also
necessary
to
explore
what
motivational forces will lead to
preventive action, and to involve
the youth themselves in designing
appropirate messages.
In HIV education, as in most
other educational programmes, it
296
is equally important to identify the
effective communication channels
to reach the target population.
Selecting an appropriate channel
to communicate, often depends
upon the needs and concerns of
the audience. Both personal and
mass communication approaches
have a place. By and large, per
sonal communication may be
more effective if the audience is
small, easily identified and at high
risk after HIV exposure. This
group is also best reached through
peer
education
approaches.
Another advantage of personal
communication is its potential for
talking about issues which would
not be possible or permitted
through mass communication
channels. On the other hand,
mass communication may be
appropriate for reaching and
influencing larger youth audien
ces.
What is important is that
whatever channel is used, whether
singly or in combination, it, must
capture the attention and interest
of the audience.
“Talking AIDS” to youth can be
carried out in a variety of
settings—in schools and colleges,
at youth clubs and within nonformal education programmes
addressed
to
out-of-school
youth. Non-governmental orga
nizations have a vital role in this
effort, reaching out to school drop
outs, street children, drug users,
youth involved in prostitution, and
other such hard-to-reach youth.
There are also today several
youth organizations in the coun
tries of South-East Asia who,
through their networks, can spread
the AIDS message to both urban
and rural audiences.
In a Regional Statement on
Youth Involvement in AIDS Pre
vention and Control at a WHO
workshop participants from eight
countries of the South-East Asia
Region expressed their strong
belief that organized youth efforts
have an important role to play in
AIDS prevention programmes,
especially in “youth to youth”
motivation
and
behavioural
change and recommended that
youth and youth organizations be
provided with adequate informa
tion and knowledge of how HIV is
transmitted and prevented with
the ultimate objective of effecting
behavioural change.
Talking AIDS to youth thus goes
far beyond just telling the young
all about AIDS and how it is
caused. Youth must also be
helped to take action and to be
motivated to adopt and maintain
safe
behaviours. The
WHO
Global Programme on AIDS is
giving high priority to activities
related io youth and adolescents
with an increasing focus on pre
vention activities for youth.
Curricula guidelines for AIDS
education programmes in schools
have been prepared. Guidelines
are being developed for out of
school youth and the effectiveness
and reach of the peer education
model and community outreach
programmes are being assessed.
The Programme is convinced that
the epidemic of HIV infection and
AIDS cannot be brought under
control unless more AIDS preven
tion efforts are directed at young
people. Talking about AIDS to
youth would certainly be the first
step.—WHO Kit
Swasth Hind
Developing and implementing
school policies to address
HIV infection and other
health policies
A. Isaksson, S. Bahri, D. O’Byrne, S. Chowdhung , J. Reinders, K. Fraser
This report is based on the deliberations of a working group that was facilitated by Andri
Isaksson, UNESCO. The participants were: Sonia Bahri, UNESCO; Shankar
Chowdhury, All India Institute of Medical Services; Katherine Fraser, National Association
of State Boards of Education (USA); Desmond O’Byme, WHO; and Jo Reinders, Dutch
Centre for Health Promotion and Health Education. The report was presented at the con
ference by Sonia Bahri, UNESCO.
ECAUSE of the urgent need to enable young
people to void HIV infection, it is important for
schools to be able to plan and implement HIVrelated policies and programmes without delay.
However, there are obstacles to the successful
implementation of any new educational effort within
most educational systems. Due to the sensitive
nature of behaviours related to HIV transmission,
these obstacles may be greater for education about
AIDS and HIV than for other new efforts. In many
regions of the world, formal education on sexual mat
ters either does not exist, is inadequate or is provided
too late in adolescence (1).
B
Establishing an HIV-related school policy is fun
damental to the successful involvement of schools in the
prevention of HIV/AIDS. In the context of this
report, HIV-related school policy means a general
direction or strategy for action adopted by a govern
ment, responsible authorities or institutions to
address issues related to AIDS, HIV infection, STD
and other significant health problems.
Why are HIV-related school policies needed?
The policy development process engages educa
tion and health officials, teachers, school counsellors,
community leaders, parents and students in deter
mining the role schools will play in preventing
AIDS/HIV, STD and other important health pro
blems. It also can help facilitate understanding,
commitment and support among leaders and con
cerned citizens.
(1) WHO Features, No. 152, December 1990
Nov.-Dec. 1993
HIV-related policies can help overcome some of
the most common institutional barriers to
implementing new educational efforts. These
include: assignment of responsibility, conflicting
priorities, fragmented programming and overloaded
curricula; and lack of defined ways of addressing the
issue, resources and training for school personnel.
Frequently, HIV-related school policies are
needed for the following reasons:
• To develop understanding, commitment, and sup
port among leaders and community members as to
the problem, intervention methods and expected
results. Without commitment and support, schools
will have difficulty addressing sensitive health issues
such as HIV/AIDS.
• To provide a context for changes in school pro
grammes. School personnel will be reluctant to
accept responsibility for implementing the necessary
changes for providing education to prevent HIV
infection, if they have not been given a reason and
strong direction and support
• To promote consistency in education about HIV
and sex between the school and the home.
• To help establish a framework for the evaluation of
school’s HIV-related activities.
297
• To provide parameters and direction to outside
organizations that offer or are asked to help the
school probed education about HIV for students
and teachers.
• To address ethical and legal issues related to
sex education.
The nature
policies
and
scope
of
HIV-related
school
HIV-related school policies commonly reflect the
goal of preventing the spread of HIV infection and
minimizing the negative impact of HIV/AIDS.
They often include a statement providing a rationale
and support for the necessity of school-based HIVeducation.
HIV-related school policies can provide vision
and context for integrating education about HIV into
a more comprehensive and holistic approach, such
as one that includes education to prevent pregnancy
and STD, that promotes a positive and healthy view
of sexuality, and that addresses other relevant and
interrelated health issues. They can help establish
coherence between HIV-related education, school
health services and the school climate. They also
can provide support for education designed to help
young people acquire the knowledge, values,
attitudes, skills and support needed to avoid impor
tant health problems, including HIV infection,
and discrimination.
HIV-related
guidance about:
school
policies
can
provide
• Resources for planning and implementing educa
tion about HIV, including provision for supporting
personnel preparation, materials development and
dissemination
and
cooperation with other
organizations.
• How explicit education about HIV and AIDS
should be, taking into account the age and develop
ment levels of students.
• The amount of time that should be devoted to
education about HIV.
• The placement of HIV in the curriculum.
• Qualifications and training of staff.
• Instructional materials.
• Programme evaluation.
• Involving parents in the programme so as to pro
gressively build support and minimize concerns.
298
• Establishing a supportive environment that does
not discriminate against students or teachers based
on their sexual orientation or gender.
• Accommodating student and school personnel
who are infected with HIV, protecting their privacy
and confidentiality, and taking appropriate hygienic
precautions with exposures to blood.
Suggestions and considerations in planning
implementing HIV-related school policies
and
Some important considerations and suggestions for
planning and implementing HIV-related school
policies follow:
• In initiating the development of HIV-related
school policy, information should be provided to
school personnel and the wider community about the
extent to which young people are at risk of HIV
infection, STDs, unintended pregnancies and other
important health problems; about evidence that
school-based efforts can influence behaviours
associated with important health problems; and
about the extent to which young people worry about
sexual issues.
• The health agency, school assisting institutions,
teacher’s unions, students and parents, should be
involved in policy development
• HIV-related school policy should be based on
three essential components: prevention, solidarity,
and care, with the greatest emphasis on
prevention.
• Encourage schools to develop local policies, within
the general guidance and framework of governmental
or national policy to be able to meet their specific
needs and concerns.
• Controversy should be addressed immediately,
openly and diplomatically.
A process to find consensus is essential for establish
ing a broad supportive base. For policies to be
effective, there should be consensus and a willingness
to cooperate with other implicated parties, such as
parents, teachers, and religious organizations.
Once HIV-related school policies are developed,
they must be communicated to those persons for whom
they are intended. This is an essential part of the
process, and will help assure their implementation.
—Courtesy: Hygie
Swasth Hind
ROADS THAT HIV WILL NOT TAKE
The range of present attitudes towards AIDS is similar to the attitudes once seen
towards syphilis in the early 19th Century. Myths and emotional hysteria can be
generated due to misinformation about AIDS. Many myths about HIV today cen
tre around the manner in which it can be transmitted. Extensive research has
shown that there are only three well defined routes of HIV transmission. The
studies show that:
HIV Docs Not Spread By:
• Drinking water from the same
glass as an infected person.
• Swimming in pools used by
people with HIV or AIDS.
• Getting bitten by a mosquito
that has already bitten an infec
ted person.
• Getting bitten by an infected
person.
• Socialising or casually living
with people with HIV or
AIDS.
• Caring and looking after people
with HIV or AIDS.
• Use of the same toilets as AIDS
patients or people infected
with HIV.
• Shaking hands with people with
AIDS or HIV.
• Hugging or kissing a person
with HIV or AIDS.
• Casual ,contact such as sitting
next to an infected person, or
by coughing and sneezing, or
from water, food, clothing, cups,
glasses, plates, forks, spoons
and other shared objects.
NOV.-DEC. 1993
• Receiving and reviewing litera
ture from areas of the world where
there is AIDS.
• Donating blood.
Bedbugs, flies, lice, fleas and other
insects and pests DO NOT spread
HIV.
♦
♦
♦
299
13 MILLION HIV POSITIVE WOMEN BY 2000
EW figures released by the
World Health Organization
on 7 September 1993, show that by
the year 2000, over 13 million
women will have been infected by
HIV and about 4 million of them
will have died. More than 1
million women will become infec
ted in 1993 alone.
cumulative number of AIDS cases
will quadruple by the year 2000.
But, though there is no cure yet for
HIV infection or AIDS, people’s
suffering and isolation can be
lessened by appropriate treatment,
support and care. At the same
time we need to prevent new infec
tions in women and children.”
Speaking at the opening of the
2nd International Conference on
HIV in children and mothers in
Edinburgh, Dr Michael Merson,
Executive Director of the WHO
Global Programme on AIDS
said:
In industrialized countries,
transmission is still often through
homosexual contact or injecting
drug use. But there is an ominous
rise in heterosexual transmission.
Last year in the USA, AIDS cases
in women were almost 10% higher
than the year before. In 1992, sex
became the leading cause of AIDS
in American women. In Scotland
a significant proportion of new
HIV infections in some cities are
acquired through sex between men
and women. Drug injecting is the
background to many of these infec
tions, acquired through sex with a
male drug user.
N
“A decade ago women and
children seemed to be on the
periphery of the AIDS epide
mic. Today, as the holding of this
conference shows, women and
children are at the centre of our
concern. AIDS has not spared
them. On the contrary, the epi
demic wave has affected millions of
women and their children, and
millions more are threatened.”
WHO estimates that almost half
of all newly infected adults are
women. As infections in women
rise, so do infections in the infants
bom to them. To date, these total
about 1 million, of whom half a
million have already developed
AIDS. On average, world wide,
about one-third of babies bom to
HIV infected mothers are them
selves infected.
More than 14 million people
world wide are believed to have
become infected with HIV since the
start of the epidemic. However, so
far less than one-fifth of these have
gone on to develop AIDS, and
fewer still have died of the
infection:
“We are still in the early stages of
the epidemic in terms of the disease
and death it will cause,” says Dr
Merson. “So many people have
already been infected that the
300
In many developing countries,
heterosexual transmission has
been predominant from the out
set In
sub-Saharan
Africa,
women becoming infected with
HIV now outnumber men by 6 to
5. The number of women becom
ing infected continues to rise. In
Malawi, infection rates among
women attending ante-natal clinics
increased from about 3% in 1985 to
over 30% this year.
But why is it that HIV infections
in women are growing world wide?
Dr Merson outlined three main
reasons.
*
Women are biologically more
vulnerable. As the receptive
partner, women have a larger
mucosal surface exposed dur
ing sexual intercourse; more
over, semen contains a far
higher concentration of HIV
than vaginal fluid. Hence
women run a bigger risk of
acquiring HIV infection — and
other sexually transmitted dis
eases (STDs).
*
Women
are
epidemiologically
vulnerable. Women tend to
marry or have sex with older
men, who may have had more
sexual partners and hence be
more likely to have become
infected. Women are also
epidemiologically vulnerable to
HIV transmission through
blood. In the developing
world women frequently re
quire a blood transfusion dur
ing pregnancy or child birth
— for example, because of
anaemia, or hemorrhage.
*
Women are socially vulnerable to
HIV. Men are expected to be
assertive and women passive in
their sexual relationships. In
some cultures, men expect sex
with any women receiving their
economic support. Whenever
these traditional norms pre
dominate, the result is sexual
subordination, and this creates
a highly unfavourable atmo
sphere for AIDS preven
tion. An environment in
which it is difficult or even
impossible for women to protect
themselves from sexual trans
mission, through mutual fide
lity or condom use.
Summing up what can be done
to reduce the vulnerability of
women to HIV infection, Dr Mer
son highlighted a number of sug
gestions. Among them are:
— biomedical scientists should
give top priority to developing
a vaginal virucide or mic
robicide active against HIV
and other STDs
— national AIDS programmes
should implement effective
interventions aimed at men,
such as needle exchange pro-
Swasth Hind
grammes for injecting drugs
users and vigorous condom
promotion
women should be encouraged
to seek and should receive
good STD care
young girls, who are especially
vulnerable, should be taught
how to protect themselves
from HIV infection
and, men everywhere can help
put an end to social traditions
which lead to women’s sub
ordination
“Women face extra challenges in
protecting themselves and their
children from HIV infection” con
cludes Dr Merson. “But this
social vulnerability is hard for
women to challenge as individuals,
or even through female solidarity
alone. It will take an alliance of
women and men working in a spirit
of mutual respect.”—WHO.
Promising progress on HIV vaccine,
says W.H.O. AIDS Chief
r Michael Merson, Execu
D
tive Director of the World
Health Organization Global Pro
gramme on AIDS, said that there
has been important progress in
HIV vaccine development but that
an effective HIV vaccine was still
years away. In his keynote add
ress, Dr Merson called on res
earchers to intensify their efforts—
especially in basic research—in the
search for an HIV vaccine. He
was addressing the 9th Inter
national Congress of Virology
meeting in Glasgow on 9th
August, 1993.
“The progress to date on HIV
vaccine development is encourag
ing,” says Dr Merson, “but there
must be no let-up in research to
develop a safe, effective and univer
sally available vaccine. We know
it is possible to prevent the sexual
transmission of HIV through the
adoption of safer sex practices,
including condom use, and the
treatment of sexually transmitted
diseases. We know the pandemic
can be slowed—and we can do it,
with sufficient commitment and re
sources—but this is not enough.
We need a vaccine to complement
our existing prevention strategies.
AIDS is already devastating some
societies, and the worst is yet to
come.”
Nov.-Dec 1993
Since 1987, 15 so-called can
didate vaccines have entered Phase
I and, in some cases, Phase II
human trials to assess their safety
and immunogenicity. Thirteen of
these 15 candidate vaccines have
been tested in HIV-seronegative
volunteers as preventive vaccines
and eight in HIV-infected volun
teers as therapeutic vaccines
designed to prevent or delay pro
gression to AIDS.
efficacy in preventing or delaying
the onset of AIDS.
The candidate vaccines evalua
ted to date in HIV-seronegative
volunteers have been found
generally safe and well tolerated in
doses capable of inducing HIV
specific
immune
respon
ses. These immune responses
have usually developed only after
multiple doses of the immunogen,
the component of the vaccine
which produces an immune res
ponse; and the level of HIV
antibodies produced has been
generally low, short-lived and
relatively strain-specific. Their
relevance to prqtection is not yet
known.
“One scenario we should like to
avoid is the development of an
expensive vaccine which works in
specific areas, and that will be useable and affordable exclusively in
industrialized
countries. This
would be insufficient for controll
ing the global epidemic. For a
vaccine to help control the global
HIV pandemic, it must above all be
effective and appropriate for
developing countries, where more
than 80% of all infections are
occurring.”
In the trials involving HIVseropositive volunteers, the can
didate vaccines have been shown to
be well tolerated, safe, and capable
of inducing increased and broader
immune responses. No informa
tion is yet available on their
The largest group of the can
didate vaccines being developed
and tested in humans today are
subunit
recombinant
vac
cines. Some promising results
have been obtained using these
approaches, but they may not be
the only way to a safe and effective
vaccine, says Dr Merson.
All the candidate vaccines now
being developed and tested in man
are using the following approa
ches:
* synthetic peptides
* subunit recombinant
* live vectors
* inactivated virus
301
But, recently, WHO decided to
put the development of a live
attenuated HIV vaccine on today’s
research agenda. A meeting of
leading scientists and experts in
medical ethics convened by the
Global Programme on AIDS
recommended that a live atte
nuated approach for HIV vaccines
should be intensively explored, in
parallel with other vaccine
research.
animal models should be conduc
ted. Other candidate vaccines
must proceed into efficacy trials as
soon as possible, before such
human trials could ever be con
sidered seriously. The results of
these efficacy trials, either positive
or negative, will be critical for the
risk/benefit analysis that will help
us decide whether to proceed to
testing live attenuated HIV vac
cines in humans.”
“With the millions of lives at
stake in this pandemic, every
possibility must be examined,” says
Dr Merson. “For instance, we
know that some of the most effec
tive and affordable vaccines, such
as those against polio, measles and
yellow fever, are based on live
attenuated vaccines which use a
virus weakened or altered so that it
does not result in disease. Before
human trials could ever be con
sidered, numerous studies in
WHO estimates the cost of effec
tive AIDS prevention in developing
countries to be between S 1.5 and S
2.9 billion a year. Such an invest
ment could halve the number of
new adult infections this decade,
from nearly 20 million to 10 million.
This would not only save many
times this figure in the cost of
AIDS cases averted but more
importantly, it would also save
millions of lives and untold
human suffering.
However, it is clear that although
behaviour change which will help
slow the spread of HIV can be
achieved, behavioural interven
tions alone can never stamp out the
transmission of HIV. A safe and
effective vaccine is needed to com
plement the existing prevention
strategies:
“We now have a number of effec
tive interventions to prevent HIV
transmission, such as promoting
safer sex and providing condoms,
and diagnosing and treating sex
ually transmitted diseases. But
these have been only partially suc
cessful, and a safe and effective vac
cine would be an important
tool to complement the existing pre
vention strategies,” concludes Dr
Merson—WHO.
REVAMP MEDICAL EDUCATION,
Says W.H.O. AIDS Programme Director
r Micheal Merson, Execu
D
tive Director of the World
Health Organization (WHO)
Global Programme on AIDS,
speaking at the World Conference
on Medical Education in Edin
burgh (8—12 August 1993) has
called for a fresh look at the way
doctors are educated.
“AIDS is a catastrophe in slow
motion that will be with us for
decades to come. It poses a
challenge to medical education
because of the kind of care it
requires, the approaches needed
for AIDS prevention and in its
interactions with society. Doctors
need to learn how to work as part of
a team with other health and social
workers, and
they need to
encourage and support families in
caring for their loved ones at home.
Above all, they need to consider the
patients as knowledgeable allies,
not as passive recipients of care,
and involve them fully in the entire
care process, including decision
making about treatment”
Dr Merson said that the doctor of
the future would need:
* greatly
improved
com
munications skills
* a better understanding of the
interplay between health and
human rights
* greater familiarity with infec
tious diseases
* a serious grounding in pub
lic health
* an appreciation of the social
environment of the disease
The existing medical school
curriculum must be changed to
meet the needs not only of AIDS
but also of other diseases, Dr Mer
son added. These include:
* chronic diseases such as
arthritis and diabetes which
lend themselves far less to cure
than long term care and sup
port, with the full involvement
of the patients themselves;
* preventable conditions such as
lung cancer and heart disease,
where information and educa
tion about life style is the key
to prevention; and
* drug dependency where a
sound public health approach
including provision for needle
exchange and other supportive
programmes should take
priority
over
repressive
practices.
“If the challenges I have outlined
were confined to AIDS and AIDS
alone, I would not be arguing for a
revamped medical school curri
culum. Medical education needs
rethinking precisely because AIDS
is not unique. Many of the
features of AIDS can be seen in
illnesses prevalent today not only
in the industrialized world but in
developing countries as well” he
said.—W.H.O.
Contributions to “Swasth Hind” from health and social welfare workers on public health topics are invited.
Articles should be typewritten and suitably illustrated. They ordinarily should contain about 1200 words and
sent in triplicate to the Editor, Central Health Education Bureau, Kotla Road, New Delhi-110 002.
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302
Swasth Hind
Preventing the Spread of HIV:
Whose Responsibility?
Individual
Individuals must adopt a lifestyle and behaviour which is compatible to health
and curtails the transmission of HIV. Individuals with HTV/AIDS must take
personal responsibility to ensure that they will stop the further spread of
the virus.
Family
Families must adopt values which promote health. The family must
provide understanding, compassion and care to help any family mem
ber with HIV/AIDS in coping with the unusual situation and maximiz
ing his or her health potential to refrain from infecting others.
Society
Societies must avoid discriminating against people with HIV/AIDS and
promote a supportive environment characterized by protective social
norms. Societies must also strive to minimize socioeconomic factors
like poverty which tends to aggravate the situation.
Health Personnel
Health Personnel have the dual responsibility of providing care and
counselling to people with HIV/AIDS. They must take appropriate
precautions to prevent the spread of the infection in other patients
and among themselves; act as a role model for their community by
providing compassionate and respectful care; and educate individuals
and groups about the facts related to HIV.
Nov-Dec. 1993
303
Media
The mass media represent the most readily available and potentially
most economical means of imparting information about HIV/
AIDS. Alongwith other forms of communication, the mass media can
effectively raise public awareness and concern about HIV/
AIDS. However, mass media has to adopt a responsible attitude in
reporting about HIV/AIDS, avoiding inaccuracies which may generate,
rather than clarify, misconceptions about HIV/AIDS.
Health Educators and NGOs
Health educators and NGOs can help in spreading the right messages
about HIV/AIDS by initiating a learning process for mass audiences in
communities. With their involvement at the grassroots, NGOs can pro
vide the critical link between health educators and the community.
One of the most important and challenging preventive measures against AIDS have been indeed directed
towards preventive interventions, including the use of information, education and communication (IEC), to
increase knowledge and change attitudes. This aims to facilitate behavioural change that will prevent the
spread of HIV/AIDS. WHO on its part focuses on an important theme related to AIDS each year on 1
December—the World AIDS Day. —W.H.O.
HEALTH MINISTER LAUNCHES
WORLD DEVELOPMENT REPORT, 1993
Report,
1993 is an important land
mark in our understanding and
appreciation of the place of health
in the process of development.
This was disclosed by the Union
Minister for Health and Family
Welfare, Shri B. Shankaranand on
7th July, 1993 in New Delhi while
launching of the World Develop
ment Report, 1993.
The Minister further said that
important changes had taken place
in the global and Indian health
scenario. There had been signifi
cant achievements, and also avoid
able failures. Life expectancy had
continued to increase and infant
mortality continues to decline.
The expanded programme of
immunization had drastically
reduced the occurrence of measles
and polio.
economic environment that ena
bles people to improve their -own
health; it would be cost-effective to
reallocate government investment
from specialised care in tertiary
health care facilities to program
mes of control of infectious dis
eases and mal-nutrition that would
help the poor most and greater
private sector involvement in
health should be facilitated and
properly regulated.
Shri Shankaranand commended
the initiative taken by World Bank
for mobilising assistance to prevent
and control the pandemic of AIDS
and health programmes.
The Minister also said that the
government had agreed with the
three pronged approach, advocated
by the Report, for improving health
in developing countries. The
governments need to foster an
The Minister asked the medical
professionals to come forward and
involve suitable mechanism for its
effective participant in providing
the health care to the commu
nity. —PIB
W
304
ORLD Development
Swasth Hind
CCH & FW RECOMMENDS EDUCATION COMMISSION
IN HEALTH SCIENCES
rpHE Central Council of Health
JL and Family Welfare (CCH &
FW) has endorsed in principle the
draft National Education Policy in
Health Sciences providing for the
educational needs and training
requirements of all major cate
gories of health care professio
nals. The Council also recognised
the need for setting up an Educa
tion Commission in Health Scien
ces. The three-day conference of
the CCH & FW which concluded
on 16th July, 1993 in New Delhi has
also recommended that a detailed
programme of action based on the
policy framework be developed
and placed before the Council at
it’s next meeting.
The Council recommended set
ting up of Family Welfare Commit
tees at the village/Panchayat,
intermediate and District level
Panchayats to promote family
planning. In a resolution, adop
ted, the Council took note of the
73rd Constitution Amendments
Act and felt that the Village Com
mittees can play a significant role
in promoting the acceptance of
family planning by creating aware
ness and persuading couples to
adopt spacing methods and pro
mote maternal and child health
care, ensure compliance of the
Child Marriage Restraint Act and
monitor working of health pro
viders at the sub-centres through
community sanction. The Coun
cil also commended to the State
governments to involve Zila Parishads and Municipal Corporations
for promoting the Family plan
ning programme.
Nov.—Dec.
1993
An important conclusion of the
Council related to the need to
streamline the financing of the
health sector to ensure optimal
utilization of resources. The
Council recognized the need to
maintain full sectoral allocations
for the national programmes as
originally planned and noted that
funds provided for national pro
grammes, especially for essential
consumables and drug should not
be diverted, as they affected the
most vulnerable and poor.
The Council noted the emer
gence of HIV/AIDS as a serious
public health problem affecting all
the States and Union Territories.
The need to ensure strict obser
vance of the mandatory require
ments relating to blood-safety was
stressed. It was also noted that the
control of sexually transmitted dis
eases (STD) would have to be an
important component of the AIDS
Control programme. The need to
integrate it with general and
primary health care to provide
easily accessible and non-stigmatised counselling and services
was stressed. It was recognised
that the ultimate solution was to
launch an innovative communica
tion strategy, encompassing all the
target groups.
The Council emphasised the
need to upgrade the standards of
Indian System of Medicines (ISNT)
& Homoeopathy colleges to meet
their realistic needs. The setting
of specialized treatment centres
and strengthening drug control was
also supported. The Council
welcomed the central government’s
initiative to intensify the malaria
control programme in tribal areas
by meeting 100 per cent of the
cost. It called upon state govern
ments to strengthen primary health
care infrastructure in tribal areas,
and felt that the programme in the
non-tribal areas should continue
on the existing equal cost sharing
basis between the states and
the centre.
In view of the added danger of
spread of TB on account of HIV
the Council supported urgent
measures for uninterrupted drug
supply to those undergoing treat
ment and strong public health
education campaign on TB con
trol. The CCH & FW appre
ciated the progress made under
the National Leprosy Eradication
Programme. It also welcomed
the inclusion of the MDT pro
gramme to all endemic and mod
erately endemic areas with a view
to eliminate the disease by the
2000 A.D. Special emphasis was
also placed on the need for
establishing District Blindness
Societies.
It was noted by the Council that
167 million people were exposed
to the risk of iodine deficiency,
leading to goitre, cretinism and
neurological disorders. All the
states were enjoined to issue
notifications banning the con
sumption of non-iodised salt and
to enforce the ban orders strictly
while involving the public dis
tribution system in the sale of
iodized salt.—pib •
305
COMBAT AIDS COLLECTIVELY,
Health Minister tells SAARC Members
S
HRI B. Shankaranand Union
Minister for Health and
Family Welfare, has called upon
the South-Asian Association of
Regional Cooperation (SAARC),
countries to make a collaborative
effort to combat spread of the AIDS
disease. Inaugurating a SAARC
Seminar on AIDS on 21st June,
1993 in New Delhi, the Minister
said
sharing
of
know
ledge and expertise airjong the
member countries of SAARC on
Sexually Transmitted Diseases
(STD) and AIDS would strengthen
the National AIDS Control Pro
gramme of each member country.
Noting that AIDS was not
isolated among one group of peo
ple, the Minister said it is estimated
that the South-Asian region had
about 1.5 million HIV cases. Since
there was no vaccine or cure, the
only possible intervention strategy
was prevention, he said. Stressing
the need to generate enough aware
ness to avoid the kind of risk
behaviour which facilitated the
spread of HIV infection, he said,
this required an imaginative com
munication strategy, as com
municating about AIDS/HIV and
STDs necessarily involved discus
sion on sexual practices.
AIDS is a social disease and
involvement of all sectors was
needed, he said. It was necessary
to integrate efforts of SID/HIV/
AIDS prevention in all aspects of
development and training that
take place in this region, he
added. Special targetted interven
tion needs to take place for youth,
school children, women, industrial
workers, road transporters, uni
formed personnel and various
other segments of society who are
vulnerable to this infection. Efforts
in this regard must be taken up in
earnest, he urged.
As more and more number of
H1V/AIDS cases are reported, there
was urgent need to ensure con
fidentiality and social protection to
those affected by this disease. He
pointed out that the health system
by itself would not be able to take
care of all the HIV infected per
sons. The focus would thus shift
to home-based care. To make this
possible, it was necessary to ensure
that the community was favourably
disposed to people living with the
virus. Lessons learnt from leprosy
and Tuberculosis control had given
enough indicators to learn that
society needed to be geared up from
the very beginning through aware
ness programme on these issues.
Care had to be taken to not stigma
tize any one particular group or
individuals, said Shri Shankara
nand.
Valedictory
The first step towards a collective
effort by the SAARC countries to
combat the AIDS disease was
taken with the conclusion of a
three-day ‘SAARC Seminar on
AIDS’ on 23rd June, 1993 in New
Delhi. Delivering the valedictory
address, Shri
Paban
Singh
Ghatowar, Deputy Minister for
Health and Family Welfare noted
that the HIV infection had no res
pect for international borders and
posed common threat to the coun
tries of the South-Asian region.
The Minister said that AIDS was
not merely a health problem, it had
socio-economic, moral, legal and
ethical ramifications. A unity of
efforts, he stressed, was thus
required not only within countries
but between countries of the world
and all sections of the com
munity. He said the government
had launched a comprehensive
AIDS control programme involv
ing a multi-sectoral and multi
disciplinary approach.
—PIB
DISASTER PREPAREDNESS
Dr P. Raja Ram, Deputy Director General (Medical)
*,n Jl*c
centre, addressing the symposium on Stop Disasters. On his left is Mr
A.K. Sharma, Divisional Officer of Delhi Fire Semce and
Dr V.S. Singhal, Director, CHEB on his right.
306
The Central Health Education Bureau, Directorate
General of Health Services organised a symposium on “Stop
Disasters : Focus on Schools and Hospitals” on the occasion
of International Day for Natural Disaster Reduction on 13th
October, 1993 in New Delhi.
While introducing the subject. Dr V. S. Singhal, Director.
Central Health Education Bureau said that although natural
disasters cannot be stopped but definitely we can prevent the
damage and destruction due to such disasters.
Dr P. Raja Ram, Deputy Director General (Medical)
while inaugurating the symposium said that the natural and
man-made disasters in the world are on the increase during
the past decade. And methods are available for reducing
the loss of lives and goods caused by these disasters. There
is a need to create public awareness about prevention and
mitigation of the ill-effects of these disasters. It is better to
prevent than regret, he said.
The other speakers were Dr B. K. Verma, Director
(Emergency Medical Relief), Mr. A.K. Sharma, Divisional
officer of Delhi Fire. Service and Mr. J. S.
Manjul, Deputy Director (School Health Education).
An exhibition on Disaster Preparedness was also
organised by Central Health Education Bureau on the
occasion.
SWASTH HIND
Shri Paban Singh Ghatowar, Deputy Minister for Health and Family
Welfare, inaugurating the Health Education Campaign for inmates of
Tihar Jail, New Delhi.
A view of the inmates of Tihar Jail, New Delhi.
HEALTH EDUCATION CAMPAIGN IN TIHAR JAIL
The Central Health Education Bureau organised
a ‘Health Education Campaign’ for the inmates of
Tihar Jail. The Deputy Minister of Health & Family
Welfare, Shri Pawan Singh Ghatowar, inaugurated
the month-long activities on 2nd October, 1993 at the
Jail premises in New Delhi.
The campaign aimed at providing health educa
tion for the 9,000 jail inmates to enable them to look
after their own health. There were special groups
like women and juveniles among them.
Considering the need of this very special group
of the society, various activities like exhibition, group
talk, skit, film shows and painting exhibitions were
organised on AIDS and prevention of tobacco
consumption.
Shri Paban Singh Ghatowar, Deputy Minister of Health and Family
Welfare, viewing the exhibition set up at the Tihar Jail, New
Delhi.
Dr V.S. Singhal. Director, CHEB, addressing the valedictory
function. Mrs. Kiran Bedi, Inspector General (Prison)—extreme
right—presided.
Nov.—DEC.
1993
An evaluation of the campaign revealed that the
effort was appreciated by jail authorities and inmates
equally. It created awareness on both the topics so
executed for practicing safe health.
The exhibition was concluded with a positive
note by both Director, CHEB and the Inspector
General (Prison) to have these exhibitions in future,
too on other topics.
307
Role of Mass Media in AIDS Prevention
Mass media particularly has a vital role to play in the prevention of AIDS.* Media has to
be careful and responsible in the reporting of AIDS and HIV. According to the London
based UK NGO AIDS Consortium for the Third World, media reports can be misleading
due to:
• Inaccuracies, or careless use of language.
• Indiscriminate reporting on scientific information, or unbalanced selection of
scientific stories.
• Misinterpretation or sensationalizing of information.
• Personal attitudes of reporters and editors which have influenced their
reporting.
• Misleading headlines, subheads and editorial introductions.
• Repeating information, which though reported accurately at that time, has later
been proved wrong.
• Failure to keep pace with rapidly changing information.
• Unfortunate use of quotes which seem to give credence to inaccurate and some
times damaging misinformation.
Authors of the month
Shri P. R. Dasgupta
Dr A. K. Mukherjee
Additional Secretary & Project Director,
Director General of Health Services
and
and
Dr Shiv Lal
Additional Project Director (Tech.)
National AIDS Control Organisation
Ministry of Health & Family Welfare
II Floor, IRCS Building
1 Red Cross Road
NEW DELHI-110 001
Dr K. M. Pavri
Asstt. Professor
and
Dr D. Scngupta
National Consultant
Dr S. Kant
Dr S. Vcnkatesh
Dr C. Singh
Senior Resident
Centre for Community Medicine
Al IMS. Ansari Nagar
NEW DELHI-110 029
Dy. Asstt. Director General (P.H.)
Dr V. K. Tewari
Directorate General of Health Services
Nirman Bhawan
S.T.D. Centre
Safdarjung Hospital
NEW DELHI- 110 029
NEW DELHI-110 011
M. Sharada
and
Dr S. K. Kate
K. C. Singh
CA.R.C.
Professor of Medicine
Institute for Research in Reproduction
Jehangir Merwanji Street
Parel, BOMBAY - 400 012
Indira Gandhi Medical College
National Medical Library
(D.G.H.S.)
Ansari Nagar
Ring Road
NEW DELHI - 110 029
Project Director
308
NAGPUR (Maharashtra)
S waste Hind
BOOK REVIEW
Implementation of the Global Strategy for
Health for All by the Year 2000 :
Second Evaluation
Eighth Report on the World Health Situation
This seven-volume work provides a detailed
assessment, at global, regional, and country levels, of
the extent to which strategies to develop health systems
based on primary health care are being successfully
implemented. The assessment which also constitutes
the Eighth Report on the World Health Situation,
draws upon findings from national evaluations and
data submitted by 151 countries covering 5200 million
people and representing 96% of the world population,
thus providing an unprecedented basis for a frank
appraisal of health conditions and the factors that
influence them.
Emphasis is placed on changes in the world
health situation as measured through data, covering
the period 1985-1990, on several well-defined indi
cators of health status and progress in reaching the
social goal of health for all. Noting that the health for
all strategy is essentially a quest for social justice and
equity, the report gives particular attention to changes
in the health status of vulnerable or disadvantaged
groups and to the plight of populations in the least
developed countries. Throughout, an effort is made
to identify the lines of action needed to move forward
in a world characterized by continuing population
growth, increasing health problems, and shrinking
funds for health and development.
The report consists of seven volumes : a global
overview (volume 1) followed by individual reports
from each of WHO’s six regions (in press). All
regional reports were prepared according to a common
outline. Each begins with an overview of socio
economic developments, changes in the health system,
and changes in health status as indicated by statistics
on morbidity and mortality. An evaluation of overall
achievements, particularly concerning implementa
tion of the strategy for health for all, is followed by an
analysis of problems likely to dominate the future and
the actions that might be taken. Each regional
volume also features a series of richly detailed profiles
on health conditions for each country.
—Volume 1 : Global Review
1993, vi + 183 pages (available in English. Arabic. Chinese.
French. Russian and Spanish in preparation)
ISBN 92 4 160281 3
‘ Sw.fr. 35.-/USS31.50
In developing countries: Sw.fr. 24.50
Order no. 1231008
WHO ♦ Distribution and Sales • 1211 Geneva 27 •
Switzerland
The first volume provides a global overview of
changes in the world health situation as determined
through an analysis of data submitted by 151 countries
for 1985-1990. Focused on a number of well-defined
indicators of health status and its socioeconomic and
environmental determinants, the report aims to dis
cern trends, measure progress, define problems, and
thus guide countries in their continuing efforts to
strengthen health systems and improve the acces
sibility and quality of care. Emphasis is placed on fac
tors linked to progress in the achievement of coverage
by primary health care, equity in health, and sus
tainability in the national approaches employed.
The book has eight chapters. The first evaluates
global political, economic, demographic and social
trends and considers their health implications, includ
ing several consequences linked to the continuing
global recession. The second chapter, devoted to
health systems, evaluates the success of national
efforts.to achieve universal access to essential health
care. Factors that have slowed progress are identified
together with other factors consistently linked to the
successful development of health systems. Subse
quent chapters review progress in health care coverage
and assess changes in financial resources, human
resources, and health technology.
Expanded
immunization is identified as the greatest public
health success story of the past decade.
A chapter devoted to health status uses data on
mortality, morbidity and disability to discern trends,
identify the leading causes of death and ill-health,
and profile the major determinants of health. En
vironmental policies, hazards and risks are covered in
.the next chapter, which concludes that, national
capabilities for controlling environmental pollution
have improved very little since 1984. The remaining
chapters analyse the main achievements in terms of
health care coverage and changes in health status, dis
cuss major trends in health and consider how these
trends may develop. The final chapter identifies
issues that need to be addressed in order to accelerate
progress towards health-for-all goals.
ISSUED BYTHE CENTRAL HEALTH EDUCATION BUREAU (DIRECTORATE GENERAL OF HEALTH SERVICES), KOTLA MARG,
NEW DELHI-110002 AND PRINTED BY THE MANAGER, GOVERNMENT OF INDIA PRESS. COIMBATORE-641 019.
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