ICMR BULLETIN VOL. 22-No. 11 & 12-NOVEMBER-DECEMBER-1992
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- ICMR BULLETIN VOL. 22-No. 11 & 12-NOVEMBER-DECEMBER-1992
- extracted text
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ISSN 0377-^910
Vol.22,No.ll-12
November-December, 1992
mV INFECTION : CURRENT DIMENSIONS
AND FUTURE IMPLICATIONS
The din of our celebrations of victory over
smallpox had barely died when mankind was struck by
a deadlier and more virulent infection - the human
immunodeficiency virus (HIV) infeciion. Acquired
immune denciehcy syndrome (AIDS) is (he Huai stage
of this viral infection. First identified in 1981, in the
USA, the infection has continued its relentless march
from one continent to another.
PROFILE OF THE PANDEMIC
By July 1992, a cumulative global total of over
500,000 adult AIDS cases have been reported to the
WHO in 168 countries1. But it is estimated that the
actual number may be nearer 1.7 million (Figi). It is
believed that over half of all adult AIDS cases thus far
have occurred in sub-Saharan Africa. In addition, it is
estimated that by early 1992 more than 500,000
paediatric AIDS cases also may have occurred with
more than 90 per cent in sub-Saharan Africa.
Based on currently available data the WHO
climates that a cumulative total of 10-12 million adults
and 1 million children have been infected with the HIV
since the beginning of the epidemic. The sub-Saharan
Africa bas over 7 million infections; North America
and Latir America (including the Caribbean Islands)
have oxer 2 million, South and South-East Asia over
1.5 million; Europe (including countries comprising
tl,c erstwhile Soviet Union) lets over 500,000; North
Africa and the Middle East have 75,000； Australasia
h is over 30.000 and East Asia and the Pacific have
ai^proxiinatcly 25,000.
U is believed that nearly I million persons have
newly acipiired the infection during the first six months
oi 1992. Of these about half live is sub-Saharan Africa,
al out one quarter.in Asia and the Pacific (vast majority
in South and South-East Asia), and a little more than a
te uh i:ve in Larin America and the Caribbean. It is also
estimated that nearly one half of the new adult
infections have occurred among women.
As of 1 November 1992, a total of 1,250 casfis- of*
A/DS have been reported from South-East Asia, 95%
of these are from Thailand and India.
Epidcinic in India
.,
The first HIV seropositive individual in India was
identified in 1986 among the prostitutes of Madras city.
Since then the surveillance activities were gradually
eK[ andc(:, resulting in HIV testing of over 1.5 million
peisons by the end of October, 1992. The surveys
co'/ered various groups, including heterosexual
prcmiscuous males and females, injecting drug users
(ID Us), pregnant women, blood donors, and recipients
of blood and blood products. The data for all groups
Thii9 issue commemorates the World AU >S Day (December 1, 1992)
Reported : 5,00,000
Estimated : 17,00,000
a hemophiliac was reported a month later. SmCfe then,
242 full blown AIDS cases have been reported till
October 31, 1992,to the MinistryHealth & Family.
Welfare from 16 Slates and Union Territories of the
country.
HIV Infection in India: Current Figures
Fig.l Cumulative percentage of adult cases (Mid - IS'92).
(♦ not including USA)
combined, showed that the HIV prevalence rates grew
from 0.2% in 1986 to 0.7% in 1992. In Bombay HIV
prevalence among commercial sex workers has j .iinped
from 2% in 1988-89 to about 40% in 1991. In Manipur
the prevalence of HIV,was about 54% in IDUs. Studies
conducted at the Christian Medical College (CMC),
Vellore on time trends of HIV inlCvtion among the
thrt^e promiscuous groups combined (ie prostitu* es and
male and female STD patients) show a 1.5 fold
increase in prevalence from about 15 per 1 )00 in
1986-87 to about 23 in 1991-92. Time treads of
infection among prostitutes alone show that the
prevalence increased by a factor of 12, from 37 per
1000 in 1986-87 io 452 per 1000 in 1990-91. Similarly
there is a trend of increasing prevalence among the
male and female STD patients, but at a lower rate than
in the prostitutes. In pregnant women, and blood
donors the prevalence has remained stationary or has
increased very slightly.
Through these surveys, it was established lhat
female sex workers in the States of Maharashtra and
Tamil Nadu and IDUs in three North-Eastern States of
Manipur, Nagaland and Mizoram are leading risk
groups for HIV infection. There are indications that
injecting drug use is practiced in Calcutta and Madras
and a large homosexual population was identified in
Bombay, but HIV prevalence in these groups has not
been studied.
The first AIDS case in India which was reported in
May 1986 was infected by blood transfusion during
coronary bypass surgery in the USA. The second case,
114
According to the reports provided by the
Government of India, New Delhi the situation as on
31st October, 1992 in India was that of the 1,528,567
individuals screened, 10,856 were seropositive; a sero
positivity nue of 7,1/1000.
Cuirent status in the AIDS cases, siate-wise
breakup, probable source of infection and category of
scropusitives is shown in Tables I-IV.
Table l.AIDS cases in India
Male
Female
Indians
Foreigners
177
10
51
4
228
14
Total
187
55
242
Table Il.Probable source of infection in Indians
Category
In India
只也.usexual promiscuity
152
27
6
0
8
21
J
1
1
0
9
0
202
26
Blood transfusion
Blood product infusion
Homosexual contact
Spouse of AIDS patient/
seropositive person
Injecting drug addict
Total
Abroad
Tiihle 111. Breakup of scro positives
Auslrahisia, North /Xmcrica mid VVcsteni Europe
Seropositives
%
Heterosexually promiscuous
Homosexuals
.
Blood donors
Patients on dialysis
Antenatal mothers
Recipients of blood/bld pdts.
Relatives of AIDS patients
Suspected ARC/AIDS cases
Drug users IV
Others
4483
29 .
1682
44
49
209 '
83
383
1647
2247
41.3
0.3
15.5
0.4
0.5
1.9
0.7
3.5
15.2
20.7
Tbtal
10856
100
Category
Table IV.Stale-wise number of reported AIDS cases
(as on 31.10.92)
State
No. of cases
Maharashtra
Tamil Nadu
Delhi
Kerala
Punjab
Pondicherry
Manipur
West Bengal
Goa
Gujarat
Jammu & Kashmir
Himachal Pradesh
Haryana
Rajasthan
Andhra Pradesh
Uttar Pradesh
93
73
29
16
8
6
4
3
2
2
1
1
1
1
1
1
TOTAL
242
ROUTES THE INFECTION TAKES
Summary information prepared by WHO on the
basis of reports available at the beginning of 1992,
shows the following routes of infection flab!eV)2.
The population grou p mainly a f fee ted haw
remained homosexual or bisexual r^ien and injectin；
drug users, although heterosexual transmission is(«r
the rise. Marked differences continue to exist in ihe
relative proportion of AIDS cases among homosexual
men and IDUs. The incidence of HIV infection among
homosexual men appears to have decreased inarkeJly
since the mid 1980s. Perinatal transmission u as ih)i
considered a major route of infection during I98l)s, bm
is increasing as the number of HIV infected women has
grown.
Sub-Saharan Africa
Heterosexual transmission of HIV continues to he
lhe predominant mode of spread. Because of (his. the
numbers of HIV infections in men and women are more
or less equal. As with other STDs there is a-slight
excess of women infected with HIV for a variety of
sociological and biological reasons: the male :uul
female ratio is approximately 1:1点 HIV transmission
from an infected woman to her foetus or infant is a
widespread and increasing problem. High rates of
STDs are believed to be important factors that have
facilitated heterosexual transmission of HIV in this
region. Parenteral transmission through HIV infected
blood contimics to be iclativcly sinall^iccouiHing Gu,
less than 10% of all infections. 丁he problem is
declining as routine screening of donated hlood for
HIV is being implemented widely. It is estimated that
about 750,000 HIV infected infants .had been born in
Africa by 1992.
South and South-East Asia
Although the spread of infection began only in
mid or late 1980s, its progress has been rapid. fn South
Asia the predominant mode of transmission is
heterosexual. There is some transmission through drug
injecting. In South-East Asia, HIV transmission was
initially predominant among injecting drug users.
Heterosexual transmission has been increasing rapidly
among multiple sex partners, and since 1989 this
appears to be the predominant mode of transmission.
The pandemic in this region is. still at an early siage,
but indications are that is growing quickly. There is
concern that the pandemic in this region may be
growing at a pace reminiscent of sub-Saharan Africa in
115
the early 1980s, but may have an even greater potential
for spread given the adult population of nearly 500
million as comp a red with 225 million in the subSaharan Africa.
Latin America and Caribbean
Estimates of total HIV infections are difficult to
make for this region because of relatively limited data
available. In Cenlial America there has been a 40 *
fold increase in the rates of reported clinical AIDS
cases in women in the last tour years.
According to recent analysis 10,000 children in
Latin America -have already been burn with HIV
infection. In addition to the groups of HIV infected
homosexual or bisexual nien, there is increasing
heterosexual transmission. HIV infection among
injecting drug users also appears to be growing in some
countries.
Tlie cumulative total of HIV infections as of 】992
is estimated to be over 1 million, and the total number
of AIDS cases is estimated to be about 150,000.
East Asia, Pacific, Eastern Europe and former
USSR, North Africa and Middle East
The predominant modes of transmission in these
areas are not fully delineated because of the relatively
recent spread of HIV in these areas. Limited data are
available on the prevalence of HIV infection and the
number of AIDS cases.
Table V.Summary of predominant modes of HIV
transmission
Mode of transmission
• Estimated
efficiency
%
Sexual intercourse
Vaginal
Anal
0.1 -10
% Wai
infection
(Global)
75-80
60
15
Blood borne
Transfusion
Injecting drug use
O&ers (eg tattoos)
> 90
0.5-1,0
< 0.5
5
10
small
Perinatal
20-40
10
116
PROJECT ING THE COURSE Ol< THE
*
Estimates and Projections
Estimates of the currein siluation and
for the future of HIV/A1DS are crucial to health car.
planning and for designing of prevention and treatinem
strategies. Such estimates are necessarily made by using
the available(Iata however inconiplete. and the
extrapolating these data lo specific populaiions.
Mathematical models are used to bridge (he gaps in
information. Forecasts of the future course of the
epidemic depend largely on the underlying assumptions
about the transmission dynamics of HIV in tec (ion.
Even if some adjustments are made for reporting
delays, based on calculations of average past reponing
delays, there is little assurance that such adjustment
will be adequately correct for current or fnturc
reporting delays.
Modelling these dynamics is extremely difficult
because of the large number of biological and
behavioural variables required to describe the spread of
HIV. A range of models exists for the purpose. But
none appears to be simple enough to be useful and
complex enough to re fleet the realities of the disease.
Estimates of HIV infections can be made using rhe ■
available HIV prevalence data and then exirapokuing it.
In the other commonly used model AIDS ease rep()rts
and annua! progression rates of HIV infection to
development of AIDS have been used to estimaie ihe
number of annual HIV infections by back calculation.
A simplified variation of this method uses an estiinaicJ
ratio of HIV infections to AIDS eases to calculate
HIV infections. All these methods have limitations.
hi 1988 the WHO used a Delphi survey to project
HIV prevalence to the year 2000. hi
lv'92, "io
Harvard School of Public Health, USA, estimated and
projected the numbers of HIV infection which may
occur globally. Their projections are depicted in
TableVI [James Chin, Second Internationa! Congress
on AIDS in Asia and Pacific (SICAP), 1992|.
Tnble Vl.Cumulutive adult HIV projections to the
year 2000 (in millions)
Area
WHO
Harvard
'High，
•Low'
North America
Western Europe
Sub-Saharan
Africa
South-East Asia
Latin America &
Caribbean
01.63
00.85
15.00
01.80
01.19
20：78
08.15
02.33
33.61
10.25
02.37
11.28
02.14
45.06
15.51
。
Th us&n du
E • W HIY
Total
37.20
30.10
Naids
T hu
104.66
Fig,2 Cummulative projections for India.
Estimates and Projections for India
The data generated through sero-surveillance
activities has been used for making projections (Fig2)
and estimates (TableVII) for India also. Using a mode!
developed by the WHO the following scenario is
predicted for India (Shiv Lal, SICAP, 1992).
Table VII.Estimates of the number of HIV infections
in urban India based on serosurvey data (1991)
Group
Female prostitutes
Clients of female
prostitutes
Injecting drug
users
Male homosexuals
S A females
(15-45 yr)
S A. males
(15-45 yr)
Rural S A
population
Estimated Prevalence Estimated
number
no. of
(%)
(in million)
+ves
1
3
15
7.5
150000
225000
50
25000
0.15
43
20
0.07
30000
30000
52・
0.34
177000
263
NK
NK
0.05
•
FIbtal
S A : Sexually Active; N K : Not Known
> 637000
The Delhi Chapter of the Institute tor Research tn
Medical Statistics has developed a mathemacica! mode!
for estimating the current number of HIV infecte j
persons in India. According to their calculations (he
estiinaicd number of infected persons in India in
1991/92 is between 0.44 and 0.61 million (Dr. Pada n
Singh,S1CAP, 1992).'
In order to make realistic projections it is
necessary to collect more reliable data on HIV
prevalence and disease progression in specific risk
groups. Better information M
about sexual
behaviour. More data are req'ed on size of IDUs and
patterns of sharing needles sd interaction between
drug abuse and sexual behaviour. Knowledge i< -needed
about the effects of other infections, the infect；ou<ness
of an infected person, the factors that are crucial in
converting an asymptomatic to symptomatic state, :!nd
the percentage of people who will progress from HIV
infection to AIDS.
Predictions/projeeuuns of HIV is a tricky business.
It relies heavily on the accuracy of the data used f<-r
modelling. Seroprevalence studies, thus form tlie corner
stone for generating reliable information iha( is
representative of specific population groups. In India.
ELISA based test has been used tor screening purposes
and Western Blot as the supplemental test. Cost of the
hard ahd software of these tests has hindered (he
expansion of serosurveillance activity. There is a need
to use. an alternative strategy to conduct these activities
economically.
*
ALTERING THE COURSE OF HIE EPIDEMIC
Evolution of AIDS/IIIV Control in India
Whatever is known today about HIWAIDS in
India is largely due to the foundations laid by the Indian
Council e Medical Research (ICMR) in close
collabo. ation and cooperation of the Ministry of Health
占
.：ly Welfare and the Directorate General of
,Services, Government of India. The existence of
HIV infection in India was shown through the efforts of
ICMR. Centres were established throughout the couniry
for serosurveillance and they were linked to Reference
Centres for supplemental Western Blot testing and
quality control. The results of serosurveillance provided
insights to the main routes of transmission and
identified the major high risk groups. Further,
operationalizing the blood donor screening programme,
and testing of blood products for HIV infection was
undertaken by the ICMR. Training and human
resource development was an important contribution in
setting up the screening facilities in ?hc country. The
surveillance activities also highlighted the fact that no
section of the community is safe and that more and
more people were getting infected. The virus was
spreading rapidly.
Based on the information generated by the
Council's efforts the Government of India formulated
and launched the N.o费d AIDS Control Programme
(NACP) in 1987 - with
year of detection of HIV
infection in India. The programme had three main
components viz. surveillance, screening of blood and
blood products, and health educaliot! and infonnation.
In 1990, a three year medium term plan was prepared in
consultation with the WHO. The plan at an estimated
cost of US $ 20 million, focussed on tour metropolitan
cities (Delhi, Bombay, Calculta am! Madias) and four
States (Maharashtra, Tamil Nadu, Manipur, and West
Bengal). During this period the rapid evolution of the
epidemic became clearer and it was decided to expand
and accelerate the activities of the Programme. With
thi(s in view an expanded comprehensive strategic plan
for a period of five years (1992-96) for control of
H1V/AIDS in India was formulated. The plan envisaged
a broader range of activities and required extensive
inter-sectoral and inter-disciplinary co-ordination.
The Government of India sought the assistance of
the World Bank fbr implementing the strategic plan for
118
prevent.ion and control of AIDS in India, ar?d
subsequently a US $ 100 million project was drawn up
with the Wor'd Bank loan acting as a start-up
inveslincnt. For the nation-wide iinp.lemciKation of this
project it was considered necessary to have an
organization at the centre dealing exclusively wiia
AIDS prevention and control. Thus was born the
National AIDS Control Organization (NACO) in July
1992.
Establishment of N/kCO
The HIV/AIDS control straiepy under ihe NACC>
would have seven components1
Strengthening progranum, hiuna\*cinent, monitoring,
review and evaluation
A strong and effective programme management
structure is foreseen at the national and state levels.
Four co-ordinating bodies have been formed at the
central level: a National AIDS Committee representing all ministries, selected private
organizations and NGOs; a Board for AIDS Control formed from officials of the Ministry of Health and
Family Welfare to oversee the programme, funding an(2
policy; National Progratume Co-ordinating Team
operating as a technical mission to implement
programme activiries; and a National Techriical
Advisory Committee to provide technical support U)t!：c
Programme. Simultaneously at the state level, an .
Empowered Committee headed by the Chief Secretary/
Additional Chief Secretary will oversee ihe
programme. The State AIDS cell will be
strengthened/established with appropriate resources and
staff. The technical aspects uf the programme will be
reviewed periodically by the State technical Advisory
Committee.
Suryeillance and research
The objectives of this component are monitoring
the development of the HIV/AIDS epidemic, pruvicir.^
relevant information requ；r d for niobilization of the
nation-i? :socia! lenders and vxterr•:-J
oUppon, ua granuning targ.；t-uriented ipterventioft
activities, and nieasuring their impact on the epidemic
development. The sufveiHance would inciuJe mo
aspects: HIV surveillance »nd AIDS case surveillance.
*
Infonnation educanon and c()inmunication(l^C) and
social mobilization Jar prcvenfion of HI V
transmission through behaviour
This component seeks to ident;/y and formuiate
strategies for raising awareness among gswl public
about HIV and AIDS so as to inculcate positive values,
attitudes and behaviour for self protection from the
disease. A comprehensive information, education and
communication strategy must seek to garner and fully
utilize the communication skills available within and
outside the government, and mobilize allies in the effort
at every level to work for preventing the spread of
AIDS on a participatory basis.
To accomplfsh this a comprehensive programme
will be developed with the following elements: media
campaigns utilizing standardized messages, targeted
interventions for high risk groups, collahoratiun and
support of the .NGOs, social mobilization, training,
operational research, evaluation and monitoring. This
component will link closely with other components of
the programme.
Control of sexually transmitted diseases
Sexually transmitted diseases (STD) are associated
with the same risk behaviours that put a person at risk
for HIV infection, and ultimately AIDS. In addition,
STDs are now recognized as an independent risk-factor
for HJV infection and AIDS, facilitating both the
acquisition and transmission of the HIV. It is this
relationship to HIV infection that renders STD control
imperative in the control and prevention of HIV
infection.
In the first place, control of STDs will remove
these diseases as a risk factor and so reduce HIV
transmission. In the second place, comprehensive STD
control programmes, by providing good quality clinical
services to STD patients, also provide access io t/iis
sometimes heterogeneous and often elusive group. As
STD patients are an importam risk group for HIV
infection, including for example prostitutes and their
clients, this provides a unique opportunity for I EC,
counselling and social.mobilization interventions.
The existing STD control program me will be
revitalized, pilot programmes will be initiated in the
major metropolitan cities.
Condom pro^ranimin^
1 leicroscxtia! intcrcouisc is the doniiiEnit mik1•which HIV is transmitted in India., Recent WHO
estimates suggest that in 1991 there may have heen
more than 6,50,000 HIV infeetjed Individuals in hM：.:
who have relations with a monogamous, unin.ected
partner. The only feasible method recommended e
avoid transmission of infection during sexual
intercourse is by the proper and consistent u：：e
condom.
Recognizing that some people have unikiplc Sex
partners and engage in risky sexual bchavidi-r,
acknowledging tlie experience of exp、
seroprevalence rates in other countries with HfV
transmission patterns similar to those in India.
Government of India has established a strong pusiiion
of support for condoni promotion for STD/Hi V
preventionensure that people who chooseengage
in risky sexual behaviour have access to good quality,
low cost (or tree) condoms with information (hat is
needed for proper and effective use.
Blood safety
There are 1018 blood banks in the coun*
handling an estimated 2 million units of bigd ner
annum. This works out to be about 3.3 units njr
hospital bed, which is much lower than the WHO nunn
of 7 iiiuis per annum per beil. Of the 101S banks. oOS
are under government/public sector. A signiiicantiy
high number, ie 203 blood banks are run by private
profit-making institutions. These are the conunercia!
blood banks which primarily obtain their blood tYur.i
professional donors.
In addition, voluntary
organizations such as the Red Cross run 56 blood banks
in the country. With the rapid expansion cf heahh
services to the periphery and
such as
cardiac and neurosurgery being csid
.扑…
、
metropolitan and bigger cities, the deinand
-.
and components is expected to rise rapidly. M；顷"
expansion of the volunury donor base, largely by
NGOs and other agencies, is the greatest single need
tbr improving blood Weiy in hidiu.
The Governmenl hg established a nc(vv<»r*;
testing centres for the testing of blood which arc L?、,」:
in metropolitan cilies, capitals of Slates and in [(八g
hiving a population of more than 0.5 million.
are now being expanded with the intention that every
unit of blood collected will be tested for satety.
The blood safety programme will develop and
strengihen the national blood transfusion system, ensure
adequate supply of blood to the blood centres, and
ensure safety of blood and blood products. This will
involve upgrading existing centres, extensive training,
and the expansion of the voluntary blood donation
system. The Drugs and Cosmetics Act has been
amended to ensure that all blood and blood products
available in India, are HIV-free, and that standard
manufacturing practices are followed. Simultaneously
30 component separation facilities would be established
to ensure more optima! and rational use of blood.
Reduction of impact of AIDS/HIV
Counselling for HIV infected individuals and
AIDS cases will be integrated into lhe existing
counselling and health care systems. Training of AIDS
counsellors will be given priority. In addition, an
assessment-will be made of potential home care
schemes to accommodate future AIDS cases.
Guidelines for the management of people with AIDS
are being prepared, and training for health workers
caring for AIDS patients will be an ongoing activity.
The project takes a multi-pronged approach and
focuses on the most critical interventions to limit HIV
transmission today. It also sets the basis for more
extensive HIV/AIDS control activities in the future.
The project activities will be integrated to the
maximum extent within the existing health
infrastructure and there will be extensive collaboration
with the private sector and NGOs in areas in which
they have a comparative advantage.
Birth of National AIDS Research Institute
AIDS is a reality in India. It cannot be wished
away. There is enough data to indicate the devastating
course the infection is taking in several countries
especially in the African continent. The current
estimates and future projections tor India are alarming.
During the last seven years the Council had pioneered
AIDS related work in India and played a key role in
generating information about all aspects of HIV
infection in India that vve know today.
120
Having done its bit in assisting the Government to*
fornnilate and operationalise NACP, (he Council can
now focus with greater zeal and vigour on research
issues. The emerging picture of HIV infection, which is
likely to engulf the entire country, is one that will
challenge the nation*s capabilities in terms' of
biomedical research, health care, and health education
and economics. Encouraging news about developnicnr
of a vaccine and therapeutic agents offer a gliinmer of
hope. India should be in a state of preparetlness to field
test, adopt and adapt the emerging technologies needed,
for control of HIV/AIDS in India.
There is an urgent need to develop self-reliance.
indigenous te. \ oology and expertise to deal with the
AIDS problems in India. Information on natural history
of the disease, clinico-pathological spectrum should be
generated. Isolation of virus and its characterization is
to be taken up on priority to know the degree of
similarity with the strains known in the Western World.
If the Indian strain turns out to be different, the
suitability of using in India, diagnostic kits and vaccines
developed for the Western strain would need to be re
examined, and if possible, develop our own tools for
the purpose.
Realizing the importance of the HIV infection and
the crucial role it would play in shaping lhe health ut
the people of India, the Government has set-up (he
NACO. It is the focus for the implerr.. . ation of the
NACP. To spearhead India's research efforts on
HIV/AIDS a National AIDS Research lns(i(u(e (NARl)
has been established by the ICMR at Pune,
Maharashtra. The Institute is expected to be multi
disciplinary in nature, initiating, co-ordinating and
evaluating multifaceted studies on HIV infection.
The objectives of NAR! includes the following (i)
provide leadership in research on H!V infection ；m<!
AIDS; (ii) conduct in-depth virologicak inimunolugieal,
clinico-palhological, epidemiological studies io define
the natural history of HIV infection in India; (iii) study
sociological, anthropoUigical and psychological aspects:
(iv) establish suitable hospital facilities for clinical
studies and laboratory research in AIDS related
opportunitistic infections with training in cast
management; (v) develop suitable preventive and
-counselling strategies; (vi) impart training for human
resource developments; and (vii) undertake field and
clinical trials of chemotherapetnic, immunoprcphylactic
and immunotherapeuctic agents as and when they
become available.
UNDERSTANDING THE EPIDEMIC:
RESEARCH STUDIES
HIV Infection
IDUs
The AIDS scenario in India has been rapidly
changing with the tremendous increase in HIV
seropositivity among the prostitutes in Maharashtra
Tamil Nadu as well as in other states. The prostitute?'
and the professional blood donors have been identified
as the major high risk groups in these areas. However,
an alarming situation has been created due to ar
explosive epidemic of HIV infection in some NorthEastern states viz. Manipur, Nagaland, and Mizoram,
primarily due to the presence of a large numher ol
intravenous heroin users during last couple of years.
Heroin is available freely in these states from the
Golden Triangle through the international border with
Myanmar and along National Highway 39.
Following detection of the first HIV positive IDU
in Manipur in 1989, systematic studies have been
carried out by the 1CMR Unit in these states.
Community based survey by key informant technique
and snowballing has revealed that the prevalence of
IDUs varies between 1-2% of the total population in
urban areas of the three states. The prevalence of HIV
varies between 10-50% in IDUs. The substance abused
are heroin and analgesics. Over 10,000 HIV positives
among estimated 25,000 IDUs are fast spreading the
infection to prostitutes and other sex partners. Condom
use is low (1.3%). The studies have highlighted the
urgent need for targeted intervention among IDUs and
their sex partners, prostitutes and their cbents including
truck drivers.
Manipur, Mizoram and Nagaland represent only
3% of India's population but contribute about 15% of
the country's seropositive cases.
HIV Infection and Tuberculosis
The epidemic of HIV has trigerred off a secondary
epidemic of tuberculosis worldwide. It is estimated that
more than 3 million people are dually infected with the
tubercle bacillus and HIV. Of these, 2.4 million are in
sub-Saharan Africa where the AIDS epidemic is
having a devastating effect. There has betin upto 100%
increase in reported tuberculosis cases in the last 4-5
years. HIV seropositivity rates vary widely from region
to region (from 17 to 55%) among those with
tuberculosis. Tuberculosis has emerged as the
common presenting condition of AIDS in Thailand.
At the Tuberculosis Research Centre (TRC),
Madras. 220 HIV positive persons are being followed
up for develQpm'ent of tuberculosis. Of these, 115 had
an abnormal chest radiograph. The sputum of 34 of
these patients showed Mycoba cteriurn tubercult)sis c»n
culture. Another 34 had grown non-tubercu!ous
mycobacteria. Tuberculin reaction of 12 mm or more
was seen in 113 patients (51%). Forty two infected
individuals (34 with positive bacteriology and 8 with
persistent abnormalities on X-ray) have been started on
a 9 month short course anti-tuberculous therapy.
Another study from the National Institute of
Virology(NIV), Pune, shows that of the 269 HIV
positive persons, 11 had concomitant tuberculosis
infection.
In order to study the trend of HIV infection in
tuberculosis patients,screening of all cases of
tubercuh^sis who reported to TRC, Madras, the District
Tuberculosis Centre(DTC) and TB sanatorium.
Ve-lore, has been undertaken. Of (he 307 I tested
dining 1991, 12 were positive on WB. At NIV, Pune
359 tuberculosis patients were screened for HIV, 4
tested positive by WB.
PPD reactivity has been used in several countries
to estimate the risk of development of tuberculosis in
HIV infected persons. Tuberculosis skin test with 5
tuberculin units of PPD producing an induration of 5
mm or more in HIV positive persons has been
suggested to indicate M.tuberculosis infection. The
validity of this test in Indian conditions should be
assessed. Guidelines for clinical management of
tuberculosis in HIV positive persons and role of
chemoprophylaxis (using isoniazid alone ur in
combination with other drugs) in tuberculin reactive
individuals need to be worked out.
MTV in Andamans & Nicobar Islands
Recent investigations carried out by the ICMR
among the jail inmates at Port Blair, Andaman &
Nicobar Islands revealed that 23% of Thais, 3%
Burmese and 1 Pakistani were infected with HIV.
These foreigners had entered illegally through sea-route
for fishing and smuggling. A good number of them
admitted to have sexual contact with local girls which
included both the sex workers at Port Blair as well as
tribal girls in different peripheral islands. Therefore,
study on seropositivity for HIV infection risk behaviour
of several sub-groups is being undertaken in different
islands. There is an urgent need to implemen
intervention methods rapidly to contain the spread of
infection which is still believed to be low.
Detection of HIV-2
Until recently epidemiological investigations had
indicated that, with a few notable exceptions； HIV-1
and Hl V-2 had occupied quite distinct geographical
areas. As a consequence the laboratory differentiation
of HIV-1 and HIV-2 infections was not considered to
be
major problem. However, HIV-2 has made
subs(；m(ial and rapid inroads into countries, such as
some of chose of West Africa, where HIV-1 had been
by far the more prevalent HIV infection, Moreover,
recent serosurveyC utilising combined HIV-1+2
screening tests and appropriate supplemental procedures
have now identified several countries in which
substantial number of HIV-2 infections have been
diagnosed, where formerly only HIV-1 had been
recognized. HIV-1 and HIV-2 are circulating in the
same risk groups and a proportion of infected
individuals appear to be infected with both HIV-1 and
HIV-2. Elsewhere HlV-2 infection occurs much less
frequently than HIV-1 and.the occurrence of dual
infection is likely to be a rare event.
The simultaneous circulation of both HIV-1 and
HIV-2 in more geographical regions increases concern
about the frequency of and interpretation of dual
reactivity in serological tests for anti HIV-1 and antiHIV-2.
The modes of transmission for HIV-2 have been
shown to be identical to those of HIV-1 and it is clear
that infection with either virus leads to
immunosuppression and AIDS. Some data suggest that
the incubation period for AIDS may be longer for
HIV-2 and that transmission may occur less readily,
particularly from pother u> child. However, apart
from the risk to offspring of HIV-infected women the
significance of the diagnosis in terms of prognosis arid
preventive counselling are the same and consequently a
differential diagnosis is of little value for these
purposes.
On the other hand, specific data on the prevalence
of HIV-2 infection is valuable for the purposes of
napping the spread of HIV-2 infection and wiil
influence the choice of appropriate screening tests and
supplemental strategies. Studies of the pathogenesis of
HIV-2 and its comparison with that of HIV-1 will be
dependent upon feasible and accurate discrimination
between the two infections and dual infections. The
valid analysis of the efficacy of future expected
interventions by chemotherapy, immunotherapy and or
vaccination will in most instances depend upon
accurately identifying whether subjects are, or become,
infected with HIV-1, HIV-2 or both viruses.
Studies carried out at the NlV, Pune; CMC,
Vellore, Institute of Immunohaematology (IIH),
Bombay and other centres have shown that HIV-2
infection exists in India. During 1991/92, screening of
200 blood samples for HIV-2 at NIV, Pune, showed
that 75 (37%) were reactive to HIV-1 only, 14 (7%) to
only HIV-2, and an equal number 14 (7%) was reactive
to both HIV-1 and HIV-2. HIV-2 infection was
detected mostly in prostitutes and STD patients. All the
14 HIV-2 positive samples were indeterminate by HIV1 Western Blot (\VB). Thus it is suggested that HIV-1
WB indeterminate samples should be tested for
presence of HIV-2 antibodies. As the prevalence of
HIV-2 is increasing, it may be necessary to use
combined HIV-1 and HIV-2 kits for surveillance
purposes.
Virus Isolation and Characterization
Laboratories at the All India Institute of Medical
Sciences (AIIMS), New Delhi; and NIV, Pune, have
continued their efforts on HIV isolation and
characterization. In addition to these laboratories,
National Institute of Cholera &. Enteric Diseases
(NICED), Calcutta, has also standardized newer
techniques including PCR, reverse transcriptase and
antigen detection assays. P-3 facilities are being
established at these centres. At NIV, Pune, virus
isolation was attempted from the blood of 55
seropositive individuals. Two of the 55 were found
positive by reverse transcriptase enzyme assay, and one
proved reactive also for antigen by the Abbot antigen
detection kit. Further work is in progress.
Follow up of Scropositives
At All MS, New Delhi; NIV, Pune; UH, Bombay;
and CMC, Veliore, seropositive individuals are being
up tor clinical :nxl immunological profile. At
NIV, Pune, the mean CD4/CD8 ratio, and percentage
of CD4 cells were found to be significantly decreased
in HIV scropositives as compared to the healthy
controls. At CMC, Veilorc, the ratio and counts of
CD4 and CD8 of asymptomatic HIV infected
individuals, AIDS patients, sexual partners of
scropositives vyho remained HIV negative and normal
controls have been studied. Of the three parameters
studied, CD4 numbers correlated well with HIV
infection, progression to clinical disease and subsequent
result. The WHO criteria for diagnosis of a clinical
case of AIDS was applied to Indian cases at A【IMS、
New Delhi. The study showed that delayed cutaneous
hypersensitivity, CD4+ cell counts and CD4/CD8
ratios were good indicators of immunodeficiency.
Absolute lymphopenia was a relatively rare feature.
Studies are in progress.
Socini Aspects of KIV infection
Tb obtain baseline data on the psychosocial habits
and characteristics of different risk groups, a study on
jail inmates of the Central Jail, Pune was undertaken.
During 1991/92, 998 inmates (952 males, 44 females
and two eunuchs) were interviewed. The inmates were
found to have come from a poor socio economic
background. Their exposure to sex was early;
premarital and extramarital sex was prevalent with an
average of four partners; maximum being 9 in the case
of the eunuch interviewed, though 51 inmates
(including four prostitutes) had more than 50 partners.
The partners were mainly of the opposite sex, though
homosexuality was reported by a few. These findings
are of serious concern because as many as 42 inmates
(35 males, 6 females and one eunuch) were found to be
positive for・ antibodies to HIV.
*•
Sentinel Surveillance
Sentinel HIV testing for surveillance purposes is
being pursued by the Council to monitor the trend in
HIV infections over time and place. In sentinel
surveillance, selected groups within a population act as
'sentinel* groups. It is believed that these data would
provide information of sufficient accuracy for
monitoring and targeting HIV/AIDS prevention and
control activities. Testing is unlinked and anonymous.
It is essential that laboratory quality assurance
procedures be maintained by all HIV testing
laboratories, and procedures th ar ensure as far as
possible the correct laboratory diagnosis of HiV
reactive sera are vital to HIV/AIDS prevention and
control efforts. Both internal and external quality
assurance are essential and be adhered for monitoring
the standard of local laboratories.
IMPLICATIONS FOR THE 1990s
Based on the available data on the current global
status of the pandemic, WHO estimates that during
1990s, 10-20 million new HIV infections may be
expected in adults, mostly in developing countries2.
During the same decade, the WHO projects that 5-iO
million children will have been born with HIV, the
majority of them in sub-Saharan Africa. The number of
AIDS cases will increase rapidly during the 1990s/
from an estimated 1.7 million in mid 1992 to a
cumulative total of close to 10 million by the year 2000.
This increase is inevitable because it is estimated that
about 10-12 million have been infected with the virus
that leads to AIDS, a figure likely to increase four fold
(30-40) by the end of the century. In addition, there
will be 10 million or more children less than 10 years of
age orphaned as a result of AIDS, primarily in
developing countries.
Through the 1990s, homosexual men and injecting
drug users will continue to be the population groups
most affected by AIDS in Australasia, North America
and Western Europe, but it is expected that new
infections will .occur.predominantly in heterosexuals
with multiple sex partners.
The projected total of HIV infected infants in subSaharan Africa by the end of 1990s is 4.8 million.
123
These figures are based on perinatal transmission rate
of about 30%, Upto 70% of inlants of IHV infected
mothers will be born uninfected. These uninfected
infants will constitute a growing group of potential
orphans, since musl of their IHV i(Heeled mothers will
die of AIDS within 5-10 years of their birth. AIDS
•*\ r”h, ?<•
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many emmuics this would wipe out (he gainy in child
vlvn! jjrhh'viul
I wo
!n In* f»e
l/i ll(IH f|j
ill "l|h
ilil Il 11 ih V'U*1'： ht|| \ III l: if>*|
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)S dviiihh in ymipg vhildicu and
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population growth by more than 30%. The adull
inoriallty rale may more ihan triple.
Projections derived from HIV modelling in
Thailand indicate that if no major changes occur, there
may be a cummulative total of 2 to 4 million HIV
infections by the end of 1990s.
It is expected that the developed countries would
be better equipped to combat the HIV/AIDS problems
because of greater literacy, better financial resources,
and lower prevalence of STDs. During the 1990s the
mjijor issues will focus on health care cost, and equity
| in benefits and burdens. In the developing countries the
(disease is likely to bring (undamentai changes in the
ieconomic structure. There will be impact on the work
iforce as the age of highest economic productivity
:coincides with the age group of highest infection rate.
Regional trade may be hurl. Foreign investors will be
! discouraged. Revenue from tourism would be hard hit.
AIDS may be a huge drain on economies of highly
:infected countries. Health care expenditures on caring
:for AIDS affected persons may put a severe drain on
:national resources. Finally, AIDS may in time,
undermine political stability in some countries.
The interaction between HIV and other infectious
agent is likely to be of great public health concern.
The most significant may be M.tuberculosis. It has
been shown that individuals with dual infection of HIV
and TB develop clinical tuberculosis more rapidly than
persons without HIV infection. WHO estimates that by
early 1992, about 4 million or more adults had become
infected with both HIV and M.tuberculosis. There is a
high prevalence rate o f M. tuberealoxis i n feet ion in subSaharan Africa, Latin America and Asia. As
124
prevalence of HIV infection in these regions inc raises,
the 1990s is likely to witness a secondary epkleinic of :
tuberculosis in^wake of the HIV infection. In some ,
countries infection with drug resisteni M.tuberculosis is
emerging as a serious problem. It is feared that several
other countries may have io face this as major public
Hl \ \ h ii|»s
A1 pi cn I I he 11* is 加i
», f«. i r 1H V hU eft h'n
I |*H|
/ \\ |lh 山H H'd" 1<I 山 Hb” l| hit** hi hH
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piuluni* ihu Ii2 u| uii mhxiud HuilvUhuii auJ
the niiwl nl A!l)辛 YHiplMlih 'I Ih*
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use include iizidothymidinc(AZ,I,), dideoxyiriosine(dd!)
and dii!0oxycytii!inc(KlKlC), Tl心u dri心 arc
；iiki
expensive. Efforts are underway tv develop safer,
effective and economical anti-HIV drugs. One option is
to
develop
non-nucleoside
RT-inh:bitors,
benzodiazepines (also called TlBO compounds). These
are very specific and highly potent drugs but
unfortunately the virus rapidly develops resistance to
them. Drugs acting on virus replication at other stages,
such as TAT (a regulatory gene) inhibitors and protease
inhibitors are undergoing preliminary clinical :rials.
Combination therapies to improve the efficacy and
reduce side effects are also being tried out viz AZT -r
ddl or AZT + ddC(Kal!ings L.O.SICAPP, 1992).
Prospects of a Vaccine
Medical oninion varies on the prospects for a
vaccine against HIV infection. Some think it is in the
realm of reality others fee! that tKe technical barriers
may never be fully overcome. About 14-15 candidate
vaccines are in the early stages of testing. Some ut
these have already been shown to be safe and capable
of producing immune response, and will go on to be
studied for effectiveness to protect against infection,
disease or both. It should be envisaged that efficacy
trials of preventive vaccines will be conducted in
populations with high HIV incidence, both in developed
and developing countries. With the support of the
WHO, the national plans for HIV/AIDS vaccine
development and evaluation are being prepared in
Brazil, Rwanda, Thailand, and Uganda to facilitate the
collaborative participation of the scientific community
in the conduct of HIV vaccine trials. The candidate
vaccines of interest include those developed by using
recombinant virus envelope structure, gp 120, and also
by using peptides from V3 loop of the gp 120 envelope
glycoprotein. (Kallings LO, SICAAP, 1992)
The findings from phase I/H human trials of
candidate vaccines show that induction of cytotoxic T
lymphocyte has been infrequent with the candidate
vaccine to date. Moreover,
neutralizing antibodies
have been low and of limited duration of few weeks to
few months. (Barker, FL, SICAAP, 1992).
k appears that the first large scale efficacy trials of
preventive vaccines could be initiated as early as
1994/95. The first vaccine may need to be further
improved (o enhance its efficacy. This could take
another 5-10 years. Therefore, best estimates are a
minimum of ten years before a preventive vaccine is
fully evaluated and available.
Cost Effective Strategies for Selection and Use of
IIIV Antibody Tests
Recently the WHO has proposed alternative
laboratory HIV testing strategies which do not require
the Western Blot testing for routine public health
purposes4. Currently the procedure uses a highly
sensitive enzyme-linked immunosorbent assay (ELISA)
followed by lheWB assay. WB is relatively expensive
and technically demanding. Advances in technology
have produced tests which alone or in combination
provide results of equivalent accuracy and at much
lower cost from those obtained with WB tests. In
addition to newer ELISA tests, these tests include
'simple* and 'rapid' tests. Three types of strategies.
have been suggested. They are independent of each
other and not sequential. The use of type of strategy
(VII/111) depends upon the objective of testing and
prevalence of HIV infection.
Strategy / : The serum sample is tested only once. Sera
are
tested
for
HIV .antibody
by
one
ELISA/Rapid/Siniple (ERS) test. Serum that is
lCacfive is considered HIV positive and non-reactive as
HIV antibody negative.
Strategy // : In this strategy the positive sera is tested
uncc again. Any serum，)und reactive when tested
once is retested with a second ERS based on a different
antigcn preparation and/or different test principle
Serum that is reactive on both tests is considered HIV
antibody positive. Serum that is non-reactive on first
text is considered HIV antibody negative. Any serum
that is reactive on first but non-reactive on second is
also considered antibody negative.
Strategy 〃/ : Any serum found reactive when tested
once, is tested twice again. This strategy involves 3
serial ERS tests on sera. As in strategy H, the 3 tests
should be based on different antigen preparations
and/or different test principles. Serum that is nonreactive on the first test is considered HIV antibody
negative as is serum that is reactive in the first test but
non-reactive in the second. Serum that is reactive in
the first and second test but non-reactive in the third is
considered to be equivocal.
In the selection of HIV antibody tests for use in
strategics II and HI, the first test should have the
highest sensitivity, whereas the second and third test
should have higher specificities than the first.
Where the objective of HIV testing is identification
of asymptomatic HIV infected individuals, strategy III
is proposed where HIV prevalence is less than 10%,
and strategy II where HIV prevalence is more than
10%. Where confirmation of HIV antibody status is
required tor diagnosis of HIV related disease strategy II
is recoin mended. For objective of surveillance,
strategy II is recommended when HIV prevalence is
less than 10% and strategy I at prevalence more than
10%, Where the objective is transfusion safety, or
safety of transplantation at all HIV prevalences,
strategy I is to be used (TableVIII).
Table VIII. Proposed HIV testing strategies by
objective of HIV testing, HIV prevalence
Objective of testing
Tianstiision/donation safety
Surveillance
Diagnosis
Clinical signs/symptoms
ofHIV/AfbS
Asymptomatic
Strategy to be used
HIV prevalence
> 10%
<10%
I
II
I
I
II
II
HI
II
Use of such alternative testing strategies will lead
to considerable cost saving. It is believed that at 10%
HIV prevalence, the estimated cost of strategy III
would be about half the cost of a WB based strategy.
125
CONCLUSIONS
The result of the studies conducted in India since
1986 allow the following conclusions to be drawn:
(i) considering the incubation period of AIDS, and
that several full-blown adult AIDS cases resulting
from indigenous transmission have been recorded,
it is presumed that HIV was introduced to India
somewhere in the early 1980s. An epidemic
spread of the virus started in 1985-1986;
(ii) by 1992 the virus has spread to most of the States
and Union Territories of the country;
(iii) there are two distinct patterns of HIV
transmission: sharing of syringes and needles
by IDUs in North-Eastern India, and multipartner
sex in the rest of the country;
(iv) in some population groups with identified risk
behaviour HJ V has been transmitted at an alarn ing
speed, so that 30% of prostitutes have been
ipfected in a 3-4 years period in Bombay and about
50% of injecting drug users just in one. year in the
city of Imphal.
Due to the timely initiative of the !CMR, the
surveillance for detection of HIV infection was started
at a time when the number of cases was very small.
This has provided us with an advantage denie.l to
majority of nations where HIV iir ccrion and A J DS
was already high by the rime (he presence of infecJon
was detected. India also has the advantage to learn
from the experience of other countries in planning and
operating successful national AIDS con:rol
programmes, and the advantage of also avoiding failed
policies and approaches. The advantages should net be
allowed to slip away.
The view that HIV/AIDS is a 'health' problem though important, is far too narrow a frame work to
examine the wider implications h has. Its impact must
be visualized in the context of social and economic
problems which plague the country, and which stem
from this infection. The potential for HIV/AIDS
spread should be perceived keeping in mind the general
conditions of human development, and its interaction
with socio-economic change. The HIV/AIDS epidemic
threatens to tear apart the very fabric of our society.
126
Selling up of a Nat io n al AIDS Cn nt
Organization by the Government of Ind'.n tor*impleinentation of the control programme, a nJ
National AIDS Research Instirute by tKe '(?.、,！父
provide leadership for mulli-faceted r-es earch in AI OS
signals a major commitment of rhe Government of
India for prevention and co nt ro Lof HIV infecGc；n mJ
AIDS. Within a decade of identification of !.hv
infection tremendous advances in scienut'sc researc^ on
HIV/AIDS have explored nev/ frontiers of knowledge
bringing hope for cost-effective diagnostic approaches,
therapies and preventive vaccines.
But as of 1992, there is nothing to su)p rhe n!V
infection in its tracks, except conimunic'itiun,
information and education. There is no cure. A missive
research programme has been mounted :<>
drugs effective against HIV. Some anti IV drugs h：”。
shown encouraging results, but these are expensive and
can cause severe adverse reaction, which prevent :-?e:r
widespread use in developing countries.Even 2 an
effective vaccine is developed within rhe rex:
of years, technical and financial obstac-es prebabiv wiH
limit its use and thus, its impact on the spread of ihc
disease. The upward trend of HIV/AIDS in 冷90s is
unlikely to be checked, unless those at ri•<k :"e
encouraged b? change rheir life-sty'es. 1'lie tl：：：以：
dimensions and future irnplications
frightening. Like science, the community So shou：G
gear itself tc meet the challenge. Only through a
spirited and committed response by the coimnuivry
we hope to emerge victorious against this v• r3:
disease—AIDS, once again as wc had against sfna!hx；x.
Rvfcrencw:
1.Current global situation of the HIV/AIDS panucmic. W'|()/GPA
July, 1992. S/C AAP, 1992.
2.Currcnl and future dimcnsiuns of ihc HIV/AIPS
capsule suiiurary. WHCjGI'-Ii'RES/SFIjVZ. J, 1^92.
以,日、•. A
3.Strategic Plan for the Prevention and Control ofAIDS in India.
1992-96. Ministry of Health & Family Welfare, Government a：
India, 1992.
4.Recommendations for (he selection and use of H!V
Wkfy Epuiemioi Rec., 67:145, 19^2.
tes!s.
This write-up has been contributed by Dr.Lalii Kanl,!CMR
Headquarters, New Delhi.
Position: 6704 (1 views)