ICMR BULLETIN VOL. 24-No. 11 & 12-NOVEMBER-DECEMBER-1994.pdf

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ICMR
BULLETIN
Vbl. 24, No. 11 & 12

November-December, 1994

AIDS AND THE FAMILY
The year 1994 has been designated as the International
Year of the Family and this year*s theme for the World
AIDS Day is "AIDS and the Family**. The focus will
be on the effect of AIDS on families, the role of families
in AIDS prevention and care of those with HIV infec­
tion and the contribution of the family to the global
efforts for containment and control of HIV infection.
There is a growing realisation that families whose
bonds are based on love, trust, nurturing and openness
are best placed to protect their members from HIV
infection and give compassionate care and support to
those affected by HIV/AIDS.

Families can play the crucial role expected of them
only if they are well informed and have ready access
to factual and updated information on HIV/AIDS and
their role in HIV/AIDS prevention, control and man­
agement. In India interpersonal communication from
health personnel has been shown to be a dependable
and sustainable method of providing information. The
health personnel can readily tailor the messages to suit
the varying needs of the audience in any type of setting;
the personal touch and repeated reiteration may in the
long run, be more successful in bringing about the
desired changes in lifestyle.

The family

Most working physicians and paramedical person­
nel graduated long before the HIV pandemic hit the
world. In this issue of the Bulletin an attempt is being
made to provide a summary of current information on
epidemiology, diagnosis, management and prevention
of HIV infection, so that the health personnel can fulfill
the role in providing accurate information on various
aspects of HIV infection to the community and the
families. Specific efforts are made to address and
clarify some of the common but often unvoiced queries
regarding apparently conflicting information on these
aspects, as well as contradictions in the existing guide­
lines for management of HIV related health problems
between developed and developing countries.

The concept of family need not be limited to
ties of blood, marriage, sexual partnership or
adoption. Any group whose bonds are based on
trust, mutual support and a common destiny may
be regarded as a family. So religious congrega­
tions, workers* associations, support groups of
people with HIV/AIDS, gangs of street children,
circles of drug injectors, collectives of sex work­
ers and networks of governmental, nongovern­
mental and intergovernmental organizations may
all be seen as families within the over-arching
family of humankind. (World AIDS Day News­
letter 1994 - No.2)

This issue commemorates the World AIDS Day (December 1, 1994)

Division of Publication & 1 nformation, ICMR, New Delhi - I 10 029

7

Epidemiology Of HIV Infection
In the eighties the science of epidemiology and art
of forecasting had been extensively used to assess the
magnitude and the dimensions of the HIV pandemic and
devise appropriate intervention to limit adverse effect
of HIV infection and contain its further spread. In the
early 80s the only method available for detection of HIV
infection was clinical signs and symptoms of AIDS.
Most of the reported patients of AIDS were from USA,
Western Europe and Sub-Saharan Africa1. Majority of
these young men and women succumbed to the disease
within a year or two after diagnosis. The general public
had an impression that AIDS is a uniquely devastating
disease killing young men and women in their prime.

than infect men. STDs and reproductive tract infections
(RTIs) especially ulcerative lesions of the genitalia
increase the risk of HIV transmission both in men and
women. The transmission rate is higher in homosexuals
especially in the passive partner and those using drugs
which might disturb the immune system. Because of the
large numbers of sexually active men and women (ac­
counting approximately to 50% of the global popula­
tion) and frequency of exposure, sexual transmission
accounts fbr over 80 per cent of the HIV infection load.

Parenteral transmission

Parenteral transmission of HIV due to transfusion/
infusion of blood or blood products containing HIV is
the most efficient method of HIV transmission with an
estimated transmission rate of over 90 per cent. Par­
enteral transmission also occurs following use of con­
taminated syringes and needles. Transmission risk following
such an exposure is estimated to range from 1-5/1000
exposures. This mode of transmission accounts for the
HIV infection among intravenous drug (IVD) users and
majority of accidental infections within the health care
delivery system. In spite of the relative inefficiency of
this mode of transmission the spread of HIV infection
among IVD users is very rapid because (i) the preva­
lence of HIV infection among drug users is high;
(ii) majority of drug users share unsterilised needles
and syringes when they shoot the drug; and (iii) most
drug users have three or more injections per day.In any
country HIV infection load due to parenteral transmis­
sion depends upon two factors viz the prevalence oflVD
use in the country and the extent to which screening
of blood and blood products is being practiced.

With the availability of HIV antibody kits for detec­
tion of asymptomatic HIV infection in the second half
of the eighties, serosurveys on large population groups
became possible. By the late 80s the World Health
Organisation (WHO) started utilising available data
from seroprevalence studies among asymptomatic in­
dividuals in different countries as the method of obtain­
ing reliable data on HIV infection load2. On the basis
of serological studies, it is now well established that
all over the world there are three major modes of
transmission of HIV. Sexual transmission is the
commonest (> 80%); heterosexual transmission accounts
for 70-95 per cent of all sexual transmission in different
countries. Parenteral (5-10%) and perinatal infection
(1-10%) are the other two modes of transmission.
Follow up of HIV infected persons have established
there is a long (2-20years) asymptomatic period follow­
ing HIV infection; clinical AIDS represents the final
immunocompromised phase which is rapidly fatal. Thus
contrary to the initial impression, HIV infection is only
the latest addition to the long list of Sexually Trans­
mitted Diseases (STDs), with a long asymptomatic
period; it is not a highly contagious infection that
decimates young men and women in the prime of their
life.

Parenteral infection due to the accidental infection
in the health care delivery system from patient to
patient, from patient to health care provider and health
care provider to the patient has been reported both from
developed and developing countries. However, these
are relatively rare events.

Mode of Transmission

Perinatal transmission

Sexual transmission
Sexual transmission is one of the most inefficient
methods of spread of HIV infection. The risk of in­
fection is estimated to range from 1/1000 to 1/100
exposures. Women are more likely to get infected rather
116

Perinatal infection occurs in 20-50 per cent of
infants born to seropositive women. Perinatal infection
rates are lower in Asia and developed countries, and
among asymptomatic women; perinatal infection rates
are higher in women who are viraemic (either in the
early stages of HIV infection or with AIDS) or those

who had a previous HIV infected child. Some studies
have suggested that the infection rates may be lower
following caesarean section but this has not been con­
firmed by others. Contribution of perinatal infection to
HIV infection load in any country depends upon preva­
lence of HIV infection in women, perinatal transmis­
sion rate, and birth rate.
Modes of transmission

The vast majority of all HIV infections occur
through sexual intercourse. HIV can also be
transmitted by infected blood or blood products,
by the sharing of contaminated needles, and from
an infected woman to her baby before birth,
during delivery, or through breast-feeding. It is
nof spread through ordinary social contact. (World
AIDS Day Newsletter 1994 - No.2)

Concept of Risk Groups

Epidemiologists use the term "risk groupsM to
describe group of persons at higher risk of having any
disease. In case of HIV the concept of risk groups has
been used to estimate the magnitude of infection in
specific groups and device appropriate intervention
strategies.
The high risk groups are small groups with clearly
defined lifestyles that render them readily recognisable
and highly vulnerable to HIV infection. Early in the
epidemic, majority of AIDS patients were from these
groups. Individuals showing high risk behaviour should
receive adequate counseling, screening and follow up
care so that the steep rise in seropositivity in these
groups can be controlled and substantial reduction in
the morbidity and mortality is achieved.

Interphase group
The interphase group consists mainly of men and
women who have multiple sex partners; they form the
link through which infection spreads from the numeri­
cally small high risk group to the numerically vast low
risk group. Prevalence of HIV infection in the inter­
phase group is lower than that of the high risk group
but higher than that of the low risk group. In commu­
nities where remarriages and divorces are common and
multiple sex partners are accepted sexual norm the rate
of spread of infection to the general population is higher
because of the relatively large size of the interphase

group. Providing counseling, screening and treatment
of STDs and promotion of correct and consistent use
of condoms are measures that will slow down the spread
of HIV infection to and from the interphase group.
Low risk group
The low risk group comprises individuals from the
general population; majority of individuals in this group
acquire HIV infection from their spouses who have
multiple sex partners. Seropositivity rate in the low risk
group is low initially, and rises slowly. The steepness
of rise in seropositivity rate in the low risk group
depends upon the size of the interphase group and
prevalence of HIV infection in the interphase group.
Because of the sheer size, the low risk group contributes
the largest number of HIV infected persons and AIDS
patients in the community. Except for perinatal and
accidental transmission, HIV infection in the low risk
group is usually an end infection.

Magnitude of the Problem
Over 75 per cent of all infected persons live in
developing countries with very limited access to health
care. In USA and Europe the HIV epidemic curve has

A worldwide problem
More than 16 million adults and one million
children had been infected with HIV by mid-1994
since the start of the pandemic, according to
estimates by the World Health Organization. Around
four million adults and children had developed
AIDS. Although Africa has borne the brunt, no
continent has been spared. HIV is now spreading
fast in Asia and Latin America. (World AIDS Day
Newsletter 1994 - No.2)
plateaued. The Sub-Saharan Africa will also experience
the plateau during this decade. Asia is currently show­
ing the steep rise both in HIV infection rates and
number of infected persons. It is expected that the
number of HIV infected persons in Asia might cross
those in Africa by the mid 90s. By 2000 AD 40 million
persons are likely to be infected by HIV; at least half
of these are likely to be women and children. The
cumulative number of AIDS patients will be around 10
million. Heterosexi 1 and perinatal transmission of
117

HIV infection will account for over 95 per cent of all
infections and nearly 90 per cent HIV infected persons
will be living in developing countries. In 1992 it was
estimated that there might be about 3 million uninfected
infants bom to HIV infected women. Most of these live
in developing countries and are likely to lose one or
both parents as a result of AIDS during the 90s, and
become orphans. This figure is likely to double by the
mid 90s.

India

Impact of HIV on the Family
HIV infection in men, women and children has an
impact not only on the affected person but also on the
entire family and the community. If the breadwinner
is infected, his ill health imposes a severe strain on the
slender resources of the family; cost of health care and
loss of wages due to ill health are the readily measurable
economic dimensions; the adverse impact on social,
emotional aspects and the family bonding are less
readily measurable but equally distressing.

India has the unique distinction of having started
the national serosurveillance for HIV in 1986 during
the silent phase of the HIV epidemic not only among
high risk groups but also in the low risk group to obtain
information on the magnitude and major mode of trans­
mission of HIV infection. In 1994 the estimated preva­
lence of HIV infection in high risk and intermediate
groups is rising but in the general population, seropositivity
is still low (1-2/1000). Based on the available data it
has been estimated that between 2 and 3 million persons
(more than 50% of them are women and children) have
already been infected with HIV in India. Every year
approximately 30,000 of the 27 million deliveries in
India occur in seropositive women and between 6-8000
infants are perinataliy infected with HIV. At present the
number of AIDS patients in the country is small.
However, over the next decade persons who got infected
in the eighties will develop AIDS, resulting in a steep
and progressive increase in the number of AIDS pa­
tients in India.

Traditionally women are the home makers and care
givers. Illness in children or the husband adds to the
already heavy workload of women especially in devel­
oping countries. If the breadwinner is too sick to earn,
the wife has to take up this role too. With all these
stresses and strains if she too falls ill, the effect on the
family is catastrophic. If both the husband and wife die,
the uninfected children become AIDS orphans.

Impact of AIDS on Mortality Rate

Early in the AIDS epidemic both in developed and
developing countries, there were reports of discrimi­
nation against HIV infected persons. To some extent
the social stigma associated with STD does continue
to exist in respect to HIV infected persons. With
increasing realisation of the vulnerability of women and
children in the HIV pandemic, the family — joint/
extended and relatives do come along to form the social
safety net. The neighbours, colleagues at the work place
and social workers in the neighbourhood extend a
helping hand as and when needed to the extent possible.
Thus HIV infection has an indirect impact on a much
larger number of persons than the infected person
alone.

Throughout the world AIDS has become an impor­
tant cause of mortality in men and women during the
reproductive age and among infants and children. In
the USA, AIDS is ranked as the fourth leading cause
of death in men and the sixth leading cause of death
in women of child bearing age. It is the tenth leading
cause of death in children between 1-4 years. Because
of the lack of reliable cause and age specific mortality
rates it is difficult to compute similar figures for
developing countries. However, AIDS is an important
cause of maternal, under five and adult mortality in
Africa; Asia may face a similar situation in the next
decade.

118

An additional burden for women
Nearly half of all newly infected adults are
women. But as women are the traditional care­
givers, even uninfected women are affected by
HIV when it enters a family. Women widowed by
AIDS are often rejected and stripped of their
belongings. (World AIDS Day Newsletter 1994 No.2)

The ripple effect on families

Every day, around 6000 people are newly
infected with HIV. But several times this number
will be newly affected by HIV every day through
the impact on each infected individual's family
and community. (World AIDS Day Newsletter
1994 - No.2)

Natural History Of HIV Infection
HIV infection is a unique STD without local genital
manifestation at any time during the infection but with
grave systemic manifestations. Due to the lack of local
symptoms infected persons remain totally unaware that
they have been infected. Four to six weeks after initial
infection these persons may get fever at times with
lymphadenopathy and rash. The symptoms resemble
common viral fever or infectious mononucleosis and
disappear with or without therapy. This episode is
called as "seroconversion illness” because it coincides
with the appearance of a detectable amount of HIV
antibodies.

Following the sero-conversion illness, HIV infected
persons have a long but unpredictable asymptomatic
period lasting for 2-20 years (average 10 years). Good
nutrition, freedom from infection, and lack of exposure
to drugs or unhygienic environment are the factors
which are associated with a longer asymptomatic pe­
riod. During the asymptomatic period HIV antibody
titres remain high; the CD4, CD8 counts as well as
CD4/CD8 ratio remain normal. The person remain
apparently healthy and can function normally. These
individuals are, however, infected and are capable for
transmitting HIV infection through sexual, perinatal or
parenteral routes. The asymptomatic individuals who
are unaware that they are infected play a major role in
transmission of HIV infection by all modes in any
community.

After a variable period of time the immuno sup­
pression, characteristic of the late stages of HIV in­
fection, begins. There is a progressive fall in CD4
counts; currently the CD4 count is being used in many
centres for defining persons with AIDS; cut-of points
of CD4 count of 500 or 200 have been used by diffe. v<it
centres. With the onset of immunosuppression the infected
person falls prey to repeated episodes of pathogenic or

opportunistic infections. The pattern of infection among
the immunosuppressed HIV infected individuals de­
pend upon the presence of infection in the community,
earlier infection experience of the person and the
immunisation status.
Tuberculosis is one of the most common infections
among HIV infected persons in both developed and
developing countries. Clinical manifestation of tuber­
culosis may be typical or atypical; lesions are often
extrapulmonary or widely disseminated. These patients
respond well to short course chemotherapy. However,
recurrences and relapses are frequent. Repeated admin­
istration of chemotherapeutic drugs may result in an
alarming rise in multi drug resistant strains which may
pose a grave threat to effective treatment of tuberculosis
both among HIV infected persons and in the general
population.

Repeated infections of the skin, respiratory and
gastro-intestinal tracts are seen in the majority of AIDS
patients. Infections may be due to a wide variety of
pathogenic and opportunistic organisms — bacteria,
fungi, parasites and viruses. Common bacterial infec­
tions with Shigella or Salmonella may be associated
with severe bacteraemia and high mortality rates.
Mycobacterial infections with Mycobacterium tubercu­
losis in the tropic and M. avium intracellulare in the
temperate zones are common. Candidiasis is the most
common fungal infection. Parasitic infections include
amoebiasis, giardiasis and cryptosporidiosis. Viral
infections due to a variety of organisms are also re­
ported in AIDS patients. All these infections tend to
be invasive, severe and present with atypical manifes­
tations. Each episode readily responds to effective
antibiotics/chemotherapy; but both severity and re­
peated episodes take their toll.
Abnormalities of the nervous systerf leading to
progressive neurological deterioration and behavioural
changes are known to occur both in adults and children.
These are very often not recognised as being manifestatiop。of HIV infection especially in IVD users. However,
retrospective analyses have shown that several of the
behavioural abnormalities including suicidal and homi­
cidal tendencies might in fact be attributable to these
CNS changes. In paediatric AIDS neuro-psychological
regression might be a major distressing manifestation
in children who survive beyond two years of age.
119

Case Definition Of AIDS
Over the last decade there had been several efforts
to evolve a case definition of 'AIDS' within the existing
limitations of HIV testing facilities and other laboratory
facilities. The case definition of AIDS is an essential
prerequisite for evolving and evaluating appropriate
therapeutic regimens for the care of AIDS patients as
well as building up a AIDS surveillance system. For
the purposes of surveillance WHO has recommended
that an adult or adolescent (> 12 years of age) is
considered to have AIDS if a test for HIV antibody
gives a positive result, and one or more of the following
conditions are present:
(i) > 10 per cent body weight loss or cachexia, with
diarrhoea or fever, or both, intermittent or constant,
for at least 1 month, not known to be due to a condition
unrelated to HIV infection

(tuberculosis) and chronic diarrhoea (amoebiasis,
giardiasis) are common. Even though HIV antibody
tests are available in major treatment facilities,it is
possible that at the moment a number of AIDS patients
are being missed in India and are treated for the
opportunistic/pathogenic infection and/or for undernu­
trition inevitably resulting in underdiagnosis of AIDS
cases. With increasing awareness about AIDS, the
pendulum may swing towards over diagnosis. However,
the problem of under or over diagnosis is unlikely to
materially affect the patient management in India, because
the treatment for pathogenic/opportunistic infections
and efforts to improve nutrition are the same, irrespec­
tive of the HIV status of individual.

Drugs And Vaccines For Treatment Of AIDS

Initial enthusiastic reports about the usefulness of
azidothymidine (AZT) have not been substantiated by
(ii) cryptococcal meningitis
subsequent studies; at best AZT prolongs the asymptomatic
phase or the longevity in AIDS patients by a few
(iii) pulmonary or extrapulmonary tuberculosis
months. Use of other virucidal drugs like dideoxy inosine
(iv) Kaposi's sarcoma
(DDI), singly or in combination, or use of virucidal
(v) neurological impairment that is sufficient to prevent drugs with immunomodulators have been attempted
independent daily activities, not known to be due to a
without any substantial reduction in the side effects or
condition unrelated to HIV infection (for example,
improvement in the salvage rate. The cost of the drugs
trauma or cerebrovascular accident)
as well as the cost of the clinical and laboratory
(vi) candidiasis of the oesophagus (which may be pre­ monitoring are prohibitively high and very few in the
developing countries can afford them.
sumptively diagnosed based on the presence of oral
candidiasis accompanied by dysphagia)
Intensive global research has been focussed on

(vii) clinically diagnosed life-threatening or recurrent
episodes of pneumonia, with or without etiological
confirmation

(viii) invasive cervical cancer
The major feature of this expanded surveillance
case definition is that it requires a HIV serological test,
and includes a broader spectrum of clinical manifes­
tations of HIV such as tuberculosis, neurological
impairment, pneumonia, and invasive cervical cancer3.
It is simple to use and has a higher specificity than the
earlier (Bangui)WHO case definition.

finding a therapeutic or prophylactic vaccine for AIDS.So
far about 15 vaccines have reached the Phase I clinical
trial stage. The efficacy of these vaccines in terms of
prevention of HIV infection or prolonging the asymptomatic
period of HIV infection or prolonging the survival in
AIDS patients is yet to be ascertained in human beings.
Given the difficulties in the preparation and testing of
vaccines, the antigenic variability of HIV, the intracel­
lular nature of the organism, the wide and unpredictable
variability in the course of HIV/AIDS, it is unlikely
that any therapeutic or prophylactic vaccine for HIV/
AIDS will be available for clinical use within the next
decade.

Diagnosis Of AIDS Cases
Clinical diagnosis of adult AIDS in developing
countries is difficult; chronic undernutrition is not
uncommon especially in the poorer segments of the
population. Weight loss associated with persistent cough

120

Management Of AIDS Cases
Public concern regarding AIDS stems from the
knowledge that there is no curative therapy or prophy­
lactic vaccine for this infection. HIV per se, does not

kill but infections and malignancies that occur in these
immunocompromised persons are responsible for the
suffering and death. Global research efforts have re­
sulted in better diagnostic tests and effective drugs
(though many do have severe side effects) for treatment
of several pathogenic or opportunistic infection seen in
AIDS patients. In developed countries where CD4
monitoring is done on all seropositive persons a fall
in CD4 count below 500 even in the absence of any
clinical signs, is an indication for institution of antiviral
therapy. It is unlikely that in India there will be wide­
spread laboratory based monitoring of immune status,
or use of AZT and other virucidal drugs because these
are not affordable.

HIV and AIDS
AIDS (acquired immunodeficiency syndrome)
is the late stage of infection with the human
immunodeficiency virus (HIV). AIDS can take
more than ten years to develop, and most people
die within three years of it being diagnosed.
(World AIDS Day Newsletter 1994 - No.2)

Gudelines for Hospitalisation
In the Indian context it is essential to evolve appro­
priate guidelines for hospital admission of persons with
HIV/AIDS so as to ensure that health care services do
not get overwhelmed by trying to provide care for HIV/
AIDS cases and that persons with all other ailments do
get due attention. AIDS patients require hospitalisation
for treatment of acute pathogenic or opportunistic infections
and treatment of acute life-threatening emergencies.
Many will require emergency or elective surgical in­
tervention. Malignancies occurring in AIDS patients
would require appropriate management.

Nutritional support in HIV infection
Nutritional support is needed in HIV infected individu­
als to (i) maintain optimum nutrition during the long
asymptomatic period;(ii) prevent further deterioration
of nutritional status during acute episodes of infection
in AIDS patients; and (iii) improve nutritional status
during the 'stable' symptom-free period in AIDS pa­
tients.

It is relatively easy to achieve and maintain opti­
mum nutritional status in asymptomatic seropositive

individuals. This goal can be achieved by minimal
inputs into health care, counseling and health education
both in developed and developing countries. It is possible
that good nutrition and freedom from common infec­
tions may prolong the asymptomatic period.
Once clinical symptoms appear it is very difficult
to maintain optimal nutrition. However, efforts should
be made to prevent further deterioration by ensuring
adequate intake of a well balanced diet to meet the
increasing nutrient requirement due to infections. Vitamins
and mineral supplements in appropriate doses to meet
the increased requirements may be given. Parenteral
nutritional support should be resorted to for short
period only if there are clear indications.

Care of chronic illnesses
During the chronic and terminal phases of their
illness, AIDS patients require symptomatic and
supportive treatment. The management of this phase of
illness can be readily undertaken at home, with the
hospital outpatient visits providing the necessary medi­
cal monitoring and therapy. The patients are much more
comfortable at home in the midst of the family; the
family can provide them with the emotional and psy­
chological support as well as physical comforts that is
needed. There are, however, situations where support
from the family may not be available. Such patients have
to be provided with care so that they can spend the last
days of their lives in some comfort in hospice like
facilities. Special efforts may be made to explore fea­
sibility of involving non-governmental/voluntary agen­
cies for providing this type of care.

Screening For HIV Infections
Testing for HIV infection has been a controversial
issue. In developed countries counseling and informed
consent of the individual prior to HIV jesting are
mandatory and confidentiality of results is strictly
maintained4. Under the existing conditions of illiteracy,
social and other taboos obtaining informed consent
from th。person undergoing HIV testing in India poses
several problems. The Expert Group of the Indian
Council of Medical Research (ICMR) discussed the
issue and recommended that in the Indian context HIV
infection should be considered as a sexually transmitted
disease or transfusion transmitted disease. The clinician
will decide on the basis of clinical assessment whether

HIV testing is required for an individual patient, in
exactly the same way as they would decide on any other
laboratory investigation of patients under their care. All
donors of semen and organs should be screened for HIV
infection to prevent iatrogenic infection in the recipient.
All donated blood should be screened for HIV antibod­
ies; this is also mandatory fbr blood used fbr blood
product manufacture.The testing facility should be made
available to those who voluntarily seek testings5. HIV
testing may be done for research purposes on approved
research protocols after obtaining clearance from con­
cerned institutions. Health service personnel need not
be screened for HIV antibodies because patients are not
at risk of acquiring HIV infection during the course of
health care delivery related contacts with health per­
sonnel. Health care seekers need not be screened fbr
HIV infection because they are unlikely to infect health
care persons or other health care seekers provided
universal precautions fbr infection control are observed.

Care Of Seropositive Persons
All HIV infected individuals require counseling
because of the social stigma attached to the disease and
the invariably fatal outcome of the infection. They
require health monitoring. This can be done on an
outpatient basis. Health education to infected persons
and their families is essential for reducing the risk of
transmission of infection. All HIV seropositive persons
should be taught simple precautions against common
infectious diseases prevalent in the community, because
reduced morbidity due to infections may prolong the
asymptomatic phase of the disease. During the
asymptomatic period, seropositive persons may require
health care fbr problems related or unrelated to HIV
infection. All HIV infected persons should receive the
prophylactic and therapeutic care required. Elective
and emergency surgical procedures should be provided,
as and when required. However, invasive palliative
procedures such as renal dialysis for chronic renal
failure may not be indicated in these, individuals.

HIV Infection And Pregnancy

HIV Infection - Pregnancy Interactions
Contrary to the initial reports, pregnancy does not
have any adverse impact on course of HIV infection.
HIV infection, does not appear to have any adverse
122

effect on health of the pregnant women, course of
pregnancy, labour, peurperium or lactation.

HIV readily crosses the placental barrier. The conse­
quences of intrauterine infection on the foetus vary
depending upon the period of gestation at the time of
infection, degree and duration of viraemia. Increased
abortion rates have been reported from Africa but it
is not clear whether this is due to HIV infection or to
other confounding factors. The available minimal data
mainly from the European collaborative study indicate
that use of AZT in early pregnancy is not associated
with any increase in the abortion rates or congenital
malformation rates. Data from collaborative studies in
the USA indicate that use of AZT in the second and
third trimesters of pregnancy is not associated with any
adverse effect on the baby except for a higher preva­
lence of anaemia. Data, however, are insufficient to
draw any firm conclusions regarding the absence of any
adverse consequences on the foetus or beneficial effect
in terms of reduction in the intrauterine transmission
rate. Maternal HIV infection is associated with a higher
rate of premature delivery, intrauterine growth retar­
dation and higher perinatal mortality rates6,7.
Screening for HIV in Pregnancy

Screening fbr HIV during pregnancy along the lines
of screening fbr syphilis during pregnancy has many
ardent advocates. The major reason fbr screening for
STD like syphilis in pregnancy is to provide therapeutic
intervention to prevent intrauterine infection. This
justification does not exist fbr HIV. In many developed
countries counseling women about STDs and HIV and,
after obtaining informed consent screening them for
STD including HIV has been included as a part of the
“routine" antenatal care. In these situations there are
adequate facilities for post test counseling and care of
women, if any are found to be seropositive6-7. In India
such facilities are neither available nor affordable.
Counseling fbr medical termination of pregnancy (MTP)
in early pregnancy in parous seropositive pregnant
women may provide the rationale for HIV screening in
women who report early in pregnancy in our country.
Howevei,screening of all pregnant women is impossible
because majority do not attend antenatal clinics; screen­
ing facilities are neither available nor affordable. So
most HIV infected asymptomatic women will continue
to remain undetected.

Management of Pregnancy in Seropositive Women
The fate of the unborn child is the major reason
for concern regarding HIV infection in pregnancy, lb
prevent these potential calamities, MTP may be done
in the first trimester, should the patietns desire it.
However, many of the known seropositive women may
not opt for it especially if they do not have a living
child.

Women who want to continue pregnancy should be
provided with adequate, appropriate, antenatal care. In
the USA in woman who opt to continue pregnancy, the
prophylactic use of AZT is considered especially with
falling CD4 count8; many obstetricians prescribe pro­
phylactic chemotherapy against pnuemocystis pneu­
monia. In developing countries like India, seropositive
women who opt to continue pregnancy are provided
with antenatal care; specific efforts are made to promptly
diagnose and treat any opportunistic or pathogenic
infections in these women. Routine CD4 cell counts,
prophylactic chemotherapy against infections in
immunocompromised individuals and prophylactic therapy
with AZT or similar virucidal drugs are not possible
or affordable.
During labour specific efforts may be taken to
reduce any invasive procedures such as scalp vein blood
sampling, use of scalp electrodes to monitor foetal heart
rate, to reduce the risk of transmission of infection to
the foetus during labour. In the Indian context caesarean
section is associated with maternal consequences not
only in the present pregnancy but also in the subsequent
conception. Hence normal vaginal delivery will con­
tinue to be the mode of delivery in HIV infected women
who do not have any specific indications fbr caesarean
section until such time as there is unequivocal proof
that the risk ofHIV transmission is lower with caesarean
section. Stringent precautions should be taken to pre­
vent accidental spread ofHIV infection while providing
health care especially during delivery. Specific efforts
have to be made to keep appropriate provisions for
looking after the low birth weight neonates.

and their presence may provide some protection against
transmission of HIV infection through breast
milk.Estimated risk of transmission of HIV infection
through breast milk is between 1-3 per cent of all the
perinatal infections.

Breast Feeding in Seropositive Women
All available data suggest that breast feeding will
protect HIV infected infants from other infections and
may prolong the survival period.There are no tests by
which infected infants could be identified at birth.
Unless all infants born to seropositive mothers are
breast fed, HIV infected infants will be denied the
benefit of breast feeding. In view of this it is essential
to encourage all seropositive women to breast feed. In
India, the advantage of breast feeding by far outweigh
the small potential risk of HIV infection through breast
feeding; this is especially important in seropositive
mothers from low income groups among whom, breast
feeding holds the key fbr infant nutrition, growth,relative
freedom from infection and survival9-10. Therefore, in
the Indian context, breast feeding by the biological
mother is to be advocated fbr all iniants bom to
seropositive women.

Breast Feeding in the HIV Epidemic

In India breast feeding is essential for infant surviv­
al and growth especially among the poorer segments
of the population. Hence breast feeding by the biologi­
cal mothers should continue irrespective of the HIV
infection status of the mother or infant, known or
unknown. Promotion of breast feeding should continue
to be the national policy9-10.
HIV Infection And Immunisation

Increasing prevalence and awareness of IHV infec­
tion has led to concern about efficacy and safety of
immunisation of the infants born to seropositive moth­
ers and queries about the Universal Immunisation
Programme (UIP) in the absence of any information on
the HIV status of the majority of infants.

HIV .And Breast Feeding
HIV infection has no adverse effect on lactation and
lactation has no adverse effect on the course and outcome
of HIV infection. HIV has been isolated from breast
milk. HIV antibodies are also present in breast milk

Immunisation in Seropositive Infants
HIV infected infants are apparently healthy and do
not have any immunodepression at birth. They usually
remain asymptomatic during the first six months
123

of life. They respond normally to immmunisation admini­
stered during the asymptomatic period. Experience
with inactivated vaccines given to HIV infected children
indicate that these immunisation are free from major
short or long term side effects. Immunisation might
offer some protection against the common infections
during infancy in HIV infected children when
immunodepression occurs. It is therefore essential that
all infants born to seropositive mothers should receive
all the vaccines on schedule. Special attention should
be given to ensure that these infants receive BCG
vaccination soon after birth , because (i) BCG vacci­
nation cannot be given to infants once immunodepression
sets in, and (ii) tuberculosis is one of the most common
pathogenic infections in HIV infected infants in devel­
oping countries like India. If for any reason BCG
vaccination was not administered at birth it should be
administered as soon after birth as possible. However,
BCG vaccination should not be administered in seropositive
infants if they have become symptomatic for AIDS.

It is essential to ensure that all seropositive infants
receive DPT, polio and measles vaccines on schedule.
If given on schedule most of the infants would have
completed their immunisation prior to onset ofsymptoms.If
seropositive infants had not received immunisation on
time and have become symptomatic, it is essential to
give them DPT, polio and measles vaccine, because
(i) all the available data indicate that in immu­
nocompromised HIV infected in&nts risk of natural
infections is greater than the risk of immunisation even
with live attenuated vaccines (except BCG); and (ii) so
far no major adverse effects of vaccination on HIV
infected infants have been reported. Some paediatricians
advocate that in symptomatic HIV seropositive infants
killed polio vaccine may be used instead of OPV.
Universal Immunisation Programme and HIV Epi demic
The WHO Expert Group on Immunisation has
recommended that there is no need to modify any of
the existing guidelines for the Universal Immunisation
Programme; all asymptomatic infants inespective of
the fact that HIV status of the mother or infant is not
known, should receive all vaccines both live attenuated
and killed as per the existing schedule9. The advent of
the HIV infection only calls for continued vigorous
implementation of UIP even after the advent of the HIV
epidemic. It is essential that the immunisations are

124

administered on schedule so that all infants receive all
the immunisations except measles before six months of
age when almost all the HIV infected infants are in the
asymptomatic phase.
HIV And Children

During the first six months of life, growth and
morbidity of HIV infected infants is similar to uninfected
infants from the same community; subsequently re­
peated infections and growth faltering appear.Paediatric
AIDS is characterised by failure to thrive, poor weight
gain/actual weight loss, hepatosplenomegaly, recurrent
fever, respiratory infection, diarrhoeal diseases and
bacterial or fungal infections of the skin.
Because of the limitations of the HIV screening
programme in women, the majority of seropositive
infants in India will remain undetected during infancy.
Growth monitoring and investigation of infants showing
growth retardation and repeated infections is likely to
be the commen method by which paediatric AIDS
patients are detected in India.
Care of HIV Infected Infants

Physicians in developing countries advise admis­
sion only fbr treatment of life threatening infections and
malignancies in children with AIDS. Monitoring of
HIV infected children, providing appropriate care for
repeated episodes of pathogenic/opportunistic infection
are best done at home with the help and cooperation
of the family members. Children are certainly happier
at home, than in the crowded hospital wards among
strange, ill children. Hospital admission for only gravely
ill children is a useful strategy to ensure that inpatient
beds are not all taken up in the care of chronically ill
children with AIDS and adequate beds are available for
care of children suffering from other illnesses.

Children pay a growing price

Increasingly, children are paying the price of
AIDS — either by being infected themselves or
through the effect of AIDS on other family members.
They may lose their parents and have to live on
the streets if other relatives cannot or do not step
in with support. (World AIDS Day Newsletter
1994 - No.2)

It is possible that some of the chronically ill paediatric
AIDS patients do not have their parents or any family
to look after them, ft is essential that some provision
is made for care of such children in hospices.
AIDS Orphan

There have been reports of discrimination and aban­
donment of AIDS orphans, from some developed coun­
tries and urban areas of some developing countries.
Faced with the lack of support from the traditional
family and the social security network, AIDS
orphans will face severe deprivation and contribute to
a steep rise in under nutrition, morbidity and mortality
during childhood. The majority of the world's AIDS

An extra threat in the 1990s
Many families in the 1990s are disrupted by
political upheaval, civil unrest, migration, and
other factors. For millions of them, HIV is an extra
threat. If a breadwinner falls ill with AIDS, they
face losses of income and sometimes food sup­
ply. (World AIDS Day Newsletter 1994 - No.2)

orphans live in Sub-Saharan Africa. During the eighties
in several countries in Africa life had undergone major
disruptions due to political upheavals, wars and migra­
tion; millions had to cope with the HIV epidemic on
the top of all these. When the breadwinners — men and
women in the reproductive age were lost, the family
and community lost the little income they had and even
food supply was threatened. In the midst of all these
calamities, in these rural communities there were many
whose immediate family members were dead or unable
to look after HIV affected men, women and infants, or
AIDS orphan. The community shared what little they
had and attempted to look after these ill and destitute
persons. These reports prove that poverty and illiteracy
are no barriers to sharing what little they have and
caring for others. In the context of developing countries
building up a community and familial support network
appears to be the culturally most appropriate, most
effective and least expensive method of providing care
to AIDS orphans.

Prevention Of HIV Infection
It is obvious that at the moment there are no
effective drugs or vaccines for prevention or treatment

of HIV infection; nor is one likely to become available
in the foreseeable future. Under these conditions it is
essential that efforts are directed to inform the popu­
lation about the urgent need for lifestyle changes so that
there is a reduction in the risk of HIV infection.
Specific efforts have to be mounted to prevent sexual,
perinatal, parenteral and accidental infection with HIV.

Prevention of Sexual Transmission

Sexual transmission is the commonest mode of HIV
transmission and hence deserves maximum efforts for
prevention. Sexual transmission can be prevented by
abstinence or fidelity between uninfected partners. There
are, however, situations in which the persons may be
unable to give up multipartner sex and sex with persons
whose infection status cannot be assessed. Under these
conditions these persons may be taught to correctly and
consistently use a condom so that the risk of infection
can be reduced10,11.

Sexual transmission can be prevented

Sexual transmission of HIV can be prevented
by abstinence, fidelity between uninfected part­
ners and safer sex, which includes non-penetrative sex and sex with condoms. Children need
education about AIDS prevention before they
become sexually active. Everyone needs easy
access to condoms in case of need. (World AIDS
Day Newsletter 1994 - No.2).

Condom
Condom usage for STD prevention was promoted
in the preantibiotic era when effective treatment for
STDs was not available. The advent of HIY infection
led to a revival of a massive programme for condom
promotion all over the world. Available data indicate
that good quality condoms are correctly and consis­
tently used by motivated couples to provide substantial
but not total protection against STDs. However, in the
settings where potential risk of STD/AIDS transmis­
sion is the greatest, the quality of the condoms as well
as its correct use is likely to be suboptimaL In India,
where the acceptability and what is even more impor­
tant, use effectivity of the condom is low even in the
Family Welfare Programme, it might be unrealistic to
125

depend heavily on its protective effect against HIV
infection. Two other implications of advocacy of condom
use have to be kept in mind, (i) because of lack of
awareness sporadic and incorrect users may feel that
they are protected and continue to indulge in casual sex;
and (ii) inherent method failure with condom (between
5-20%) has not been clearly explained and hence when
persons who have been using condoms consistently
develop HIV infection there might be a backlash against
condom use.
Intrafamilial use of condom has been advocated as
a method to prevent sexual transmission to the spouse
from a potentially infected partner. Studies carried out
in Africa indicate that this is not a feasible proposition;
request for condom use has been reported to lead to
marital discord because it is interpreted as being due
to the suspicion of infidelity.

Condom use in seropositive couples
If both the partners are found to be seropositive
there is no need for them to use a condom during sexual
intercourse; however, specific efforts should be made
to prevent vertical transmission by providing effective
contraceptive care. If one of the spouses is seropositive
they should be counseled and taught to correctly and
consistently use condoms.
Condom promotion in the general population

In India it is estimated that there are over 200
million sexually active couples. Even if all the popu­
lation accept and are willing to correctly and consis­
tently use condoms, it will be an enormously expensive
and logistically difficult task to supply billions of
condoms every year, year after year for several decades.
Considering all these factors, it might be preferable to
advocate a mutually faithful monogamous relationship
as the best and culturally most readily acceptable method
of prevention of HIV infection in the Indian population.
In couples who are known to have multiple sex partners,
correct and consistent use of condoms may be advocated
as a method to reduce the risk of HIV transmission.

has to be paid to the prevention of vertical transmission
because in the populous developing countries where
over 75 per cent of all the HIV infected persons live,
birth rate remains high. Unless adequate emphasis is
given fbr contraceptive care, these countries will, over
the next decade, have to bear the burden of having over
90 per cent HIV infected children and AIDS orphans.lt
is therefore imperative that contraceptive care aimed at
minimising these problems receives the attention that
it deserves in the AIDS Control Programme.

Contraception HIV interactions

Among all the contraceptives only the correct and
consistent use of the iatex condom has been shown to
prevent HIV infection. Diaphragm and cervical cap do
not protect against HIV infection. There is as yet no
clear cut evidence that the female condoms protect
against HIV infection. Several spermicides including
Nonoxinol 9 have been shown to have anti HIV activity
and inhibit multiplication of HIV in vitro; however,
unequivocal proof for their efficacy in vivo in the range
of concentrations likely to be seen in different users,
is not available.lt is possible that when used along with
a latex condom these agents may provide more effective
protection than when either is used alone. So far no
adverse interactions between any of the currently used
contraceptives and HIV infection have been reported.
The fear that intra uterine devices (IUDs) and hormonal
contraceptives might have adverse interactions in HIV
infected persons has not been substantiated9,10.
Contraception for seropositive women

Prevention of Vertical Transmission

It is imperative that safe and effective contraceptive
care is provided for all seropositive women because of
the known adverse consequences of HIV infection during
pregnancy.The choice of a contraceptive method for the
individual should take into account risks and benefits
of the contraceptive method, lifestyles and contracep­
tive preferences of the individual, availability of con­
traceptives and health care facilities. If the spouse/sex
partners of the seropositive person is seronegative, the
couple should be instructed that in addition to the
contraceptive of their choice they should use condom
to prevent HIV transmission.

So far prevention of sexual and parenteral infections
had been the focus of most of the HIV/AIDS prevention
programmes. However, from now onwards special attention

Vasectomy or tubectomy appears to be the ideal
method of contraception for seropositive men and women
who have completed their families. In case one of the

126

partners is not infected, it is essential that the infected
partner undergoes tubectomy/vasectomy and the couple
consistently uses condom to reduce the risk of sexual
transmission. This policy is advocated so that the
uninfected partner can remain free of HIV infection and
has the option of remarriage and subsequent child
bearing. If the couple prefers an IUD, it can be inserted
provided there are no clinical contraindications for IUD
use. Similarly oral contraceptives (OCs) or other hor­
monal contraceptives can be adminstered to those who
opt for it. It is essential that all these women are
followed up and continued contraceptive use to prevent
vertical transmission, is ensured10.
Contraceptive care during the HFV epidemic

In India, in the majority of instances, contraceptive
care will have to be provided without any knowledge
of the HIV infection status of the individual. The WHO
Expert Group on Contraception and HIV Infection has
recommended that under these circumstances contra­
ceptive care can continue to be provided according to
the existing guidelines, even though the HIV status of
the person is not known12. Thus the national policy of
providing appropriate contraceptive care to all eligible
women can be pursued without any modifications. In
fact advent of HIV infection provides yet another rea­
son —prevention of vertical transmission — for vig­
orous implementation of the National Family Welfare
Programme.
Prevention of Parenteral Transmission
Blood product screening

In India mandatory screening prior to blood prod­
uct manufacture is a statutory requirement. Screening
of blood prior to transfusion has been initiated in major
cities; extension to smaller cities is being taken up in
a phased manner. Th is effort is coupled with efforts to
modernise blood banks including provision of adequate
component separation units, so that adequate appropri­
ate quantities of the safe blood /blood component are
available for transfusion.Efforts are also underway to
educate the public on the need for voluntary blood
donation to meet the needs.

approach this group and attempt to change their lifestyle.
Efforts to reduce the risk of HIV infection include
(i) counseling not to share syringes and needles; (ii) sterilise
the syringes and needles through use of bleach solution;
(iii) needle exchange programmes; (iv) efforts to change
over to oral drug use; and (v) efforts to coordinate with
the existing drug deaddiction programmes to wean IUD
users from use of drugs.

In these efforts the family has a crucial role to play;
the early diagnosis of drug use, screening of drug users
for HIV infection, counseling them on HIV infection
prevention and drug deaddiction all depend on the close
cooperation of the family; success in these efforts is
mainly dependent upon the continued support from the
family.
Prevention of accidental infection due to injections

In most of the developed countries presterilised
disposable syringes and needles are widely used. These
are safely disposed soon after use. In India the culture
of ensuring safe disposal of disposable material includ­
ing syringes and needles does not exist. Many health
care workers discard the used disposable syringes and
needles in cardboard cartons assuming that they will
subsequently be "safely” disposed. Anecdotal reports
on reuse of disposable syringes and needles which had
been casually dumped by the user, picked up and reused
after washing without even putting them in a steriliser
because they may become distorted by the heat, abound
in India. In view of this it is preferable to use glass
syringes and needles and ensure effective sterilisation
of them. HIV is a fragile virus. Sterilisation of syringes
and needles can readily be achieved by either autoclav­
ing at 121°C for 20 min or boiling in water for 20 min
This simple safe procedure constitutes the surest way
for prevention of accidental infection by an> organism
including HIV. If for any reason disposable syringes and
needles are used , the health care worker should sepa­
rate the syringe from the needle, separate the barrel
from the piston and drop all the three into the bleach
solution. This would ensure that these syringes and
needles will at least not transmit infections even if
reused.
Prevention of Accidental Infection

Prevention of HIV infection in IVD users

Parenteral infection in IVD users is another aspect
that had received attention. It is not very easy to

Fear of accidental infection with the HIV does
exist in all segments of society including patients
attending hospitals, health care personnel and *the

127

family members providing care to persons with HIV/
AIDS; this fear influences their bdiaviour towards
individuals known to be infected with HIV. With the
advent of the HIV epidemic specific efforts have been
made to strengthen the infection control measures in
many hospitals to prevent accidental infection from
patient to patient, patient to health care provider and
health care provider to patient and to allay the appre­
hensions about accidental HIV infection in the health
care set up. At the same time the family members of
person with HIV/AIDS are reassured that living with
a HIV infected person is safe and there is no threat of
infection to the other members.

HIV is transmitted mainly through blood and genital
secretions. Many patients in the hospital require invasive
investigations and therapeutic procedure or have open
wounds; hence the chances of exposure to blood and
body fluids are higher in the hospitals. This risk can
be minimised by taking appropriate infection control
procedures. In the home settings, invasive procedures
are not carried out and hence risk of exposure is lower.
However, all the family members of persons with HIV
infection are taught to use barrier precautions and
washing procedures identical to those followed in the
hospital while providing care.
Prevention of accidental hospital infection

In the preantibiotic era cleanliness, disinfection and
antisepsis were the hallmark of any hospital ward. With
the advent of antibiotics the fear of infections faded and
the time, effort and money spent on infection control
in health care services dwindled. The rising incidence
of hospital acquired infections (HAI) and hepatitis B
infection among the health care providers sounded the
warning bell on the need to tighten infection control
measures; advent of HIV infection provides yet another
warning and an opportunity to correct the existing
lacunae. It is essential that energetic steps are taken to
minimise if not totally prevent accidental HIV infection
because (i) ethically health care providers cannot allow
patients under their care to get HIV infection while
undergoing treatment for other ailments; (ii) effective
infection control measures are essential to allay patients
fears regarding accidental HIV infection and ensure that
both HIV infected and uninfected persons continue to
fully utilise available health services; (iii) along with
blood and blood product screening effective infecti i
control represents an area where health workers can by
128

themselves effectively ensure, arrest of further spread
of HIV infection; and (iv) the rapid and effective
implementation of hospital infection control may serve
as one of the best health education measures because
patients, their relatives and friends will see the trans­
formation brought about by the advent of HIV infection
in the hospital scenario. The change in behavioural
pattern of the health care personnel may reinforce
effectively the messages seeking behavioural changes
in the population to prevent spread of HIV infection.

The only method by which the risk of accidental
infection can be minimised is to assume that every
patient seeking health care is infected with HIV and
take proper care while handling every patient. Rigor­
ously implementing "universal precautions" fbr pre­
vention of accidental infection is the only way to allay
the fear of accidental HIV infection. The entire range
of health service activities regarding asepsis, antisep­
sis, disinfection and sterilisation need be streamlined
and strengthened13*15.

Infection control does not require sophisticated
equipment, expensive chemicals or increase in man­
power. It requires correct and consistent use of
inexpensive, time tested methods of chemical disinfec­
tion and sterilisation. The key to infection control lies
in the motivation and dedication of all health care
workers and sustained cooperation from the health care
seekers and the community. Special attention should be
paid to provision of adequate numbers of autoclaved
syringes, needles, gloves, aprons, instruments and auto­
claving facilities. HIV is a fragile virus readily des­
troyed by heat and common disinfectants. For sterilisation
of syringes, needles and instruments, autoclaving for
20 min at 121°C is the time tested, safe and certain
method13,14. Sharp instruments, endoscopes and other
delicate'instruments that cannot be autoclaved may be
disinfected using 2 per cent gluteraldehyde solution.
Accidental infection due to exposure to infected blood,
liquor and vaginal secretions should be prevented by
use of aprons, gloves etc. Commonly used barrier
precautions include; (i) plastic aprons and cotton or
paper masks in situations where splashes of blood and
body fluids are anticipated such as in labour rooms;
(ii) plastic gloves while handling specimens of blood
in the laboratory and while doing venepuncture and
similar situations where sterile precautions are not
needed13'15.

Accidental infection during washing of instruments
and linen contaminated with blood and body fluids
appears to be a rare event.In the developed countries
several steps including soaking of all instruments and
linen in appropriate chemical disinfectants prior to
washing, providing gloves and other barrier methods
to those who do the washing and mechanisation of
washing procedure through use of appropriate washing
machines have all been tried. In the Indian context the
easiest and the most reliable method for ensuring that
accidental infection does not occur during washing of
instruments and linen is to soak them for 1-2 h in
appropriate chemical disinfectants prior to washing.
Disinfection can be achieved by the widespread use of
hypochloride solutions14.
It is essential to ensure that hospital wastes disposal
is done in a fashion that prevents accidental infection.
Incineration of all hospital waste is being done in large
hospitals in India. In smaller hospitals it might be
preferable to disinfect potentially infective material by
chemicals and then disposing them in the same fashion
as the uninfected materials. Bl eaching powder solution
in appropriate concentration is the readily available,
reliable and economical method for disinfection of
potentially infected hospital waste prior to disposal.
CONCLUSION

The single crucial characteristic of a well function­
ing family is that they care and take care of the needs
for the welfare of all the members of the family. The
family holds the key to the success of the HIV/AIDS
control and prevention efforts especially in developing
countries. The surest way of ensuring that the sexual
transmission of HIV is minimised is to promote and
protect the norm of mutually faithful monogamous
relationship within the family. Parental example and
peer pressure, reinforced by the AIDS awareness cam­
paign might be the most effective method of preventing
experimentation with casual sex and drugs during
adolescence and adult life. Given the socio-economic
scenario and the limitations of social security provi­
sions in developing countries like India the family is
likely to be the major safety net that provides fbr the
care of HIV infected persons and AIDS patients and
later for support of the disrupted family and the AIDS
orphans. The family thus constitutes the best defense
against spread of HIV infection and care provider for
those already infected.

Families take care

All families, traditional or non-traditionab
can help stop AIDS spreading by making sure that
their members understand — and act on — the
facts about HIV and safer behaviour. And if one
of their members does fall ill with AIDS, families
are often the best source of compassionate care
and support. (World AIDS Day Newsletter 1994
-No.2)

Among Asians the family ties are very strong. HIV
infection reached Asia a decade later; the epidemic was
recognised and control measures were initiated in the
silent phase of the epidemic. These might help the
countries of this populous continent to limit both the
adverse impact and the rapid spread ofHIV infectiqn.The
challenge is to ensure speedy and effective implemen­
tation of the intervention measures through cooperation
and involvement of families and other care providers
in the society. The fate of mankind during the next
millennium may rest on the successful implementation
of the twin programmes of AIDS control and fertility
regulation.
References:
1.

Sato, D.» Chin, J. and Mann, J.M. Review of AIDS and HIV
infection : Global epidemiology and statistics. AIDS3 (Suppl):
301； 1989.

2.

Carrying Out HIV Sentinel Surveillance : A Guide for
Programme Managers. WHO Regional Office for Sout-East
Asia, New Delhi, 1994.

3.

WHO case definition for AIDS surveillance in adults and
adolescents. Wkfy Epidemiol Rec 37: 273, 1994.

4.

Statement from consultation on testing and counseling fbr
HIV infection. WHO/GRi/INF 93: 2, 1993.

5.

Hospital policies on care of HIV infected persons and pre­
vention of accidental infection. ICMR Bulletin 20 : 29, 1990.

6.

Schoebaum, E.» Davenny, K. and Holbrook, K. Management
of HIV disease in pregnancy. In : HIV Infection in Obstetrics
and Gynaecology. Ed. C. Baillieres. Clinics Obstet Gynaecol
6: 101, 1992.

7.

Sherr, L. AIDS in nineties : from science to policy, pregnancy
and paediatric. AIDS Care 2; 403, 1990.

8.

Sperling, R.S., Stratton, P. and members of the ObstetricGynaecologic Working Group of the AIDS Clinical Trials
Group of National Institute of Allergy and Infectious Disease.

129-

Treatment options for HIV infected pregnant women. Obstet
Gynaecol 79: 443, 1992.

Reproduction — Joint Statement. Contraceptive method and
human immunodeficiency virus. WHO/SPA/INF 87: 9, 1987.

13.

Guidelines on Sterilization and Disinfection Methods Effective
Against Human Immunodeficiency Virus. WHO AIDS Series
No.2 (2nd Edition). WHO, Geneva, 1989.

14.

Ramachandran, P. Hospital infection control. AIDS In India:
September 1993, p2.

15.

Prevention ofSexual Transmission ofHIV. WHO AIDS Series
No.6, WHO, Geneva, 1990.

Guidelines for Nursing Management of People Infected with
Human Immunodeficiency Virus. WHO AIDS Series No.3.
WHO, Geneva, 1988.

Special Programme on AIDS and Special Programme of
Research Development and Research Training in Human

This write-up is contributed by Dr. P.Ramachandran, Dy.
Director-General (Sr.Grade), ICMR Headquarters, New Delhi.

9.

AIDS Prevention. What Maternal and Child Health (MCH/FP)
Service Providers Need to Know. Regional Health ftper
No.23. WHO Regional Office for Sout-East Asia, New Delhi,
1992.

10.

Ramachandran, P. HIV infection in women. ICMR Bulletin
20: 111, 1990.

11.

12.

ICMR NEWS
The following meetings of various technical groups/
committees of the Council were held:

Task Force on Adverse
Drug Reaction Monitoring

October 17, 1994
(at Bombay)

Annual Review Meeting of
National Cancer Registry
Programme

October 24, 1994
(at Madras)

Participation of ICMR Scientists in Scientific Events:
Dr. Kalyan Banerjee, Director, and Dr. B. Lalitha
Rao, Dy. Director, National Institute of Virology, Pune,
participated in the III Asia-Pacific Congress of Medical
Virology at Beijing (October 23-28, 1994).

Dr. G.V.Satyavati, Director-General, ICMR, and
Dr. S. Radhakrishna, Director, Institute for Research
in Medical Statistics, Madras, participated in the IX
WHO Meeting of Directors of Medical Research Councils
or Analogous Bodies and Concerned Research Foci in
the Relevant Ministries at Kandy (October 24-28,1994).
Dr. Vinodini Reddy, Director, Dr. K. Vijayaraghavan,
Dy. Director and Dr. Shahnaz Wzir, Research Officer,
National Institute of Nutrition (NIN), Hyderabad, par­
ticipated in the XVI International Vitamin A Consul­
tative Group Meeting at Chiang Rai (October 24-28,
1994)).
Dr. Kamal a Krishnaswamy, Dy. Director (Senior
Grade), NIN, Hyderabad, participated in the Joint

130

Expert Panel Meeting of American Institute for Cancer
Research and World Cancer Research Fund at London
(October 26-28, 1994).
Dr. J.J. Rodrigues, Director-in-Charge and Dr. A.R.
Risbud, Asstt. Director, National AIDS Research In­
stitute, Pune, participated in the VII NCVDG Meeting
on Advances in AIDS Vaccine Development at Reston,
Virginia (November 6-10, 1994).
Dr. V. Jagadeesan, Asstt. Director, NIN, Hyderabad,
participated in the conference of the International Society
for Free Radical Research at Sydney (November 6-10,
1994).

Dr. V.P. Sharma, Director, Malaria Research Cen­
tre (MRC), Delhi, participated in the International
Symposium on Core Data Needs for Environmental
Assessment and Sustainable Development Strategies at
Bangkok (November 15-18, 1994).
Dr. N. Pralhad Rao, Dy. Director (Senior Grade),
NIN, Hyderabad, participated in the International Meeting
on Rural Household Food Security at Hanoi (November
15-19, 1994).

Dr. T. Adak, Asstt. Director and Dr. R.C. Dhiman,
Sr. Research Officer, MRC, Delhi, visited Moscow for
discussions on the bilateral programme on malariogenic
stratification and mathematical modelling for malaria
under the Indo-Russian Agreement in the Field of
Medical Sciences and Public Health (problem areaMalaria) (November 16-29, 1994).

ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES
Symposium/Semimr/Workshop/
Course/Confercnce

Date & Place

Contact Address

MICON-Intcmationa 1'94.

November 9-12, 1994;
(at Mysore)

Dr. R. Shankaran, Chairperson of the Organising Commit­
tee, MICON-Intemational'94. Defence Food Research
Laboratory, Siddliartha Nagar, Mysore.

International Symposium on Gerontology and VII
Conference of the Association of Gerontology
(India).

November 14-16, 1994;
(at New Delhi)

Dr. A.B. Dey» Organising Secretary of the Symposium,
Room No.3096, Department of Medicine, All India Institute
of Medical Sciences, New Delhi.

Brain Storming Session on Molecular Immunol­
ogy-

December 9-10, 1994;
(at Bhubaneswar)

Dr. B. Ravindran, Asstt. Director, Regional Medical Re­
search Centre, Bhubaneswar.

Seminar on Genetic Epidemiology and XX Annual
Conference oflndian Society ofHuman Genetics.

December 11-13, 1994;
(at Hyderabad)

i
Dr. J.S. Murty, Professor and Head, Department of Genet­
ics, Osmania University, Hyderabad.

lH International Conference on DNA Finger­
printing.

December 13-16, 1994;
(at Hyderabad)

Dr. La^i Singh, Organising Secretary of the Conference,
Centre fbr Cellular and Molecular Biology, Hyderbad.

XIX Conference of the Electron Microscope
Society of India.

December 14-16, 1994;
(at New Delhi)

Dr. S.K. Sharma, General Secretary, Electron Microscope
Society of India, c/o National Physical Laboratory, New
Delhi.

International Symposium on Atherosclerosis,
Thrombosis and Transfusion Medicine.

December 15-20, 1994;
(at Bombay)

Dr. D. Mohanty,Director, Institute of Immunohaematology,
Parel, Bombay.

National Workshop on Biostatistics and Biom­
etry.

December 16-18, 1994;
(at Varanasi)

Dr. Manju Pandey, Convenor of Workshop, Department of
Zoology, Banaras Hindu University, Varanasi.

Guha Research Conference 1994.

December 28-31, 1994;
(at Rameswaram)

Dr D. Balasubramaniam, Convenor of the Conference,
Centre for Cellular and Molecular Biology, Hyderabad.

Symposium on Chromosomal and Molecular Basis
of Genetic Analysis.

January 13-15, 1995;
(at Varanasi)

Dr. R. Raman, Convenor, Chromosomal Symposium, De­
partment of Zoology, Banaras Hindu University, Varanasi.

National Symposium on Modem Trends in Animal
Health and Production Research and its Impact
on Rural Development.

January 24-25, 1995;
(at Hisar)

Dr. S.K. Mahipal, Organising Secretary of the Symposium,
Department of Veterinary Public Health and Epidemiology,
C.C.S. Haryana Agricultural University, Hisar.

IV National Workshop on Mycoplasmology.

January, 1995;
(at Madras)

Dr. Usha Anand Rao, Organising Secretary of the Work­
shop, Department of Microbiology, Dr. A.L.M. Postgradu­
ate Institute of Basic Medical Sciences, Madras.

131

COUNCIUS TRAINING PROGRAMMES
Nutrition

Occupational Health

At the National Institute of Nutrition, Hyderabad:

At the National Institute of Occupational Health,
Ahmedabad:

... Annual Training Course in Nutrition (December 1,
1994-February 28, 1995).

... Training Course in Pesticide Residue Analysis
(December 5-9, 1994).

ICMR BULLETIN INDEX
Vbl.24, 1994
Main Feature

Page No.

Month

Immunity in Leprosy : I. Humoral Immunity

1

January

Immunity in Leprosy : II. Cell Mediated Immunity

23

February

Immunity in Leprosy : III. Cell Mediated Immunity

37

March

Oral Health

51

April

Summary Report of the International Conference on
Dengue Haemorrhagic Fever and National Brain
Storming Session on Dengue

59

May

Contraception During Lactation

67

June-July

Strategies to Control Micronutrient Malnutrition

79

August

Long Term Health Consequences of 腿ectomy

89

September

Role of Pyrethroid Impregnated Mosquito Coil/Mats
in Reducing Man-Vector Contact

103

October

AIDS and the Family

115

NovemberDecember

Editorial Board
Chairperson

Members

Dr. G.V. Satyavati
Director-General

Dr. Badri N. Saxena
Dr. C.R. Ramachandran

Editor
Dr. N. Medappa
Printed and Published by Shri J.N. Mathur for the Indian Council of Medical Research, New Delhi
at the ICMR Offset Press, New Delhi-110029

R.N. 21813/71

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